Denise Johnson
30 Dec 2024 · Coroner Daniel Sharpstone · Suffolk
The coroner's concerns
1. procedure-based complications
“Timely notification to ERCP practitioners following serious complications, with formal case review”
2. inadequate communication with next of kin
“Regular discussions about management plans and treatment options with NOK/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues”
3. unclear surgical consultant responsibility
“Lack of clarity around named Surgical Consultant cover for unexpected leave”
Responses
2025-0030-Response-from-East-Suffolk-and-North-Essex-Foundation-Trust.pdf ↗· East Suffolk and North Essex NHS Foundation Trust
Stated action
“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”