Steven John Amos · Prevention of Future Deaths report

On the 25th May 2016 I commenced an investigation into the death of Steven John Amos. The investigation concluded at the end of the inquest on the 23rd March 2017. The Conclusion of the inquest was a short form conclusion of accidental death, combined with a narrative conclusion. The medical cause of death was 1a) Multiple Organ Failure and Peritonitis, 1b Post Operative Leakage from an Intra - Abdominal Anastomosis.

Steven John Amos “Steven” was a 57 year old man who suffered with chronic pyloric stenosis, which was linked to his long term use of anti inflammatory pain killers and dependence on codeine. In June 2015 he underwent a gastrectomy. Post operatively his condition improved. However in April 2016 he was suffering with persistent vomiting and weight loss. His consultant suggested a further operative intervention which involved a reconstruction of the previous surgery. The risks were explained. Steven underwent the operation on the 10th May 2016. The operation was technically very awkward. Post operatively his pain was difficult to manage. On days 1 to 3 post operation he was reviewed daily by the surgical team and the acute pain team. By Friday the 13th May his pain was improving. Over the weekend Steven experienced some chest pain on the Saturday, and penile pain on the Sunday. Both were investigated, and were seen. At approximately 1am on Monday the 16th May his condition deteriorated. His blood pressure dropped, and his pulse rate increased. It is probable that leakage began to occur from his operative site around this time. Steven was medically reviewed by a junior doctor at 3.15am who was concerned there may be a leak. No medical examination by a more senior doctor occurred until 8am. No antibiotics were administered until 8 am. An urgent CT scan was not actioned until 8am. Steven did not receive analgesia between 1am and approximately 9am. The scan demonstrated a lot of intra-abdominal fluid and free gas suggesting a leak and Steven was prepared for theatre. Steven underwent an emergency laparotomy at 2pm on the 16th, which revealed a small leak from the gastrojejunal anastomosis, which had led to peritonitis. The leak was repaired. Post operatively Steven was transferred to the intensive care unit, and despite maximal clinical intervention his condition continued to deteriorate. Steven passed away at 23.24 hours on the 17th May 2016. It is likely that if Steven had been taken to theatre sooner on the 16th May 2016, his chances of survival following the emergency operation would have been increased.

Whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period.