Stephen Whitehead
28 Jun 2018 · Coroner Lisa Hashmi · Manchester (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. forgotten biliary stent
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents. Without a safety netting system, | am concerned that there is a real risk that patients will remain susceptible to what is medically recognised as the 'phenomenon of the forgotten biliary stent', resulting in future deaths.”
2. undefined short-term use of biliary stents
“Definition of 'short-term' in clinical quidance - during the course of the evidence | heard that National Guidelines on the management of common bile duct stones currently indicates that the short term use of endoscopic biliary stents followed by further ERCP (or surgery) is an established and safe management option. However, the guidelines do not provide an operational definition of 'short term'. It is therefore unclear as to what is 'safe' in terms of timeframe.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
Later report
“Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients.”