Medical Negligence Lawyers' Concern After External Review Of ERCP Service

An investigation has found dozens of failures in a type of procedure performed on patients at Rotherham Hospital.

Health bosses at Rotherham NHS Foundation Trust commissioned an external review into its Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Service after 68 patients either died or suffered complications within 30 days of a procedure.

The review by Royal College of Physicians found failures in the care of 58 patients, while 25 “suffered some degree of harm,” a Hospital Trust report said.

The service had been suspended in July 2021 and patients’ care transferred to Sheffield following a “cluster of adverse incidents and complications.”

Although the RCP reported back to the Trust in January 2023, it is believed that details of the investigation have only just been made public. They have been published in Hospital Trust board papers dated 6 June, 2025.

The Trust said it was contacting all 68 patients or their families on 4 and 5 June to apologise and to “outline what the external review has said about their individual care.”

Medical Negligence Legal Action

Specialist medical negligence lawyers at Irwin Mitchell have represented the loved ones of a patient who died - within the review time period - around three weeks after undergoing an ERCP.

The legal experts have spoken of their concerns about the report and why it has taken two years for patients and families to be informed.

Tim Annett, an expert group actions medical negligence lawyer at Irwin Mitchell, said: “The findings of the Royal College of Physicians’ review into the ERCP service at Rotherham Hospital are deeply troubling.

“The scale and nature of the care failures identified raise serious questions about patient safety. That care concerns were identified four-year-ago and failings identified two-years-ago also raises serious questions about the Trust’s transparency and clinical governance.

“While we welcome the Trust’s decision to now contact affected patients and families, and its commitment to implementing the RCP’s recommendations, it’s vital that those impacted receive not only a full explanation but also appropriate support and redress.

“We urge the Trust to ensure transparency from now on and to work closely with patients, families, and legal representatives to rebuild trust and accountability.”

ERCPs are undertaken to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines X-ray and endoscopy. It can be used to remove gallstones or take tissue samples for analysis. Patients requiring an ERCP often have complex health conditions which can be considered life limiting such as frailty or a cancer, the Trust said.

The Hospital Trust board papers said the Trust identified 959 ERCPs were conducted between 2016 and 2021. As recommended by the RCP, the care of 68 patients who had died or suffered complications within 30 days were reviewed by independent experts.

The RCP report found a range of care failures including inadequate recording of informed consent, deficiencies in  ERCP reports and poor radiological documentation.

There was also no documentation regarding treatment given to reduce risk of pancreatitis, concerns regarding stent choice, concerns regarding sedation, discharge processes and lack of responsiveness to two deteriorating patients.

A lack of discussion between medical experts and decision making were also of concern.

The board papers said the Trust had implemented the recommendations from the RCP report. It had also appointed a number of consultant gastroenterologists, either directly or through partnership with another other hospital trust. The Trust added that intended to “re-establish a high quality local ERCP service” in Rotherham.

Family Of Patient Who Died After Undergoing ERCP Speak Out After Care Failings

Expert lawyers at Irwin Mitchell represented the loved ones of Val Burkill, who died of sepsis three weeks  after undergoing an ERCP at Rotherham Hospital.

The 73-year-old of Bolton-upon-Dearne attended hospital for the procedure to remove gallstones on 1 October, 2020.

However, it was argued that Val, a retired hairdresser, wasn’t made aware of any risks or complications connected to the procedure which lasted eight minutes.

She was discharged an hour after the ERCP. Despite complaining of stomach pain, no examination was carried out. Valerie was taken back to hospital by ambulance that night.

She was diagnosed with a perforated bowel on 16 October. She developed sepsis and her condition continued to deteriorate.

Val was transferred to a hospice on 20 October and died four days later.

Following the mum-of-three and grandma-of-seven’s death, Val’s loved ones, including husband Garry, 79, instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care and secure answers.

An inquest in February 2023, recorded a narrative conclusion ruling Val developed “recognised complications” of her procedure.

In a separate legal claim brought by Irwin Mitchell on the family’s behalf, the Hospital Trust admitted failings. It admitted failings in the consent process for Val’s ERCP and that she was prematurely discharged from hospital.

The Trust also admitted that with appropriate care, on the balance of probability,  Val would have survived and made a full recovery.

Garry, a retired builder, said: “Val was a wonderful person; one in a million.  She was the most loving and caring wife, mum and grandma and I owe her everything.

“She taught me to be a deserving dad and granddad, but most of all a better person. She was so caring and selfless and would be first in the queue to help anyone.  

“We thought she was going to hospital for a routine procedure. Val was never told about any risks or complications, and we never got the impression there was anything to worry about. We thought she would be in and back home in no time.

“While she was back home in no time, she shouldn’t have been. That afternoon I could tell she wasn’t her usual bubbly self and when I called the hospital I was told she probably had trapped wind.

“By that night she was in absolute agony and was vomiting. I called for an ambulance and Val was rushed back to hospital.  She never came home.

“Because it was in the pandemic we couldn’t visit Val and instead had to rely on telephone updates. However, I don’t think the seriousness of the situation was relayed to us and I still struggle to understand how it took two weeks to diagnose that Val had a perforated bowel.

“It was only when her condition was terminal that myself and son, Lee, were allowed to see her in hospital.  Many of our family, who Val loved dearly, were unable to see her or say goodbye to her.

“Seeing her as her life slipped away is something that will stay with us forever. We still had so many years together and I feel robbed that these were taken away from us.

“It breaks my heart to think how she needlessly suffered and the treatment she received from Rotherham Trust.  

“Our family will never be the same without Val. We knew we owed it to her to get answers regarding her care but it was still devastating when the Trust admitted Val would have made a full recovery  if she had received the correct care.

“This latest news is hard to accept. We knew there were issues with Val’s care, but we never expected there to have been failings in the ERCP service on such a large scale. Not only has this news shocked us but it has brought back the horrible memories around what happened to Val and the pain and suffering she had to go through in her final weeks.

“It’s hard not to think that if she had gone to another hospital for her ERCP Val would still be alive.

“Our family continues to have concerns about whether everything is being done to ensure the safety of patients and this latest news just adds to that. Our hearts go out to the others who have been affected by failings in the ERCP service.”

Find out more about Irwin Mitchell's expertise in supporting patients and families affected by care failings at our dedicated medical negligence section. Alternatively, to speak to an expert contact us or call 0370 1500 100.