Nottingham Coroner’s Court has heard evidence relating to the deaths of Mr Doleman and three other patients – Anita Burkey, Carol Cole and Peter Sellars, following endoscopic procedures carried out at Queen’s Medical Centre Hospital (part of Nottingham University Hospitals NHS Trust) by Gastroenterologist Dr Rajaram between April and November 2020.
The inquest is set to announce its conclusions shortly.
Endoscopic Retrograde Cholangiopancreatography (ERCP), is an endoscopic technique that involves the passing of a tube down the patient’s throat and into the biliary and/or pancreatic ducts. The procedure is used to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. Complications of an ERCP include pancreatitis and tears to the oesophagus and duodenum.
William Doleman: Perforated Duodenum
William Doleman died following a routine procedure conducted at the Queen’s Medical Centre in Nottingham in March 2019.
Mr Doleman received an Endoscopic Retrograde Cholangiopancreatography (ERCP) for the removal of gallstones..
The operation was conducted by Dr Muthuram Rajaram, who was being supervised by Professor Dileep Lobo. Dr Rajaram reported that no gallstones could be found. Mr Doleman was monitored for an hour after the procedure and, reporting no feelings of pain, he was discharged and sent home.
Seventy-two hours later, Mr Doleman returned to hospital complaining of abdominal pain. Described as ‘stoic’ by his family, they suggested that the former steelworker would have been in considerable pain to prompt him to first request an ambulance and, then, take a taxi to go directly to A&E.
Sadly, Mr Doleman, who was experiencing a temperature and shortness of breath, died a few days later. A post-mortem confirmed that he had suffered a perforation, essentially a tear or hole in an organ wall, because of the ERCP procedure. This had subsequently become infected and caused his death. The inquest heard that he was at a ‘significant risk’ of developing sepsis and, as a result, his chances of survival were low. A pathologist told the inquest that it was likely, had Mr Doleman not undergone the ERCP, he would still have been alive.
Dr Rajaram admitted that a pre-existing condition that Mr Doleman had (duodenal diverticula – pouches outside the duodenum) made the ERCP procedure a more difficult one to carry out. However, he said that because he did not view any of the scans, he was unaware of the risk before he started.
Prof Lobo said Mr Doleman’s underlying conditions meant “surgery was not the first option”, but said performing an ERCP was “justified” due to concerns over his medical history.
“We had enough evidence to suggest there was something going on with [his] bile duct to proceed with the ERCP,” he said.
Prof Lobo also said he did not believe the “black defect” was the site of perforation, saying he believed it was part of a diverticulum.
The incident resulted in the untimely death of a patient who, despite his underlying conditions, would probably still be alive had it not been for that single procedure. The doctor, along with the Professor who supervised the procedure, acknowledged the perforation will have happened during the procedure, but the medical history indicated that it was the best medical option despite the difficulties.
Consultant pathologist Ian Scott
Consultant pathologist Ian Scott told the court an autopsy found evidence of perforation, as well as inflammation of the gallbladder, but “nothing concrete” proving he had had gallstones.
He said evidence Mr Doleman developing sepsis from the ERCP perforation was “the most likely source of infection”, but another source of infection could also have occurred.
“Once he’s developed sepsis he’s at great risk of not surviving,” he said.
A cause of death was given as acute respiratory distress syndrome (ADRS) and duodenal perforation, with conditions such as chronic obstructive pulmonary disorder and ischaemic heart disease also mentioned as contributory factors. His time of death was recorded as 1.25am on April 1, 2020.
Dr Rajaram Comments
Telling the inquest he had, over the year before, performed the procedure around 150 times, Dr Rajaram said that before operating on Mr Doleman he had just a ten-minute conversation with his patient. When asked if he believed there were missed opportunities, he stated that although he performed an assessment to the best of his abilities, “it is very difficult for me to answer all the questions and to make a decision in that ten-minute period.”
Anita Burkey: Perforated Oesophagus
An inquest has heard how a woman died from a perforated oesophagus after a medical procedure performed by Dr Rajaram, which involved passing a tube down her throat.
The inquest also heard that 85-year-old Mrs Burkey, who had dementia, was admitted to hospital on 2 March 2020 after experiencing abdominal pain. She had the procedure – known in full as an endoscopic retrograde cholangiopancreatography (ERCP) – on 19 March. During the procedure (where a tube is passed down the throat) Mrs Burkey sustained a perforated oesophagus.
Dr Irshad Soomro, who carried out a post-mortem examination on Mrs Burkey, said he found pus surrounding her oesophagus. He said she died two weeks after the procedure from sepsis.
This sepsis was a result of her oesophagus being perforated, Dr Soomro said.
Carol Cole – Pancreatic Duct Injury During Endoscopy
Mrs Cole also had the procedure endoscopic retrograde cholangiopancreatography (ERCP) – to treat gallstones which was performed by the Dr Rajaram on 10 September 2020. She died the following day at the Queen’s Medical Centre in Nottingham.
Glen Irving, a consultant surgeon who supervised Mrs Cole’s endoscopy, said he believed it caused her pancreatitis. Mr Irving commented:
“What happens is it [pancreatitis] triggers an inflammatory response to the whole body,”
“Although it’s to a localised area, it triggers a response in the whole body, and that can happen quite quickly.”
He said this can eventually lead to organ failure and death.
Mr Irving said Mr Rajaram had accidentally gone into the pancreatic duct twice during the endoscopy.
Mrs Cole suffered from a severe type of pancreatitis and bowel infarction. The bowel infarction or damage to the bowel was caused by restricted blood flow – thought to be caused by a blood clot.
Pending the conclusion of the inquest, Mrs Cole’s proposed cause of death is acute haemorrhagic pancreatitis.
Claim Compensation For Tears or Cuts to Organs During Endoscopic Procedures
An ERCP may be used to investigate abdominal pain or yellowing of the skin and eyes (jaundice) and to investigate whether a patient has pancreatitis or cancer of the liver, pancreas, or bile ducts.
Other things that may be found with ERCP include:
- Blockages or stones in the bile ducts
- Fluid leakage from the bile or pancreatic ducts
- Blockages or narrowing of the pancreatic ducts
- Infection in the bile ducts
Risks associated with ERCP procedure include:
- Inflammation of the pancreas (pancreatitis) or gallbladder (cholecystitis)
- A tear in the lining of the upper section of the small intestine, oesophagus, or stomach
- Papillary perforation
- Bile duct perforation
- Collection of bile outside the biliary system (biloma)
- Less common adverse events have also been described including cardiopulmonary complications, contrast allergy, impaction of a retrieval basket
Our experienced medical negligence solicitors offer a ‘No Win No Fee‘ agreement for ERCP and other endoscopy negligence claims as well as access to a network of medical experts and specialists barristers.