Woman died after medics missed gastric band fault

A coroner has highlighted the "critical failure" in the care of a woman who died after a doctor failed to spot her gastric band had "slipped".

Gemma Marshall died at Huddersfield Royal Infirmary on 15 March 2024 "from the consequences" of the device's movement, according to the the assistant coroner for West Yorkshire, Steve Eccleston.

Mr Eccleston issued a Prevent Future Deaths report to NHS England and the Royal College of Radiologists over the death of the 44-year-old from Halifax.

He said the failure to notice the slippage of the weight loss device represented "neglect in the care Gemma received".

The findings came after an inquest at Bradford Coroner's Court in December was told Ms Marshall had private surgery for the band fitting in November 2020.

She attended the hospital on 13 March 2024 with "black vomiting" and lower abdominal pain, according to Mr Eccleston's report.

Ms Marshall underwent a scan, which was reported on by a radiologist whose expertise was in a different area to gastric and abdominal imaging.

The radiologist had been working for an outsourced company because of staff shortages at the hospital, the report said.

"The scan report mentioned the existence of the band but didn't comment on the fact the images clearly showed the band was out of position," the report said.

Mr Eccleston said this represented "a critical failure in the care Ms Marshall received".

Had that been correctly reported, a referral to surgeons would have probably been made, "which might have meant she would have survived".

Ms Marshall collapsed in the shower and could not be resuscitated.

Mr Eccleston said the failure was due to a "lack of familiarity" among radiologists about how slipped bands present.

He said this was made worse by the increasing rarity of the procedure, a lack of specialists on this issue and a need to rely on temporary workers because of staff shortages.

Mr Eccleston said the hospital had taken steps "to address this knowledge gap", but a lack of knowledge across the country "remained a concern".

"Other patients could face similar failures to Ms Marshall," he added.

Both organisations must respond to the report - designed to prevent similar deaths in future - with details of the action they are taking and a timetable for them by 17 February.

In response, the Royal College of Radiologists' vice president Dr Stephen Harden said the organisation was "considering steps that we can take to improve knowledge of how slipped gastric bands present and could be identified on imaging".

Brendan Brown, chief executive at Calderdale and Huddersfield NHS Foundation Trust, which runs Huddersfield Royal Infirmary, said they "welcome the findings and learning from this report".

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