East Suffolk and North Essex NHS Foundation Trust

“The Trust acknowledges that the treating endoscopist was not informed of Mr [name redacted] readmission with a complication. The treating endoscopist was only made aware of the readmission following contact from the coroner's service. The Trust acknowledges this represents a missed opportunity for early clinical input from the treating endoscopist, for reflective learning regarding the case and equipment used (specifically, the stent size) and to have open discussions with Mr [name redacted] and his family.”

“The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 2025, all ESNEFT patient record keeping will be done electronically.”

“review The Trust's endoscopy unit audit Post ERCP complications in an annual audit. Outpatient cases where complications develop are also audited and discussed at the Endoscopy governance meeting. The Trust's endoscopy unit are now starting 3 monthly ERCP Multi-Disciplinary Team meetings, where all cases and complications will be discussed. Any inpatients who develop severe complications including pancreatitis, cholangitis, perforation or bleeding post ERCP, will be identified by the clinical team”

“The Trust has however acknowledged that the low saturations were not recorded in the notes. This learning point has been circulated to staff members, through the daily ward huddle, reiterating the need for oxygen saturations to be recorded prior to the administration of oxygen.”

“Completing falls risk assessments on admission/transfer to ward”

“We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF).”