Harry Stobie

Mr Tom Osborne 
HM Senior Coroner  
Milton Keynes Council 

06 September 2023 

Dear Mr Osborne 

Regulation 28 Report following an Inquest into the death of Mr Harry Stobie 

I am writing following receipt of a regulation 28 Report dated 04 August, following on 
from  the  Inquest  concluded  on  20  July  2023.  Mr  Stobie  died  because  of 
haemoperitoneum  after  insertion  of  a  PEG  tube.  As  you  note  in  the  regulation  28 
report, this was a recognised complication of a necessary medical procedure.  

In the regulation 28 report, you assert that Mr Stobie’s deteriorating condition was not 
monitored closely enough even though he was complaining of abdominal pain soon 
after the procedure was completed. His concerns were not escalated to a senior doctor 
for  consideration  of  a  possible  bleed.  You  state  therefore  that  the  procedures  and 
protocols following PEG insertion should be reviewed.  

I was disappointed to have received the regulation 28 report in the context of members 
of the Trust’s staff not having been called to give oral evidence at Inquest. The written 
 have been reviewed after the inquest 
statements of 
and are all felt to be comprehensive and thorough. I do not believe that the Trust was 
offered  the  opportunity  to  respond  to  your  emerging  concerns  during  the  inquest  – 
which I would have thought might have been preferable for all parties.  

By way of a summary of Mr Stobie’s care on the day of PEG insertion: 

  There was a clear indication for PEG insertion following the ischaemic stroke 
for which he was being treated (and dysphagia was improving more slowly than 
other symptoms). Mr Stobie had undergone video fluoroscopy prior to insertion. 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
   The  procedure  itself  was  straightforward  and  he  was  transferred back  to  the 
ward. Three sets of observations were undertaken over the first four and a half 
hours back on the ward. Whilst the frequency of observation should ideally have 
been  higher  over  the  first  two  hours,  the  observations  recorded  were  not 
significantly deranged. It was noted that Mr Stobie did report some pain and 
vomiting. A ward doctor was involved in his assessment at this stage, and fluids 
and analgesia were administered. The quantification, recording and monitoring 
of his pain may have benefited from being more objective / standardised – see 
below.     

  Five  hours  following  return  to  the  ward,  Mr  Stobie  appeared  less  well,  and 
observations  were  promptly  repeated.  He  was  hypotensive  and  this  was 
escalated to our rapid response nursing team and the on-call medical team.  

  At this point, Mr Stobie was found to have a tender abdomen. Within half an 
hour, a  working  diagnosis of bowel perforation  was  made,  and a plan  for  an 
urgent CT scan was made. His antibiotics (broad spectrum antibiotics having 
been  administered  earlier)  were  continued.  He  was  already  on  intravenous 
fluids following the earlier episode of vomiting. 

  Within a further 60 minutes, surgical and ICU referrals had been made whilst 

Mr Stobie was en-route to CT.  

  A  definitive  diagnosis  was  made  within  two  hours  of  the  first  abnormal 

observations, with appropriate measures put in place in the interim.   

  A consultant intensivist and a consultant surgeon attended Mr Stobie late in the 

evening.  An active decision was made for palliation. 

  Mr Stobie died 3 days later.  

The key questions appear to be (1) whether Mr Stobie’s symptoms of some pain and 
vomiting  should  have  been  seen  as  potential  signs  of  significant  internal  bleeding 
before his physiological observations began to deteriorate and, if so, (2) whether they 
should have prompted earlier imaging and, in turn, (3) whether this might have led to 
alternative action (i.e., a surgical approach to address the haemorrhage).    

On review of the inquest statements and medical records:  

 
 
 
 
 
 
 
 
 
 
 •  Mr  Stobie  was  well  with  normal  vitals  and  was  comfortable  when  he  left  the 

endoscopy room (

).  

•  Mr Stobie was returned to the ward from PEG at 13:45 hours. He complained 
of stomach pain and had been vomiting. He was prescribed an antiemetic (anti 
sickness  injection)  and  had  an  injection  of  pain  killer…  In  the  course  of  the 
afternoon, Mr Stobie remained relatively stable (

). 

•  A nursing entry in the electronic patient notes written during the afternoon but 
verified at 20:15 (i.e., following the deterioration in observations / escalation) 
references:  Had  episode  of  vomiting  and  Ondansetron  given  as  prescribed, 
vomited  (40mls).  Paracetamol,  and  [subsequently]  morphine,  given  for  pain. 
PEG  site  was  checked  –  no  oozing.  Patient  re-positioned  and  made 
comfortable (SN Amoah). 

As you note, bleeding is a recognised complication of PEG insertion.  

Routine  CXR  (to  assess  for  pneumoperitoneum)  is  not  undertaken  following  PEG 
placement  as  a  degree  of  pneumoperitoneum  is  common  post-PEG  insertion,  and 
retroperitoneal  issues  could  not  be  adequately  assessed.  Such  X-rays  would  be 
challenging  to  interpret.  I  raise  this  point  as  we  initially  understood  (between  the 
inquest and receipt of your regulation 28 report) that this may have been a specific 
concern.  

A ‘discharge protocol following PEG insertion’ is sent back to the ward with patients. 
An alert box within the protocol currently states: 

In Mr Stobie’s case, the key issue (in terms of compliance with existing protocol) is 
whether he experienced ‘prolonged or severe pain’ post-procedure. Prompted by your 
regulation 28 report, there have been further discussions with Ward 7 staff who were 

 
 
 
 
 
  
 
 
 
 
 
 caring for Mr Stobie on the day in question. It does not seem that Mr Stobie’s pain in 
the  earlier  part  of  that  afternoon  was  so  pronounced  as  to  have  mandated  earlier 
escalation. He was not exhibiting symptoms consistent with peritonism at that point. It 
is  felt  that  he  had  an  abrupt  deterioration  around  the  time  his  observations 
deteriorated.  By  the  same  token,  clinicians  do  not  consider  it  likely  that  an  earlier 
diagnosis  would  have  led  to  a  different  outcome  (given  that  fluids  and  intravenous 
antibiotics had already been administered prior to the deterioration in observations): 
general  anaesthetic  and  laparotomy  would  not  have  been  an  attractive  prospect  in 
view of co-morbidities. However, I recognise that the post-procedure guidance could 
be clearer, and the opportunity for subjectivity could be reduced.        

I  have  asked  the  wider  gastroenterology  team  to  review  the  ‘discharge  protocol 
following PEG insertion’ with a view to determining whether it would be possible or 
prudent to render the pain element of these cautions more objective (i.e., to use a pain 
scale  or  to  reference  a  failure  to  respond  to  specific  medicines).  This  work  is 
progressing well and the team has elected to incorporate use of a pain score and/or a 
trigger  of  an  AMBER  score  on  the  NEWS-2  system  in  order  to  prompt  earlier 
escalation  and  to  reduce  the  threshold  for  consideration  of  a  CT  scan.  See  the 
enclosure – appendix 3 to the relevant policy and procedure.   

They  will  also  liaise  with  the  relevant  specialist  society  (British  Society  of 
Gastroenterology)  to  see  whether  they  are  able  to  signpost  excellent  practice  in 
respect of post-procedural protocols and/or whether this is an area they could seek to 
advance towards a national consensus view. 

As  part  of  our  discussions  in  response  to  this  regulation  28  report,  we  have  also 
identified a potential gap in practice in relation to the post-procedural observation of 
patients  undergoing  other  endoscopic  interventions.  In  the  small  number  of  cases 
where patients are admitted to hospital following a higher risk endoscopic procedure 
(non-PEG)  for  observation,  we  need  to  be  explicit  about  the  nature  and  level  of 
observation expected by the lead clinicians. The gastroenterology MDT will review this 
aspect at a planned meeting in September.       

I would of course wish to conclude by recognising the very sad circumstances of Mr 
Stobie’s death and passing my condolences on to his family. His untimely death must 
be particularly distressing for them given the pretty positive trajectory of his recovery 
from his major stroke (swallowing aside) after thrombectomy.    

 
 
 
 
 
 
 
 I trust that this response is helpful.  

Yours sincerely, 

Chief Executive 

Enclosed 

Ward nursing care plan for patients post PEG and PEJ insertion: Day 1 (appendix 3 
to policy and procedures for pre and post insertion management)