A WOMAN died in hospital in Hereford following a complication during an endoscopy examination.
Majorie Thomas, of Clehonger, was admitted to Hereford County Hospital on November 21 last year, suffering with obstructive jaundice.
She was taken to theatre on November 25 for an endoscopy examination. During the examination, the duodenum – the first part of the small intestine immediately beyond the stomach – was perforated. She was also suffering from an underlying carcinoma which contributed to the perforation.
She sadly died as a consequence of her injuries and the cancer on November 28.
Dr Paul Dunn, a pathologist with Worcestershire Acute Hospitals NHS Trust, said Ms Thomas' death was due to peritonitis, duodenal perforation during endoscopy, biliary obstruction and duodenal stenosis. A secondary cause was given as well differentiated adenocarcinoma of the duodenum.
Coroner Mark Bricknell recorded a narrative verdict at an inquest last week – which is a longer explanation of what he considered the main or important issues.
He said: "Ms Thomas was admitted to hospital with obstructive jaundice consequent upon compression of the common bile duct by an exclusive well differentiated adenocarcinoma of the duodenum. An endoscopy was carried out to attempt to diagnose the cause of the biliary obstruction and to attempt stenting of the bile duct.
"During this procedure, the duodenum was perforated leading to biliary peritonitis. "The histology shows exclusive infiltration of the area of perforation by carcinoma which is likely to have been a significant contributory cause to the development of a perforation."
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