- Carol Cole, 53, died at the Queen’s Medical Centre (QMC), Nottingham in 2020
- A post-mortem examination showed Carol died from complications following an endoscopic retrograde cholangiopancreatography (ERCP) procedure the previous day
- Carol was the fourth patient to pass away over a period of six months following the procedure, which was undertaken by the same doctor
- Inquest into Carol’s death found that she died as a result of complications of the ERCP procedure and that her death was not natural.
- Nelsons representing the Cole family’s search for answers
Nottingham Coroner’s Court has today, 17 December 2021, found that there were systemic issues with regards to patient triage after four individuals died shortly after undergoing a routine endoscopic retrograde cholangiopancreatography (ERCP) procedure undertaken by Dr Muthuram Rajaram at the Queen’s Medical Centre (QMC), an inquest has heard.
Carol Cole, of Broxtowe, was diagnosed with gallstones in the summer of 2020 after experiencing abdominal pain, which culminated in her going to the QMC on 10 September 2020 to undergo an ERCP – a routine procedure that eliminates the need for major surgery and from which most people recover in a couple of hours – to remove gallstones from the common bile duct.
She was taken to the hospital that morning by her husband, Trevor, who was unable to go into the hospital with her due to the ongoing Covid-19 pandemic. A few hours later, Trevor received the call to come back and pick up Carol, who was brought out to him in the car and quickly discharged. She had a white envelope with her that Trevor and Carol both assumed was her discharge letter, as they weren’t informed of the contents by any hospital staff.
After arriving home, Carol started to feel unwell and, by 8.20pm, was in a lot of pain, describing it as feeling like her ‘insides were ripping’ and she was ‘in agony’. Over the course of the evening, Trevor called an ambulance four times, first at 8.20pm, second at 8.45pm, third at around 9.20pm and the final time around midnight.
The ambulance arrived around 1am at which point the paramedics opened the letter that had been given to Carol by the hospital, which contained a number to be called in the event of an emergency. However, Trevor wasn’t aware of this and had not opened the letter that evening due to Carol feeling unwell.
Carol was taken to A&E, where she messaged Trevor at 3.15am to say the doctors suspected she had pancreatitis and would call later that morning. However, this was the last time Trevor heard from Carol as he received a call from her sister at around midday that day to say that Carol was in the Intensive Care Unit (ICU) and that he needed to go there immediately.
Trevor, along with Carol’s sister and brother-in-law, went straight to the hospital where they were told, at around 2pm, that Carol had passed away.
At a 15-day inquest into the deaths of all four patients, which concluded on 17 December at Nottingham Coroner’s Court, the coroner, Ms Laurinda Bower, found that Carol died as a result of complications of the ERCP procedure and that her death was not natural.
Trevor Cole, who had been married to his wife for more than 20 years, said:
“Our whole family is devastated at having to adapt to life without Carol. None of us were prepared for this after the procedure was only a minor, routine operation and I had no idea that she was so dangerously unwell that evening. I was in shock when I was told that Carol was gone and can’t remember much after this other than having to break the news to our sons, Ashley and Mitchell. It was one of the hardest things I’ve ever had to do.”
“Since her passing, I’ve left my job as a bus driver as it gave me too much time alone with my thoughts, and I’m in the process of moving out of the area because the house reminds me of Carol and I can no longer face spending time alone there unless one our sons is home. It makes me incredibly sad to know that our sons have lost their mum and she won’t see their lives unfold.”
“Carol was fun, outgoing and our boys were her world. She wanted them to have the opportunities that we didn’t have growing up and she was an incredible example for them. She was taken from us far too soon and will be missed by everyone who knew her. To me, she was perfect and I will never forget her.”
Emily Rose, Associate in our Medical Negligence team, has been assisting Trevor and his family in preparation for the inquest. Barrister, Ross Beaton of 7 Bedford Row, has been representing him during the hearing.
Emily said:
“During her procedure, the guidewire that was inserted entered the pancreatic duct twice. While this complication can happen, the fact that Carol developed such a severe case of pancreatitis soon after is incredibly concerning – especially given how quickly she was discharged combined with the circumstances surrounding the three other patients who also passed away following this procedure. There were also criticisms raised in relation to the ambulance service, which caused further distress to Carol and Trevor.
“Today’s conclusion found that Carol died as a result of complications of the ERCP procedure and that her death was not natural. While it was found that an earlier arrival at the hospital would have been unlikely to extend her life for much longer, the coroner did identify that there was a failure to appreciate how unwell Carol was when she arrived and that, had this been identified, she would have been managed more appropriately.
“The coroner highlighted that, while the initial cause for concern was that all four deaths had happened at the hand of the same trainee, the evidence presented has revealed that the issue is more with the system in place for patient triage, rather than any technical incompetence of any individuals.
“While today’s findings will not be able to fill the hole that losing Carol has left, I hope that it has gone some way to providing the answers Trevor and his family thoroughly deserve, and lessens the chances of a similar situation occurring in the future.”