Overview

• Val Burkill, 73, died of sepsis weeks after an ERCP gallstone procedure in October 2020 when she was prematurely discharged and her bowel perforation went unrecognised
• An independent review of 68 ERCP cases from 2016 to 2021 determined that care fell below acceptable standards for 58 patients, with 25 suffering some degree of harm
• Investigators cited poor record-keeping, failures in informed consent, sedation problems and delays in diagnosing complications as key failings
• Rotherham Hospital suspended its ERCP service in July 2021 amid safety concerns and commissioned the external review by the Royal College of Physicians
• The Trust has offered apologies to affected individuals, explained the findings of the review and pledged to strengthen clinical governance and patient communication