Elderly woman died after surgical procedure perforated intestine

An inquest heard how an 83-year-old who suffered from a painful and potentially fatal condition died after she underwent surgery.

Senior Coroner Ian Arrow noted how Jill Ward was 83 when she passed away on November 15, 2020 due to complications following surgery at Derriford Hospital.

The inquest at Plymouth Coroners’ Court heard how Mrs Ward, a widowed retired medical secretary from Woodway, Plymstock, had previously suffered ascending cholangitis – an inflammation of the bile duct which can be caused by bacteria produced following a blockage from gallstones.

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The inquest heard how a similar previous issue, in March 2019, had been effectively solved with the assistance of antibiotics meaning surgical intervention was not necessary.

However, a repeated of the problem in October 2020 saw fewer options available.

Consultant gastroenterologist Dr Sean Cochrane gave evidence to the inquest noting that while he was not involved in Mrs Ward’s treatment, he did analyse the ‘serious incident requiring investigation’, noting that all procedure-related complications which lead to a death are reviewed.

He noted how Mrs Ward presented at the hospital with an infection of the bile duct due to a blockage, noting that with “ascending cholangitis” there was a “very high risk of mortality” in patients with this infection if there was a persistent blockage.

He observed that the starting point was “if we don’t do something invasive the patient is likely to die”

As a result of consultation with Mrs Ward, who was born in Coventry, it was decided that she needed to be operated on using an endoscope through her mouth through her stomach to the duodenum and the ampulla to trace a “millimetre sized hole”.

Dr Cochrane said the surgeons would then thread wires down the endoscope, through the hole into the bile duct so that a cut can be made in the ampulla allowing the galls stones to be pulled through, reduce the bacterial infection and allowing the patients to recover.

However, following the procedure Mrs Ward appeared well for the first day, but over the coming days her condition deteriorated over the next few days and she passed away on November 15. A post mortem revealed that the procedure had caused a perforation to duodenum [part of the small intestine] – although he noted that the records wrongly claimed the perforation was to her bowel.

In answer to question from Mr Arrow about the matter being considered a “rare but known complication” Dr Cochrane revealed that there were several potential complications from the procedure adding that this was “probably the highest risk endoscopic procedure that we routinely perform”.

Reporting inquests: This is why the media does it

As journalists, we have been asked if we “enjoy” writing about death. This question is often asked by the relative of someone who has been the subject of an inquest. They are often distressed, angry and deeply hurt.

They generally feel that we have pried into a secret part of their lives and that no-one else had the right to know about.

And we understand that completely. The answer is never “yes, I enjoy writing about death”. The answer is that none of us enjoy doing it, but there’s a very good reason why we do.

The following quote comes from the Independent Press Standards Organisation (IPSO) guidance on inquests. This is the organisation set up to offer guidance on how we should operate as reporters.

“The fact of someone’s death is not private. Deaths affect communities as well as individuals and are a legitimate subject for reporting.”

It seems quite cold – “the fact of someone’s death is not private” – but it strikes to the very core of why we write about it.

Who can attend an inquest and why are they held?

This is what you need to know. The general public is entitled to attend all inquest hearings expect in exceptional circumstances and inquests must be held in buildings which are “accessible to the public without physical barrier so that any member of the public can drop in”.

All hearings, therefore, are open to journalists, and “fair and accurate reporting of proceedings is encouraged”.

Inquests are held when the cause of death is possibly violent or unnatural, or a person died in prison, police custody or another type of state detention

It is a public, fact-finding process to establish who died and where, when and how the death happened. It won’t establish who’s responsible for the death and most inquests are completed within six months of the death.

Why report on them?

First of all, it should be reiterated that reporting on inquests is one of the hardest things reporters have to do and we acknowledge that a number of people feel we should not do it.

But there are three very important reasons why we do.

In reporting inquests, we are often drawing attention to circumstances which may lead to further deaths or injuries if no preventative action is taken.

By highlighting the facts which have led to a tragedy, there is hope that someone reading the story might be in a position to prevent a further tragedy occurring in the future; recognising the early signs of spiral which could lead to someone taking their own life, realising how little alcohol consumption it can take to cause a fatal crash, or addressing a health and safety need to prevent an accident in the workplace and so on.

Secondly, as is stated in the guidance for press issued by IPSO, there is a public interest in the reporting of inquests, which are public events in any case. In reporting an inquest, a journalist may clear up any rumours or suspicion about the death.

And thirdly, the principle of open justice applies in coroners’ courts and it is our duty to ensure that hearings are a matter of public record.

Our reports, as a result, are often an impersonal look at the facts of the case and we appreciate that this can be distressing for families.

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Where possible, we will make an approach to relatives attending the hearing and it is job of the coroner’s office to notify relatives that the media may be present and reporting on the findings.

Often, families do not wish to speak to us and we will absolutely respect that. When they do, it enables us to write a more personal account in our stories.

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We will not sensationalise. We will not be gratuitous. We will accurately report on the evidence given at the hearing and the findings to educate, clear up any doubt and to maintain the principle of open justice.

We understand that this will not satisfy everyone. We understand that people will continue to feel that we are intruding on their personal grief and that has never been our intention.

We do not enjoy reporting on what are often very personal tragedies but it is important that we continue to publish these stories and it is my earnest hope that doing so lessens the chance of similar tragedies occurring in the future.

What you can do?

It is beneficial for people to know that we attend almost every inquest in Plymouth and, when we do, a story will appear.

We understand that coroners in Plymouth are routinely letting people know that this is the case and that members of the press may be present.

When approaching families for comment at an inquest, our journalists must do so with appropriate regard for the fact that inquests may be extremely distressing to the bereaved. They must cease questioning, pursuing or photographing members of the public if asked to do so by that person or their representative.

We must never speculate and stick to the facts of the case as presented at the hearing.

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IPSO makes it clear that journalists should take particular care when reporting on suicide, to ensure that they do not provide excessive detail of the method used, which might result in someone trying to copy to method.

If you have concerns about the accuracy of reporting an inquest, wish to add a personal tribute or request amendments, you can directly contact the journalist who posted the story on Plymouth Live by clicking on their byline, emailing news@plymouthherald.co.uk or phoning 01752 293122.

Should you wish to take matters further, the IPSO helpline is open from 9am to 5.30pm on 0300 123 22 20 or you can email inquiries@ipso.co.uk.

He noted that in 2018 Mrs Ward had had her gall bladder taken out and there had been no problems with her bile duct, but post removal a stone had clearly been retained in the bile duct, first announcing itself in 2019 when she fell ill, but on that occasion antibiotics had reduced the problem.

He confirmed that the surgeon had had a “frank” discussion with Mrs Ward about the risks and noted that due to the risks involved with an elderly patient it was invariably considered more prudent that if a patient improves without this kind of surgery it was better to leave them be rather than put them at risk with surgery.

However, when the issue reoccurs, as it did in the case of Mrs Ward, and antibiotics no longer improve the health of the patient the options remain of either no treatment – with inevitably fatal results – or risk the surgery.

Recording a narrative conclusion, senior coroner Ian Arrow said Jill Ward underwent endoscopic surgery, but unfortunately it was unsuccessful and the operation caused a perforation – ” a known complication”.

As a result she developed sepsis, deteriorated and later died.

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