Helen Yuk Ying BANNISTER · Prevention of Future Deaths report

On 20th May 2016 I commenced an investigation into the death of Helen Yuk Ying BANNISTER, born on the 8th January 1947. The investigation concluded at the end of the inquest on 27th September 2017. The conclusion of the inquest was as follows:

Medical cause of death:
1a. Sepsis
1b. Bronchopneumonia and peritonitis
1c. Recent surgery to insert a gastrotomy feeding tube (PEG)

The narrative conclusion recorded:
On 13th May 2016, Helen Bannister underwent a procedure at Stoke Mandeville Hospital, Buckinghamshire to insert a gastrotomy feeding tube (PEG). The loosening of the PEG occurred at some time after discharge from Stoke Mandeville Hospital and led to a leak into her abdomen which caused the infection from which Helen Bannister died.

Helen Bannister was a resident at Lent Rise House, part of the Fremantle Trust.
Her ability to swallow and take food and drink orally had been becoming compromised and it was agreed she would undergo a procedure as a day patient at Stoke Mandeville Hospital so that she could be fed in future with a PEG feeding regime whilst retaining the ability to take some soft food or liquids orally.
The narrative conclusion (above) sets out the brief facts.
After discharge from Stoke Mandeville Hospital, Helen Bannister returned to Lent Rise. At some time during this short period she became ill and this was subsequently identified by Wexham Park Hospital and at post mortem to be due to a leak into her abdomen leading to infection. She had received emergency treatment, a washout and removal of the PEG at Wexham Park shortly before her death.
Section 3 of the Record of Inquests recorded that Helen Bannister died at 0415hrs on 17th May at Wexham Park Hospital, Berkshire as a result of sepsis.

There was, understandably, a significant volume of documents and records from Lent Rise used to record the various elements of the care Helen Bannister received whilst at Lent Rise. During the course of the investigation and in evidence at the inquest, whilst there was an indication that procedures, documentation and staff awareness had been under review since the death of Helen Bannister, there remains a significant concern that the keeping of accurate records in respect of all aspects of care, fluid intake, diet and nutrition and the proper recording of hospital discharge arrangements and aftercare instructions needs to be improved.
There remains a continuing risk that the ability of care workers, nurses, doctors and hospitals to react properly to unfolding events may be compromised by incomplete records intended to accurately document all actions taken and the relevant timings of those actions in the care of a resident.