Denise Johnson, who had a history of obesity, died at Ipswich General Hospital on 24 November 2022.

Johnson, who was also undergoing ongoing treatment for breast cancer and depression, was admitted to hospital as an emergency with abdominal pain and jaundice on 13 August 2022.

She underwent a endoscopic retrograde cholangiopancreatography (ERCP) after a gallstone was found to be causing her jaundice.

Johnson became acutely unwell post ERCP and was diagnosed with acute necrotising pancreatitis. She was admitted to an ITU for nine days for supportive care and antibiotics.

Her following care was managed at Ipswich General Hospital with ongoing advice and guidance from Addenbrooke Hospital's Hepato-Pancreato-Biliary multidisciplinary team.

Subsequent CT scanning showed severe pancreatitis with fat necrosis and peripancreatic fluid collections.

Johnson's condition deteriorated and she sadly died at Ipswich General Hospital on 24 November 2022.

Coroner Daniel Sharpstone said there had been no timely notification to ERCP practitioners following serious procedure-based complications and had been a ‘paucity of comprehensible and timely communication with the next of kin and rest of the family concerning management plans and treatment options'.

The coroner added it had been unclear who was responsible for the patient when her usual consultant was off work due to unexpected leave.

Dr Martin Mansfield, deputy chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said: ‘Our sincere sympathies go to Denise's loved ones for their loss.

‘We welcome the coroner's report and we are committed to taking forward lessons learned. Patient safety is our top priority and we take the concerns raised in the report very seriously.

‘We are working to address the issues and our full response to the report will be shared with the coroner in due course.'