Sylvia Mitchell
5 Dec 2018 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. inadequate communication about pessary removal risks
“Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs [name redacted] of the risks of not having the pessary removed urgently”
2. infection, impaction, ulceration, recto-vaginal or vesico-vaginal fistula
“Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistula”
3. death from fistula and urosepsis
“Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis”