Criticism of communication between Grantham and Lincoln hospitals during inquest into death

Grantham Magistrates Court.
Grantham Magistrates Court.

An inquest into the death of a man from Corby Glen raised concerns over communication between Lincolnshire hospitals, as an urgent procedure was cancelled when the patient received two appointments on the same date.

On March 22, Robert Hall, of Pridmore Road, died at Lincoln County Hospital from septicaemia, as a consequence of cholangitis caused by gallstones in the common bile duct. Also identified as a contributing factor was a perforated duodenal diverticulum – the first part of the small intestine.

A procedure to remove the gallstones, known as an endoscopic retrograde cholangiopancreatography, or ERCP, was attempted three days before Mr Hall’s death, but had originally been scheduled at Lincoln for three weeks earlier, only to be cancelled because he was due to see his treating consultant at Grantham on the same day.

Coroner Paul Smith said: “It does seem there was something of a hiatus in the communication between the various hospital departments and Mr Hall’s family, which led to two letters being sent to them only a couple of days apart with competing and clashing requirements to attend either Lincoln or Grantham Hospital on February 26.”

Giving evidence during the inquest, Mr Hall’s daughter Stephanie Tuohy said: “I rang Lincoln County Hospital on February 16 to explain that we didn’t know what the procedure was and that we hadn’t seen the consultant to explain anything. They readily cancelled the appointment even though it was supposedly marked as urgent.”

She then accompanied her 81-year-old father to his Grantham Hospital appointment, only to be told he should have had the ERCP. “He asked if he’d had the procedure and we said no. He asked why and he was absolutely horrified.

“He was actually quite rude,” she told the coroner. “It concluded with him saying that we were wasting his time and we were not to go back to see him until we’d been to Lincoln for the ERCP.”

It was not the only delay experienced by Mr Hall and his family. An incomplete form had already put back the initial MRI scan identifying the presence of gall stones, and when this led to the decision on January 29 to do an ERCP, a letter stating this was received by Mr Hall’s GP but not by the patient. The first time Mr Hall heard about it was when he received the competing appointments for February 26.

The next day, Mr Hall was admitted to Lincoln County Hospital with severe abdominal pain, and the perforated duodenal diverticulum was identifed and operated on with success.

He returned home, only to be readmitted for on March 13 when it was identified that the gall stone problems predominated.

By the time the ERCP was undertaken on March 19, one gallstone was too large to be removed. The plan was to try again once Mr Hall’s body had recovered, but he deteriorated rapidly and died on March 22.

Returning a short narrative conclusion, coroner Smith said: “Robert Hall died from septicaemia, that being a recognised complication of an ERCP procedure attempted on March 19, 2015 to remove a gall stone from the common bile duct.

“At the time the procedure was undertaken Mr Hall was recovering from a successful procedure to repair a perforated duodenal diverticulum undertaken on February 27, 2015.

“It is not possible to say on balance of probabilities whether the outcome would have been different had the ERCP been performed prior to that operation.”