“There are well documented and recognised risks of ERCP surgery”
Dated 21 Nov 2014, from the coroner for Black Country. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 16 Jan 2015.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated21 Nov 2014
- Deadline16 Jan 2015
- Published on judiciary.uk21 Nov 2014
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Walsall Healthcare NHS Trust | Response publishedPublished on judiciary.uk in November 2014. |
The coroner’s concerns
– There are well documented and recognised risks of ERCP surgery. These include: Inflammation of the pancreas (pancreatitis) 2-4% Infection in the bile duct (cholangitis). This is usually treated with antibiotics, but occasionally can be serious. A hole may be made in the bowel (perforation) and if this happens surgery may be necessary. Bleeding may result from the ECRP, which will usually stop quickly by itself. In severe cases, a blood transfusion or operation may be needed to control the bleeding. My concern is that patients should be advised not only to contact their GP but also the department where surgery had been performed if symptoms of pain, raised temperature continue for more than 24 hours. In this case medical evidence suggested that had she attended Hospital twenty four hours earlier then the outcome may have been different. 6 Therefore, you may consider that the information and advice given to patients on discharge may need to be altered to take into account the lessons learnt from this inquest.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2014-0506
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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