A 57-year-old woman went in for a routine procedure at Royal Glamorgan Hospital and died just days later, an inquest has heard. Janet Williams from Pontypridd, developed sepsis after complications from a procedure to deal with bile duct stones.
Described by her family as a “fitness fanatic,” Miss Williams had worked at Coleg y Cymoedd for more than 25 years and loved her job and colleagues. For the latest Welsh news delivered to your inbox sign up to our newsletter.
An inquest conclusion into her death at Pontypridd coroners’ court led by senior coroner Graeme Hughes began on Monday, May 20 and will explore the nature of her care and the circumstances of her death.
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Miss Williams attended Royal Glamorgan Hospital for an ERCP (a procedure to diagnose and treat liver, gallbladder, bile duct and pancreas problems). After pre-operation checks on October 14, 2021 she had her operation the following day but died just three days after the surgery.
Her health in the lead-up to her passing was described as “very good” and she had been training for the Newport 10k. Previously she had a bout of heart disease following a small heart attack and ongoing issues with gallstones, for which she previously had an ERCP and her gallbladder removed. Neither had a largely negative impact on her day-to-day life in recent years.
She had attended her GP in February 2021 with abdominal pain and was referred to the Royal Glamorgan Hospital in October for another ERCP after scans showed the presence of bile duct stones. Miss Williams was hoping to return home on the same day as the procedure – Friday, October 15.
During the procedure, described by Cwm Taf Morgannwg consultant gastroenterologist Dr Neil Hakwes as “quick and slick,” brushings were taken due to possible evidence of a carcinoma. A stent was inserted to help bile flow around the stones and through the duct in the meantime, with a view to a further ERCP after the results of the brushings came back.
Why we cover inquests – and why it’s so important that we do
As painful as these proceedings are for those who have lost a loved one the lessons that can be learned from inquests can go a long way to saving others’ lives.
The press has a 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’s a journalist’s duty to make sure the public understands the reasons why someone has died and to make sure their deaths are not kept secret. An inquest report can also clear up any rumours or suspicion surrounding a person’s death.
But, most importantly of all, an inquest report can draw attention to circumstances which may stop further deaths from happening.
Should journalists shy away from attending inquests then an entire arm of the judicial system is not held to account.
Inquests can often prompt a wider discussion on serious issues, the most recent of these being mental health and suicide.
Editors actively ask and encourage reporters to speak to the family and friends of a person who is the subject of an inquest. Their contributions help us create a clearer picture of the person who died and also provides the opportunity to pay tribute to their loved one.
Often families do not wish to speak to the press and of course that decision has to be respected. However, as has been seen by many powerful media campaigns, the input of a person’s family and friends can make all the difference in helping to save others.
Without the attendance of the press at inquests questions will remain unanswered and lives will be lost.
Miss Williams became uncomfortable in the following hours and reported increasing amounts of 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 put on increasingly-heavy painkillers and nil by mouth (as eating had caused pain and she had been sick) and placed under regular checks under the supervision of Dr Hawkes.
Dr Hawkes said there was a “sea change” on Saturday, October 16. He was not in attendance at this point but had prescribed fluids for Miss Williams over the weekend and, although she was prescribed more fluids on Saturday, expressed concerns at the inquest about the amount administered.
He told the inquest: “I think there is growing evidence that during the early afternoon Janet has not received optimum fluid input and her urine output has tailed off. By 7pm there is a sea change… I personally think it is at this point that Janet has moved from mild pancreatitis to moderate or severe pancreatitis.”
He added: “It has just left that question whether it is possible that a different intervention earlier could have made a difference.” Asked whether it would have affected her chances of survival he said it was “difficult to know” as the development of her pancreatitis was “frighteningly quick”.
Miss Williams was diagnosed with acute pancreatitis. On Sunday, October 17 she informed family she felt like she was going to die. Texts from her family that afternoon went unread and her family were shortly informed she had been moved to intensive care.
As late as Sunday afternoon, the family said they were told by hospital staff that Miss Williams was okay and not to worry. They told the inquest they only learned on Sunday night that she was dying. Miss Williams died on Monday, October 18.
A post-mortem examination by Dr Adam Dallmann concluded that Miss Williams developed sepsis after her operation, the primary medical cause of death. This was likely caused by pancreatitis (a recognised complication of the ERCP procedure) and ascending cholangitis, a serious infection of the biliary tree (the system linking the liver, gallbladder and bile ducts).
A relatively small malignant tumour was found in Miss Williams’ bile duct which caused some narrowing and was complicated by Miss Williams’ history of gallstones, and was noted as a lesser underlying cause. Her history of heart disease was also noted 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 the fact Miss Williams was well before the procedure likely meant the procedure itself is what triggered the infection and inflammation, but the presence of biliary stones 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 fluids given, why no antibiotics were given on Saturday, October 16 and why the case was escalated via the critical 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 rather than Sunday, he said “perhaps” due to the severe nature of her pancreatitis but it was “difficult to say” in hindsight.
When asked whether the “die had already been cast” by the time he saw Miss Williams again at 11.20am on Sunday, Dr Mulla said “I would think so,” and agreed when asked if the outcome was “bleak” by this point.
The inquest continues and will explore Miss Williams’ treatment following the ERCP procedure.