A woman died at Huddersfield Royal Infirmary following a ‘critical failure’ in her care when a problem with a gastric band was not picked up during an outsourced CT scan.
Gemma Marshall, 46, attended Huddersfield Royal Infirmary with black vomiting and lower abdominal pain. She collapsed in the shower in hospital and did not recover.
A post mortem examination found that the gastric band – a weight loss device placed around the upper stomach – had slipped, causing her stomach to twist. It led to the build up of fluid and then an arrhythmia (an irregular heartbeat) and her collapse. She could not be resuscitated.
Following an investigation and an inquest into Gemma’s death, assistant coroner Steve Eccleston has now concluded that an outsourced CT scan had failed to advise that the gastric band had slipped and this contributed to a failure to refer Gemma to specialists who could have intervened and that she might have lived.
“This failure represents neglect in the care that Gemma received,” said Mr Eccleston in a Prevention of Future Deaths Report.
The inquest was told that Gemma had private surgery for fitting the gastric band in November 2020 and on March 13, 2024, she attended Huddersfield Royal Infirmary with black vomiting and stomach pain.
She collapsed in the shower in hospital on March 15 and did not recover.
Mr Eccleston said there had been a ‘critical failure’ in the care Gemma received.
“A CT scan was undertaken on 13 March 2024 and reported on by a radiologist with expertise in musculoskeletal imaging (rather than gastric or abdominal imaging) who worked for an outsourced company.
“This was because of staff shortages in the hospital. The scan report mentioned the existence of the band but didn’t comment on the fact that the images clearly showed the band was out of position. That is that the stomach had slipped and had formed a pouch above the band.
“This was, in my view, a critical failure in the care Ms Marshall received. Had this image been correctly reported, then a referral to bariatric surgeons would have probably been made which might have meant she would have survived.”
The coroner added: “Evidence from the consultant radiologist and the consultant surgeon in the hospital was that this failure to report that the band had slipped was because of a lack of familiarity in radiologists as to how slipped bands present, something which was compounded by 1. The increasing rarity of the procedure, 2. The consequences of specialisms which are not familiar with the abdomen or bariatric issues and 3. A need to sometimes rely on outsourced third-party radiologists without the relevant specialism because of staff shortage.
“While the hospital had taken steps to address this knowledge gap, there remained a concern that this lack of knowledge as to how slipped bands present was an issue of concern across the country and that other patients could face similar failures to Marshall.”
The coroner has sent his report to NHS England, the Royal College of Radiologists and a copy has also been sent to other ‘interested persons’ including Calderdale and Huddersfield NHS Foundation Trust.
Mr Eccleston has asked NHS England and the Royal College of Radiologists to respond to his report by February 17.
In a statement, Brendan Brown, chief executive at the Trust, said: “Our sincere condolences go out to Gemma’s family and friends. The care and safety of our patients is important to us, and we welcome the findings and learning from this report.”
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