On Thursday 28 January 2010, HM CCororoner for Bournemouth, Poole and Eastern Dorset District, Mr Payne, gave his verdict on the death of Mrs Pamela Emment who died aged 69 years.
Online PR News – 16-March-2010 – – Mrs Emment was admitted to Poole Hospital on 18 May 2009 for investigations to determine the cause of her iron deficiency anaemia. On 19 May she had a gastroscopy which identified the possibility of a small gastric varix (dilated blood vessel) in her stomach. Further tests identified liver problems causing increased pressure on the veins around Mrs Emment's liver and a build up of fluid in the abdomen.
She was referred to one of the gastroenterologists at the hospital with a special interest in liver problems and he ordered further tests. Unfortunately however there was a breakdown in communication and Mrs Emment was placed as an emergency on the first available list for further endoscopy. The surgeon performing that list was unaware of the result of the previous gastroscopy and the medical history and recent diagnosis of liver disease.
On 26 May 2009 Mrs Emment underwent the further gastroscopy. The surgeon took a biopsy of the gastric varix and she sustained massive bleeding. Mrs Emment required emergency resuscitation and attempts were made to stop the bleeding by insertion of a special tube into her stomach to press on the site of the biopsy. She was transferred urgently to the Royal Free Hospital in London further procedures to seal the varix.
Unfortunately, Mrs Emment's condition deteriorated over the next few days. She started to develop lung problems and went in to multi-organ failure. In spite of intensive treatment at the hospital in London, she died on 4 June 2009.
The Coroner took the evidence and identified significant failings in communication and documentation by Poole Hospital. The surgeon performing the gastroscopy on the 26 May did not review Mrs Emment's medical records before undertaking the procedure or clarify the order of tests required when he did not understand the significance of the instructions on the endoscopy referral form. He issued a narrative verdict.
The Coroner has also issued a letter under Rule 43 and formally requested clarification from Poole Hospital as to the steps they will now take to ensure that a similar incident does not leave another family grieving for the loss of a loved family member.
John White, solicitor from Blake Lapthorn, represented the family at the Inquest hearing. He said that the enquiry had uncovered a series of catastrophic failures in communication at Poole Hospital which caused this disaster.