William Doleman, Anita Burkey, Peter Sellars and Carol Cole
23 Dec 2021 · Coroner Laurinder Bower · Nottingham City and Nottinghamshire
The coroner's concerns
1. patient pathway gaps for ERCP safety
“A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.”
2. vetting process recording gaps
“A lack of robust system for the recording of vetting of the procedure, capturing what information has been considered as part of this process.”
3. non personalised consent
“Consent is not personalised, contrary to recommendations made by the ESGE in December 2019.”
4. lack of professional accountability
“A Lack of accountability between professionals for ensuring robust vetting and consent.”
Responses
2021-0432-Response-from-City-Hospital-Campus_Published.pdf ↗· Nottingham University Hospitals NHS Trust
Stated action · 14 February 2022
“- The referral pathway has been completely re-designed and will move away from the old 'NOTis' based information system to Medway orders (the current information system in use in the Trust) from 14 February 2022. The Medway order will incorporate: information on the indication, latest blood tests, date and findings of relevant imaging, capacity for consent, awareness of LPA, highlighting potential factors for "higher risk" procedures, and seek history or symptoms of dysphagia for any procedure”