Patient death prompts RCR to act on gastric bands

A woman died in a hospital in Huddersfield, U.K., after a radiologist working for an outsourcing company failed to report that her gastric band had "slipped," according to a 16 January BBC report.

As a direct result of the incident, Dr. Stephen Harden, vice president of the U.K. Royal College of Radiologists (RCR), said the organization was "considering steps that we can take to improve knowledge of how slipped gastric bands present and could be identified on imaging," the BBC reported.

Gemma Marshall, 44, from Halifax, died on 15 March 2024 "from the consequences" of the device's movement, according to the assistant coroner for West Yorkshire, Steve Eccleston. Eccleston highlighted the "critical failure" in the care of the patient, and he said the failure to notice the slippage of the weight loss device represented "neglect in the care Gemma received," the BBC noted.

The findings came after an inquest at Bradford Coroner's Court in December was told the woman 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 the assistant coroner's report. She later collapsed in the shower and could not be resuscitated. 

The patient's scan was reported by a radiologist whose expertise was in a different area to gastric and abdominal imaging, the BBC pointed out. According to Eccleston’s report, the hospital had used an outsourcing company to report the scan because of staff shortages. "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," he stated.

If the slipped gastric band had been correctly reported, a referral to surgeons would have probably been made, "which might have meant she would have survived," Eccleston noted. He said the failure was due to a "lack of familiarity" among radiologists about how slipped bands present, and 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.

Eccleston issued a Prevent Future Deaths report to National Health Service (NHS) England and the RCR, the article continued. This led to the RCR's decision to look at how it can boost awareness of slipped gastric bands among its members.

Eccleston said the hospital in Huddersfield 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.