‘Fitness fanatic’, 57, died three days later during a routine procedure in hospital

A 57-year-old woman was admitted to the Royal Glamorgan Hospital for a routine procedure and died just days later, an inquest heard. Janet Williams out Pontypridd, developed sepsis after complications from a procedure to treat bile duct stones.

Described by her family as a ‘fitness fanatic’, Mrs Williams had worked at Coleg y Cymoedd for more than 25 years and loved her work and colleagues. Sign up to our newsletter to get the latest Welsh news delivered to your inbox.

An inquest into her death at Pontypridd Coroner’s Court, led by senior coroner Graeme Hughes, began on Monday, May 20 and will investigate the nature of her care and the circumstances of her death.

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Mrs Williams went to the Royal Glamorgan Hospital for an ERCP (a procedure to diagnose and treat liver, gallbladder, bile ducts and pancreas problems). After pre-surgery checks on October 14, 2021, she was operated on the next day but died just three days after surgery.

Her health leading up to her death was described as “very good” and she had been training for the Newport 10k. She previously suffered from a heart condition after a minor heart attack and ongoing problems with gallstones, for which she had previously undergone an ERCP and had her gallbladder removed. Neither had a largely negative impact on her daily life in recent years.

She had gone to her GP with abdominal pain in February 2021 and was referred to the Royal Glamorgan Hospital for another ERCP in October after scans showed the presence of bile duct stones. Ms Williams hoped to return home on the same day as the procedure: Friday, October 15.

During the procedure, described by Cwm Taf Morgannwg gastroenterologist Dr Neil Hakwes as “quick and smooth”, brushings were carried out due to possible evidence of carcinoma. A stent was inserted to allow bile to flow around the stones and through the duct in the meantime, with a view to further ERCP after the cleaning results came back.

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As painful as this procedure is for those who have lost a loved one, the lessons learned from inquests can go a long way toward saving the lives of others.

The press has the legal right to attend inquests and has a responsibility to report on them as part of their duty to uphold the principle of open justice.

It is a journalist’s duty to ensure that the public understands the reasons why someone has died and to ensure that their death is not kept secret. An inquest report can also clarify any rumors or suspicions surrounding a person’s death.

But most importantly, an inquest can draw attention to circumstances that could prevent further deaths.

If journalists shy away from attending inquests, an entire branch of the legal system will not be held accountable.

Investigations can often spark wider discussion about serious issues, the most recent of which are mental health and suicide.

Editors actively request and encourage reporters to speak to the family and friends of a person who is the subject of an inquest. Their contributions help us gain a clearer picture of the person who has died and also provide an opportunity to pay tribute to their loved one.

Families often do not want to talk to the press and that decision must of course be respected. However, as many powerful media campaigns have shown, the input of one’s family and friends can make all the difference in saving others.

Without the presence of the press at inquests, questions will remain unanswered and lives will be lost.

Mrs. Williams felt uncomfortable over the next few hours and reported increasing pain. She was taken for a CT scan, which showed early signs of pancreatitis.

She was then admitted as an inpatient with post-ERCP pancreatitis and was given increasingly heavy painkillers and none by mouth (as eating had caused pain and she had been ill) and placed under regular checkups under the supervision of Dr. Hawkes.

Dr. Hawkes said a “change of seas” took place on Saturday, October 16. He was not present at the time but had prescribed fluids for Miss Williams over the weekend and although she was prescribed more fluids on Saturday he raised his concerns at the inquest. about the amount administered.

He told the inquest: “I think there is increasing evidence that Janet has not been hydrated optimally in the early afternoon and that her urine output has decreased. By 7pm there is a big change… Personally, I think Janet has gone from mild pancreatitis to moderate or severe pancreatitis at this point.

He added: “The question remains whether it is possible that a different intervention could have made a difference earlier.” Asked whether this would have affected her chances of survival, he said it was “hard to know” because the development of her pancreatitis was “scaryingly fast”.

Mrs. Williams was diagnosed with acute pancreatitis. On Sunday, October 17, she informed family that she felt like she was going to die. Texts from her family that afternoon went unread and her family was soon told she had been moved to intensive care.

On Sunday afternoon, the family said hospital staff told them Miss Williams was doing well and not to worry. They told the inquest they only learned she was dying on Sunday evening. Miss Williams died on Monday October 18th.

A post-mortem examination by Dr Adam Dallmann concluded that Miss Williams developed sepsis, the leading medical cause of death, after her operation. This was likely caused by pancreatitis (a recognized complication of the ERCP procedure) and ascending cholangitis, a serious infection of the bile ducts (the system that connects the liver, gallbladder, and bile ducts).

A relatively small malignant tumor was found in Miss Williams’ bile duct, causing some stenosis and complicated by Miss Williams’ history of gallstones, and was noted as a minor underlying cause. Her history of heart disease was also mentioned, as it may have affected her body’s ability to deal with sepsis, but was not listed as a direct cause of death.

Dr. Dallmann told the inquest that the fact that Miss Williams was long before the procedure probably meant that the procedure itself caused the infection and inflammation, but the presence of gallstones increased the risk of pancreatitis and cholangitis even without the procedure.

The inquest also heard from Dr Mubashir Mulla, who explained the decisions behind the amounts of fluid administered, why antibiotics were not given on Saturday October 16 and why the case was escalated through the intensive care team rather than the surgical team. He was asked whether the outcome would have been different if Miss Williams had been moved to intensive care on Saturday instead of Sunday. He said “maybe” because of the severe nature of her pancreatitis, but in retrospect that was “hard to say.”

When asked if the “stone had already been cast” by the time he saw Miss Williams again at 11:20 a.m. on Sunday, Dr. Mulla: “I would think so,” and agreed when asked if the outcome was “bleak” on this point.

The inquest continues and will examine Ms Williams’ treatment under the ERCP procedure.

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