William King

“Failure to document consent discussions - The record of discussions with [name redacted] about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place since January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in [name redacted]'s case. The policy required clear documentation, but this was not followed in [name redacted]'s case. The Trust's subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed”

“Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to [name redacted] at any stage. There was certainly no supporting evidence to suggest the contrary”

“Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content”

“Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to [name redacted]. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring”