Megan Williams
30 Sept 2024 · Coroner James Dillon · Central and South East Kent
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. band adhesions causing bowel obstruction
“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.”
2. lack of documented self-discharge process
“The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.”
3. lack of knowledge of AAPP among clinicians
“The inquest also examined East Kent Hospital's Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.”
4. missing vomiting record
“The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
This report
“The inquest also examined East Kent Hospital's Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented”
Identical hazardConfidence 0.90 · high
This report
“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.”
Later report
“There are other clinics nationally who may be offering patients Preoperative Progressive Pneumoperitoneum (PPP) to patients who have a history of adhesional small bowel obstruction (ASBO).”
Responses
2024-0518-Response-from-East-Kent-Hospitals.pdf ↗· East Kent Hospitals University NHS Foundation Trust
Stated action · ongoing
“The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.”
2024-0518-Response-from-NHS-England.pdf ↗· NHS England
2024-0518-Response-from-NICE.pdf ↗· NHS England