Ipswich Hospital says 'lessons learned' following death of woman
42 year old Denise Johnson died in November 2022 - she'd had abdominal pain and a number of health issues
Bosses at Ipswich Hospital are being urged to review their clinical procedures and how staff communicate with patients' families - following the death of a patient there.
42 year old Denise Johnson died in November 2022 - she'd had abdominal pain and a number of health issues.
Now, following an inquest in December last year, coroner Daniel Sharpstone's published a prevention of future deaths report highlighting a number of key concerns surrounding Denise's death.
Denise was admitted to hospital as an emergency with abdominal pain and jaundice on 13th August 2022.
Investigations revealed a gallstone in the common bile duct as the cause of her jaundice.
As a result, an endoscopic retrograde cholangiopancreatography (ERCP) was performed and a plastic stent inserted for drainage.
Following this procedure, Denise became increasingly unwell and was placed into intensive care.
Her condition deteriorated further and she died on 24th November 2022.
What concerns are mentioned in the report?
The coroner's report says says staff didn't effectively communicate with Denise's family, arguing 'two-way feedback in this situation plays a vital role in maintaining patient wellbeing and safety'.
Sharpstone also suggests the hospital needs to review its clinical procedures - noting that when one of Denise's care team had to take unplanned leave, there was no clear handover of power to make sure her care continued effectively.
He explains in the report: "A clear handover process at Consultant Surgeon level for unexpected leave enables continuation of care between health care professionals and teams with continuity and oversight of treatment and management plans."
Finally, he states that any ERCP-based endoscopic complications should be 'presented in a formal setting in the presence of Endoscopy colleagues.
"There is a need for timely feedback to responsible ERCP practitioners in cases of procedure-based complications to ensure checks and learning on matters such as safety and adherence to guidelines and standard practice."
"Lessons learned"
Dr Martin Mansfield is Deputy Chief Medical Officer at East Suffolk and North Essex NHS Foundation Trust, the organisation which runs Ipswich Hospital.
Dr Mansfield said: “Our sincere sympathies go to Denise’s loved ones for their loss.
"We welcome the coroner's report and we are committed to taking forward lessons learned.
"Patient safety is our top priority and we take the concerns raised in the report very seriously. We are working to address the issues and our full response to the report will be shared with the coroner in due course.”