Date of report: 08/06/2023
Deceased name: David Wilson
Coroner name: Kevin McLoughlin
Coroner Area: West Yorkshire (Eastern)
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Mid Yorkshire Hospitals NHS Trust
|REGULATION 28 REPORT TO PREVENT FUTURE DEATHS|
|THIS REPORT IS BEING SENT TO:|
1. Mid Yorkshire Hospitals NHS Trust
I am Kevin Mcloughlin, Senior Coroner, for the Coroner area of West Yorkshire (Eastern area)
|2||CORONER’S LEGAL POWERS|
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
|3||INVESTIGATION and INQUEST|
On 18 January 2023 I commenced an investigation into the death of David Barnet WILSON, aged 67. The investigation concluded at the end of the Inquest on Tuesday 6 June 2023. The conclusion of the Inquest was a Narrative based upon the following medical cause of death; 1a Sepsis 1b Bowel Perforation (Sigmoidoscopy Procedure Undertaken on 30.12.22) 1c lschaemic Colitis, II End Stage Renal Failure, Abdominal Aortic Aneurysm (operated), lschaemic Heart Disease.
|4||CIRCUMSTANCES OF THE DEATH|
Mr D B Wilson was admitted to hospital on 27 December 2022. A CT scan indicated an inflammation in the distal section of his colon. The established diagnostic procedure to identify the cause of the suspected colitis was a flexible sigmoidoscopy. A recognised complication of this procedure was a colonic perforation. This happened in this case and resulted in his death the following day, 31 December 2022, at Pinderfields Hospital, Wakefield.
During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) The Consent form signed by Mr Wilson was a standard pre-printed form. It did not attempt to provide any statistical rating for the risks identified, which would have enabled Mr Wilson to evaluate the risks.
(2) No attempt was made to interpret or tailor the risks inherent in the procedure in the light of his extensive medical history and co-morbidities.
(3) The Consent Form did not refer to the risks of death, which befell him. He was thus not in a position to make a truly informed consent to undergo the sigmoidoscopy.
(4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for who obtained his signature at a time when he was under the influence of morphine sedation.
The objective of the Consent process should be to demonstrate a patient has made a truly informed decision at a time when he is able to evaluate the risks clear! .
|6||ACTION SHOULD BE TAKEN|
In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 1 August 2023. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
|8||COPIES and PUBLICATION|
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (wife). I have also sent it to [REDACTED], Ferrybridge Medical Centre, Ferrybridge, WF11 8NQ, who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
SENIOR CORONER, WEST YORKSHIRE (EAST)
Thursday 8th June 2023