Pauline Taylor · Prevention of Future Deaths report

On 1 December 2014 I commenced an investigation into the death of Pauline Taylor, aged 59. The investigation concluded at the end of the inquest on 3 December 2014. The conclusion of the inquest was a Narrative Conclusion, the medical cause of death being metastatic carcinoma

The deceased underwent extensive medical investigation in 2010 without a firm diagnosis being established to explain her recurring medical problems. Having identified that her right kidney had ceased to function and her ureter was severely inflamed, the Consultant Surgeon decided that a nephroureterectomy was required. He envisaged this procedure would remove the kidney and the entirety of her ureter as far as the bladder wall.

The surgery was assigned to another surgeon who performed a nephroureterectomy on 16 November 2010, in which approximately 5 cms of the ureter was removed, the remainder being left in situ. He believed that the term ‘nephroureterectomy’ left it to the discretion of the surgeon as to the proportion of the ureter to be removed.

Persisting pain in the months after the surgery eventually led to further investigations and the realisation that not all the ureter had been removed. A tumour was identified at the junction between the distal ureter and her bladder which was considered to be inoperable. In August 2011 metastases were identified in her liver and lungs. She died at home on 12 May 2012.

(1) The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid any possibility of misunderstandings between clinicians as to the extent of the procedure to be performed. One surgeon gave evidence at the Inquest that the term involved the removal of a kidney and the entire ureter. Another surgeon, however, gave evidence that the term was sufficiently broad to allow the removal of only a portion of the ureter. By the time the difference in their understanding of this term of art became clear the deceased had an inoperable tumour located in the remaining portion of the ureter.

(2) In this complex case, no firm diagnosis had been established. There was no one person in the clinical team whose role was to monitor progress, liaise with the patient and the various clinicians involved and ensure her significant ongoing problems were heard and heeded. Evidence was taken at the Inquest from an expert witness who described the benefits of a ‘case manager’ role, used in other NHS Trusts in cases characterised by uncertainty and complexity.