BRI insist they've made changes, after a man died following a low-risk procedure
Mr Di Blasi died at Bristol Royal Infirmary last December - after an endoscopy looking for cancer went wrong.
Last updated 8th Dec 2023
A Bristol hospital has insisted things have changed after a man was killed during a low-risk surgery.
Calogero Di Blasi died at the Bristol Royal Infirmary last year after an endoscopy looking for cancer on November 30 2022 went seriously wrong.
The surgeon, who had not read Mr Di Blasi’s medical records, took a tissue sample (biopsy) from an area which looked abnormal but was actually an enlarged vein.
This caused a massive bleed which the medical team were unable to control, despite maximum supportive measures. Mr Di Blasi died at the hospital on December 1 2022.
The enlarged vein (gastric varix) had been noticed during a CT scan a month earlier but was not flagged as significant.
This meant that the clinician who referred Mr Di Blasi for the endoscopy was left to review their findings when they were able to, which they did not do until the day after Mr Di Blasi’s death.
As a result, the endoscopist went into the surgery unaware of the enlarged vein and unaware that a CT scan had happened.
Following an inquest into Mr Di Blasi’s death, coroner Debbie Rookes issued a prevention of future deaths report on November 15 2023, warning: “There is a risk future deaths will occur unless action is taken.”
She stated: “One of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team, despite both referrals being made under the two week urgent referral pathway.
“The lack of communication between these teams meant that timely sharing of results did not occur. Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results.”
Now patients at University Hospitals Bristol and Weston — the NHS trust which runs the BRI, as well as Weston General — are asked if they have had any tests or investigations within the last six weeks, leading medical teams to review their medical records.
A full formal response to the prevention of future deaths report, setting out the details of the actions taken, will be sent to the coroner by January 10.
Jackie Linehan, legal director at Enable Law, part of the Foot Anstey Group, which represented Mr Di Blasi’s family at the inquest, said: “It is good to see that the trust has put measures in place to stop this from happening again. It will not change what happened, but at least they learned from it and are trying to ensure it never happens again.
“My client lost her loving husband and carer, and nothing can change the pain of her loss. My role now is to try to help her and their wider family during this very difficult time.”
Professor Stuart Walker, chief medical officer and deputy chief executive at University Hospitals Bristol and Weston said: “On behalf of the trust, I would like to offer my sincere condolences to Mr Di Blasi’s family.
“We will reflect carefully upon the findings of the Coroner, who has noted the actions already taken by the trust. We remain committed to learning and ensuring improvements are made wherever they are required.
“Our thoughts remain with the family.”