Margaret Joy Easterfield · Prevention of Future Deaths report

On 19th February 2014 I commenced an investigation into the death of Margaret Joy Easterfield. The investigation concluded at the end of the inquest on 19th February 2014. The conclusion of the inquest was that Margaret Joy Easterfield died as a result of the unintended consequence of necessary surgical treatment

Margaret Joy Easterfield required a reversal of Ileostomy loop. She developed peritonitis after requiring readmission to hospital after the surgery and subsequently died there.

I am concerned that Mrs Easterfield underwent surgery on 26th October 2012 following which there was an anastomotic leak. She was discharged from hospital on the 30th October and was readmitted on 31st October, becoming profoundly unwell in the afternoon of the 3rd November and dying on the 4th November. I consider that a leak of ileo-ileal anastomosis is relatively rare and raises the question of technical error on the part of the surgeon. Because of my concern about the incidences of an anastomotic breakdown, I am raising this matter with you as I believe you can carry out action to prevent further death.