Sandra Lomax
10 Feb 2023 · Coroner Alison Mutch · Manchester South
The coroner's concerns
1. lack of detailed national guidance on management of oesophageal strictures following chemo/radiotherapy
“The development and implementation of detailed National Guidance was the inquest was told key to improving outcomes for patients such as Mrs [name redacted] across England”
2. absence of specialist pan-GM service for complex oesophageal stricture cases
“The absence of such a service meant that cases such as Mrs [name redacted] could arise going forward given that in most hospitals even experienced radiologists/gastroenterologists would have limited experience on how to manage such cases”
3. ineffective communication of MDT outcomes to local clinicians
“an effective and consistent pan GM approach to sharing the outcomes of MDTs would improve patient outcomes”