Mrs Ibiyemi Ereohah · Prevention of Future Deaths report

On the 16th July 2019 I commenced an investigation into the death of Mrs Ibiyemi Ereohah. The investigation concluded at the end of the Inquest on the 26th February 2020. The conclusion of the Inquest was that she died as a result of natural causes contributed to by neglect.

Mrs Ereohah attended Newham Hospital on the 31st October 2017 with lower abdominal pain and anaemia. She underwent a number of investigations and concerns were raised in relation to a possible sarcoma. Her case was discussed at an MDT meeting where the concern of a possible sarcoma was downgraded to a likely benign fibroid. The consideration of the case at the MDT was inadequate. Her gynae-oncologist was not in attendance to present the case; there is no clear rationale as to why the concern was downgraded. A hysteroscopy performed on the 15th December 2017 was inadequate, as samples of the tumour and muscle wall should have been obtained. Inappropriate reliance was placed upon the biopsy result, to exclude the possibility of a sarcoma. In February 2018 Mrs Ereohah was booked for a total abdominal hysterectomy. She was inappropriately deemed unfit for surgery and did not undergo surgery at that time. There was a 4 month delay in obtaining a consultant anaesthetic review of her operative fitness. Had Mrs Ereohah undergone surgery in February 2018, her death on the 17th September 2018 would have been avoided. Mrs Ereohah continued to present to hospital with severe anaemia between February 2018 to August 2018. She underwent a total abdominal hysterectomy on the 30th August 2018. Shortly after surgery she was diagnosed with a high-grade uterine sarcoma. She was discharged from Newham hospital and readmitted to Queens hospital on the 10th September 2018. She passed away as a result of a metastatic leiomyosarcoma on 17th September 2018.

1. Many of the concerns arising in this case were considered to be due to an insufficiency of gynae-oncology consultant cover at Newham University hospital. The lack of adequate Consultant cover was deemed to have contributed to the lack of advocacy at the MDT meeting; the inability to challenge the MDT conclusion and the lack of Consultant overview of the recurrent admissions. In July 2019, the Trust agreed two key actions to address this deficiency:

• Clinical Leads at the RLH and NUH to review gynaecological oncology staffing and job planning, to ensure adequate administration time; cover when on leave/programmed for other duties, such as hot weeks.

• There should be an urgent organisational development/service level review of the NUH gynae-oncology team that is independent of the site.

As at the date of the Inquest, neither of these necessary actions had been completed.

2. Mrs Ereohah was deemed unfit for surgery by a clinical nurse specialist on the 16th February 2018. The nurse requested a consultant review which should have taken place within 3-5 weeks. It did not take place until 16 weeks later. The Inquest heard evidence that there was no system in place to ensure that all consultant reviews were carried out within a timely manner.