Finding into death of John Twycross

80y · Male·complications of necrotising pancreatitis secondary to pancreatic biopsy (EUS)

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.