Tony Jackson
23 Sept 2025 · Coroner Graeme Irvine · East London
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. undetected iatrogenic injury
“A fatal iatrogenic injury caused to [name redacted] on 19th November 2024 went undetected until 3rd December 2024, despite admission, CT scan and surgical consult on 24th November 2024.”
2. poor documentation of best interest decisions and PEG insertion
“Records of, best interest decisions, the PEG insertion and subsequent treatment were so poor as to impede the court's investigation.”
3. missing admission notes
“The Trust could not provide notes of the 24th November admission.”
4. governance failure in incident identification
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
This report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
Identical hazardConfidence 0.90 · high
Earlier report
“Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”
This report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”