Eva Eileen WHEELER · Prevention of Future Deaths report

On 24/02/2020 I commenced an investigation into the death of Eva Eileen WHEELER. The investigation concluded at the end of the inquest 15th December 2021. I made a determination at inquest that the death should be recorded in a narrative conclusion.

The medical cause of death I recorded as:
1(a) Abdominal Perforation
1(b) Sigmoid Volvulus

II Asthma, Ischaemic Heart Disease

Eva Eileen Wheeler was aged 82 and was an inpatient at Ysbyty Cwm Cynon, for rehabilitation following a soft tissue hip injury. She suddenly developed a bowel obstruction which led to a perforation and died on 17th February 2020.

NARRATIVE: Mrs Wheeler developed sigmoid volvulus in the early hours of 17ᵗʰ February, and despite appropriate treatment and diagnosis the same morning, she was not transferred to Prince Charles Hospital for further assessment and care by surgeons. A communication error between staff meant that an emergency ambulance was not called for Mrs Wheeler, and YCC had reached the ceiling of care it could offer her. This failure is unlikely to have changed the outcome for Mrs Wheeler, as her age and co-morbidities meant that she was not a candidate for emergency bowel surgery. She deteriorated rapidly on the ward, and died of an abdominal perforation at around 16:30.

(1) The communication error between staff led to a failure to contact an emergency ambulance to transfer a critically ill patient to a major hospital. Since this incident, computerisation has largely replaced written notes in this Trust, and evidence from staff did not satisfy me that any changes were embedded on the ground. I am concerned that there is not a clear and robust process in place for documenting, requesting and chasing-up emergency ambulances throughout YCC;
(2) A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth; and
(3) The on-call Medical Registrar at Prince Charles Hospital was contacted for advice, since doctors do not work at YCC overnight. Had the on-call Surgical Registrar been consulted, there may have been an earlier diagnosis of suspected sigmoid volvulus. Bowel obstructions are relatively common in an elderly patient cohort, so I question whether provision for joint discussion between the registrars should be built into a protocol.