Dennis Teesdale
7 Jun 2017 · Coroner Karen Henderson · West Sussex
The coroner's concerns
1. lack of sub-specialist personnel
“Mr [name redacted] care was compromised by the isolated position and associated lack of facilities and other sub-speciality medical and surgical clinical personnel able to assist in the investigation and management of Mr [name redacted] at Queen Victoria Hospital, East Grinstead”
2. absence of PEG placement facilities
“There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery, thereby requiring oral maxillo-facial surgeons of _ variable and unclear experience to undertake the procedure peri-operatively”
3. non-compliance with PEG insertion guidance
“Written guidance by the surgeons for insertion of PEG's was not followed with little reflection as to whether this was an acceptable procedure given Mr [name redacted] previous extensive surgery at or around the point where the PEG was inserted with concomitant poor gastroscopic trans-illumination”
4. lack of risk assessment for PEG insertion
“No risk assessment was undertaken as to whether a PEG insertion would have been appropriate, given that a non-invasive alternative of a feeding tube for enteral feeding was available”
5. absence of PEG training programme
“No formal 'training' programme for the insertion of PEG or independent competency based assessment”
6. delayed post-operative pain management
“The post-operative management of Mr [name redacted] did not follow the written guidance for the management of abdominal pain after PEG insertion. This resulted in a delay in seeking appropriate advice, timely intervention and optimal treatment of this complication”
Responses
2017-0202-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
2017-0202-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“the Trust has responded to you on your concerns and I hope that reply is helpful.”
Dennis-Teesdale-Response-1.pdf ↗· Care Quality Commission
Stated action
“The Trust is committed to learning from serious incidents and has made changes to its systems to minimise the risk of a similar incident recurring in the future, including change of PEG policy, and the introduction of a PEG pathway checklist.”