Finding into death of John Twycross
Deceased
John Twycross
Demographics
80y, male
Date of death
2011-05-31
Finding date
2017-03-10
Cause of death
complications of necrotising pancreatitis secondary to pancreatic biopsy (EUS)
AI-generated summary
John Twycross, an 80-year-old man with a history of hypertension, asthma, glaucoma and prior cholecystectomy, presented with acute pancreatitis in April 2011 after imaging revealed a suspected ampullary carcinoma. Following a negative PET scan in late April, he was referred for endoscopic ultrasound (EUS) with fine needle aspiration biopsy on 20 May 2011 to exclude pancreatic malignancy. The procedure caused necrotising pancreatitis, leading to rapid clinical deterioration despite emergency surgery. He died on 31 May 2011. The coroner found that informed consent was obtained by both referring surgeon Dr S. and proceduralist Dr T., though documentation was inadequate. While Dr T. did not specifically warn of death risk (quoted as 1 in 4000 fatalities), this was considered reasonable given the low incidence. The key clinical lesson is that consent documentation must be complete and contemporaneous, and both referring and procedural teams should coordinate information provision to patients, particularly in complex cancer cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- endoscopic ultrasound with fine needle aspiration biopsy
- known complication of EUS procedure
- prior episode of acute pancreatitis
- advanced age
Coroner's recommendations
- Consent documentation must be complete and contemporaneous with the consent process
- Information provision in complex cancer cases should be coordinated between referring specialists and proceduralists
- Written information sheets should complement, not substitute for, face-to-face discussions with patients
- Proceduralists should ensure patients have opportunity to ask questions and that understanding is gauged before proceeding with invasive procedures
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