Robert Taylor

Chief Medical Officer 
Trust HQ 
C Level, Centre Block, Mailpoint 14 
Southampton General Hospital 
Tremona Road 
Southampton, SO16 6YD 

24th November 2022 

Dear Mr Simpson, 

Please  find  below  our  response  to  your  Regulation  28:  Report  to  Prevent  Future  Deaths  which  you 
issued  on  the  8th  September  2022,  following  the  inquest  into  the  death  of  Mr  Robert  Taylor  held  on 
August 5th 2022. I am grateful for your extension for the response til the end of the November 2022. 

CIRCUMSTANCES OF THE DEATH  
Mr Taylor was admitted to Southampton General Hospital after a fall where he had suffered significant 
facial fractures and a subdural haematoma. He suffered epistaxis (nosebleed) which was treated with 
Rapid Rhinos. Subsequently he suddenly deteriorated very quickly, went into cardiac arrest and passed 
away. 

Your concerns: 

The deceased suffered facial fractures and had episodes of epistaxis. I heard evidence that when a clot 
forms within the nose the bleeding can continue and is only visible if the back of the patient's throat is 
looked  at.  I  heard  evidence  that,  in  the  Emergency  Department  and  Trauma  Admission  Unit,  the 
importance of checking the back of the throat of a patient with a history of epistaxis or facial fractures 
was not widely known. 

Our response: 

Firstly, I would like to reassure you that the Trust is committed to ensuring that our patients are safe at 
all times, and I thank you for raising your concerns with us to investigate. 

In order to review the issues you raised, I chaired a meeting with representatives from ENT, T&O and 
the  Emergency  Department,  including  nursing, medical  and surgical staff.  Additionally,  this  case  has 
been discussed at the ENT Morbidity and Mortality meeting on 10th November.  

Mr  Taylor  was  admitted  with  a  number  of  injuries,  including  a  head  injury  and  a  number  of  facial 
fractures.  He  had  a  history  of  heart  attacks  that  would  have  left  him  with  significantly  reduced 
physiological  reserve.  Mr  Taylor  also  had  a  low  haemoglobin  count  on  admission  of  86g/l  (where  a 
normal would be considered 120-150 g/l). Bleeding in facial trauma is extremely common. On the CT 
scan from admission, it is reported that 

“there are comminuted nasal bone fractures which results in hyperdense opacification of the right 
paranasal sinuses, consistent with haematoma. This can be seen extending into the nasopharynx”. 

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 At the initial meeting, as well as the concerns you raised, I examined whether the Trauma Assessment 
Unit (TAU) was the appropriate ward for Mr Taylor to have been placed. In a complex trauma case such 
as his, the head injury was the primary concern, and as Mr Taylor was not considered a major trauma 
patient and did not clinically warrant placement on either the high dependency or intensive care unit and 
that his placement on the TAU was appropriate.  

is 

from  NICE 

We  reviewed  the  national  guidance  available  for  the  management  of  epistaxis,  currently  the  only 
  (https://cks.nice.org.uk/topics/epistaxis-nosebleeds/management/acute-
guidance 
epistaxis/)  this  is  for  when  epistaxis  have  started  spontaneously  and  is  not  applicable  for  Traumatic 
injury such as the case of Mr Taylor. This highlights that there are no national guidelines that suggest 
the review of the back of a patient throat is advised.  

I explored whether your suggestion of inspection of the back of the throat needed to be built into our 
existing  pathway.  We  agreed that  this  was  not  believed  to  be  of  great  clinical  value,  nor  in  line  with 
national  guidance  however this  was  explored  further  by  the  ENT team  as  part  of  their  morbidity and 
mortality group.  

Following their M&M meeting the opinion of the ENT team was that the significant bleeding had occurred 
prior to the placement of the rapid rhino packing, and it is likely that the clot had formed, and been oozing 
from about 8pm on the previous evening. It was considered that Mr Taylor suffered an atypical posterior 
epistaxis post trauma. Anecdotally, awake patients are normally aware of the trickle of blood to the back 
of  the  throat,  not  least  because  it  is  uncomfortable  and  is  very  unpleasant  in  taste.  It  is  unusual  for 
patients not to spit this out. 

The actions that I support coming out of my discussion with the team is that the clinicians treating such 
patients would build into their education programme that patients should be explicitly asked to report an 
unpleasant taste or sensation. Following the meeting I chaired, the following was disseminated to all 
ENT, OMFS (oral-maxilla facial surgeons) and the cross covering senior house officers. 

“I’ve been asked to highlight some learning from an incident on an outlying ward involving a patient 
with epistaxis after facial trauma. 

Please could I remind all SHOs managing epistaxis and facial trauma patients to counsel their patients 
and nursing staff to look out for any continuing epistaxis either anteriorly or posteriorly.  This is 
particularly important after nasal packing has been used to ensure the bleeding has stopped.  If there 
is any doubt, then please consider returning after a reasonable timeframe to examine the oropharynx 
and ensure there is no further fresh bleeding.” 

The  case  was  discussed  at  the  ENT  M&M  meeting  on  10th  November  2022.    The  department  were 
content that the management by the SHO was clinically appropriate.  It was clearly documented that the 
posterior  bleeding,  once  identified,  stopped  after  the  was  pack  inserted.    It  was  agreed  to  raise 
awareness of epistaxis in facial trauma in OMFS and ED teams managing them.  Specific guidance to 
check the oropharynx in these situations has been added to the surgical SHO induction sessions.  

I fully appreciate that your recommendations came from witnesses interviewed in the hearing, however, 
perhaps the witness giving this advice was not the most suitably qualified or experienced person to do 
so? Whilst this was a qualified doctor, with skills and experience sufficient to cross cover ENT, they had 
not  even  completed  surgical  training  and  had  no  specific  ENT  experience  or  qualifications.  Hence,  I 
have turned to a team of experts to advise me, led by an experienced consultant not only in ENT but 
with a specialist interest in rhinology. I hope then that this input is valuable. 

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 In addition to the clinical concerns, I note your comment about the legal team not being in attendance. 
Inquests are managed by the Patient Safety Team at UHS and we do not routinely engage our solicitors 
for  inquests,  we  aim  to  attend  all  inquests  with  UHS  witnesses  wherever  possible,  attendance  is 
prioritised where witnesses have not given evidence previously. 

Yours sincerely, 

Chief Medical Officer 

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