Sarah Chappell

5th February 2024 

HM Coroner Hassell 
St Pancras Coroner’s Court  
Camley Street 
London N1C 4PP 

Dear Senior Coroner, 

Chief Nurse  
UCLH NHS Trust Headquarters 
2nd Floor Central 
250 Euston Road 
LONDON NW1 2PG 

Re: Sarah Chappell Prevention of Future Death report  

Website: www.uclh.nhs.uk 

I write to provide you with a detailed response to the Regulation 28 report dated 7th December 
2023, regarding the death of Sarah Chappell on 23rd June 2023.  We have worked together 
across the organisation with the multi-professional teams involved in Ms Chappell’s care, to 
provide a thorough response covering the six areas of concern raised in your report. We are 
committed to continuing to implement the learning and improvements identified. This includes 
a focused commitment to improving the care provided to patients with a learning disability. We 
have reviewed and strengthened our governance structures, with the chief nurse now chairing 
the safeguarding adults committee and the learning disability steering group. The learning 
disability steering group (a sub-group of the safeguarding adults committee) will seek 
assurance from clinical teams and divisional leads that the actions outlined in this response 
are met and will report via the adults safeguarding committee to the quality and safety 
committee (a sub-committee to Trust Board). This response will also be monitored through our 
patient safety committee. As part of this commitment to improving the quality of care for 
patients with a learning disability, we have also appointed a second learning disability nurse 
who has been in post since August 2023. Expanding this capacity has allowed us to both 
increase patient case management and deliver bespoke training and education for staff.  

1 

This response is made on behalf of 

, Chief Nurse, University College London Hospitals NHS Foundation Trust 

2 

Regulation 28 Report 

This response follows a report by Coroner ME Hassell on 7th December 2023 

 
 
  
  
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 

Investigation and inquest 

On 4 July 2023 I commenced an investigation into the death of Sarah Chappell, aged 43 
years. The investigation concluded at the end of the inquest earlier today. I made a 
determination as follows. Sarah Chappell died from the recognised long term complications of 
necessary medical treatment. However, in addition to these, during her last admission to 
hospital her care was suboptimal because the appropriate team did not take charge. 
Placement of her nasogastric tube was not managed appropriately over her final weeks. If it 
had been, she would have survived this episode. I recorded the medical cause of death as: 2 
1a aspiration of gastric contents 1b adhesional small bowel obstruction 1c status post 
multiple complex surgeries flowing from an Arnold Chiari type II malformation with spina bifida 
& complicating hydrocephalus 2 metastatic adenocarcinoma of the rectum 

4 

Circumstances of the death 

Sarah Chappell was transferred to University College London Hospital from the Princess 
Royal University Hospital in Orpington on 31 May 2023. She remained at UCLH until her 
death on 23 June 2023. 

5 

Coroner's concerns 

The MATTERS OF CONCERN are as follows.  

1. There was a ten-day delay in Ms Chappell’s transfer from the Princess Royal Hospital to 
UCLH. I was told that this might have been because of a lack of beds, but it might also have 
been because of confusion about which UCLH site was the accepting surgeon’s preferred 
destination, a confusion that was understood at the time by the Princess Royal to be a 
rejection of the transfer.  

2. From at least 16 June 2023, the consultant urology surgeon in charge of Ms Chappell’s 
care was very firmly of the view that he was not the best clinician to fulfil this role. He had 
long since correctly determined that she had not sustained a ruptured bladder, and thus 
considered that her care belonged with the gastroenterologists or the general surgeons. 
Despite the agreement on 16 June of the gastroenterology clinical director that Ms Chappell’s 
care should be led by the gastroenterologists, they had not taken over her care by the time of 
her death, and there had not even been a conversation between the gastroenterology and 
general surgery consultants about the transfer of care.  

3. There was a frequent misunderstanding among the medical staff that Ms Chappell’s issues 
were all chronic. Her acute situation was often not properly handed over or understood by her 
consultants. 3  

4. Whilst at UCLH, the pain relief offered to Ms Chappell (principally simply paracetamol) was 
completely inadequate. At night, her buzzer was taken away from her and her door was shut. 

5. The management of the nasogastric tube that was crucial in attempting to avoid a fatal 
aspiration was inappropriate. The tube in situ that was operating effectively was removed 

2/7 

 
 
 
 
 approximately ten days before her death. Her abdomen became extremely distended. A 
further tube placement was not attempted until the day before she died. When this proved 
beyond the nurses’ skillset, a doctor was not called to assist until the following afternoon. By 
then, two experienced doctors were unable to insert a tube and, as they were attending her 
(with her mother present), their patient suffered a massive aspiration and died shortly 
afterwards. I was told at inquest that if the nasogastric tube had been passed at an earlier 
point, this would have been done successfully and the fatal cardiac arrest would have been 
avoided. 

 6. This death occurred almost six months ago, but no proper trust investigation has taken 
place, no change in policies or procedures has been agreed, and the systems at UCLH 
remain largely what they were on the day that Sarah Chappell died. 

6 

Action taken/timescale 

The actions responded to by UCLH relate to all of the concerns (1-6). It is noted that concern 
number 1 also relates to another provider, the Princess Royal University Hospital in 
Orpington. 

1.  There was a ten-day delay in Ms Chappell’s transfer from the Princess Royal 

Hospital to UCLH. I was told that this might have been because of a lack of beds, 
but it might also have been because of confusion about which UCLH site was the 
accepting surgeon’s preferred destination, a confusion that was understood at the 
time by the Princess Royal to be a rejection of the transfer. 

Actions: 

Ms Chappell was transferred to UCLH as an emergency referral from PRUH on 1st June 
2023, as the team there believed she had suffered a perforation of her neobladder. She had 
been discussed by the PRUH team with a urology consultant on 22 May 2023 and accepted 
for transfer, however there were no available beds at the time at UCLH. PRUH appear to 
have organised Ms Chappell’s transfer to the UCLH Emergency Department without 
confirming with the Urology team at UCLH and Ms Chappell was subsequently admitted to a 
surgical ward (T14 north) when they had a bed available. Ms Chappell was then transferred 
to T14 Acute Surgical Unit on the evening of 1st June 2023. 

Recognising that there was confusion between PRUH and UCLH relating to transfer we will 
develop a referral form for urology by May 2024 to improve documentation around the reason 
for transfer and agreed decisions to inform the plan of care. This will be led by the clinical 
lead for urology and will mirror some of our best practice referrals such as in the thoracic 
service.  

Through this investigation process we have now identified that the accepting clinical team did 
not communicate the patient referral to the co-ordination centre for one week. The co-
ordination centre is responsible for managing patient transfers into UCLH. We will include the 
need to inform the coordination centre in the referral form that we are developing for patients 
identified as tertiary transfers. This includes the level of clinical priority discussed with the 
accepting consultant. This will be completed and disseminated by May 2024. 

3/7 

 
 
 2.  From at least 16 June 2023, the consultant urology surgeon in charge of Ms 

Chappell’s care was very firmly of the view that he was not the best clinician to 
fulfil this role. He had long since correctly determined that she had not sustained a 
ruptured bladder, and thus considered that her care belonged with the 
gastroenterologists or the general surgeons. Despite the agreement on 16 June of 
the gastroenterology clinical director that Ms Chappell’s care should be led by the 
gastroenterologists, they had not taken over her care by the time of her death, and 
there had not even been a conversation between the gastroenterology and general 
surgery consultants about the transfer of care. 

3.  There was a frequent misunderstanding among the medical staff that Ms 

Chappell’s issues were all chronic. Her acute situation was often not properly 
handed over or understood by her consultants. 

Actions: 

For clarification, the clinical director for gastroenterology was not involved in discussions 
relating to Ms Chappell’s care at UCLH: this was undertaken by the clinical lead for 
gastroenterology.  

On the 16th June 2023 there was a conversation between the urology consultant and the 
clinical lead for gastroenterology, culminating in a request for either joint care or 
gastroenterology input into Ms Chappell’s care. There was no agreement for joint care in 
place but agreement for the appropriate gastroenterology specialist teams (nutrition and 
neurogastroenterology) to review Ms Chappell, which subsequently occurred on the 16th June 
2023.  

We completely recognise that clearer processes both around joint care and escalation of 
decisions on ownership of care if there are disagreements are required. We will review our 
processes for allocating the named consultant in charge, agreeing joint care and escalation 
processes when there is disagreement over the named consultant by May 2024.   

4.  Whilst at UCLH, the pain relief offered to Ms Chappell (principally simply 

paracetamol) was completely inadequate.  

Actions: 

Ms Chappell was given morphine and regular intravenous paracetamol for pain relief. When 
administered intravenously (as opposed to orally), paracetamol can be as effective as 
intravenous morphine but without the side effects such as drowsiness, nausea and lowered 
respiratory rate. On 3rd June 2023, Ms Chappell’s respiratory rate and oxygen levels dropped 
following morphine administration for pain. This led to Ms Chappell requiring naloxone to 
reverse the effects of the morphine.  

4/7 

 
 
 
 
 
 
 
  
 It is evident that this experience made Ms Chappell worried about taking her pain relief and 
there is documentation that the nurse and doctors spent time with her discussing her pain 
medication.  

According to her medical records, Ms Chappell preferred to be repositioned regularly to help 
with the pain instead of taking stronger pain relief. 1:1 care was provided for Ms Chappell to 
more regularly assess and respond to her needs, including pain.  

The complex pain team reviewed Ms Chappell on 5 June 2023, and did not think Ms Chappell 
had chronic pain so they requested a review by the acute pain team. We recognise there was 
a delay for this acute pain review to be undertaken.  

We have since launched a nurse-in-charge dashboard (in January 2024) which incorporates 
a pain review. This is a live dashboard which allows the nurse-in-charge to rapidly view 
quality and safety metrics, such as pain scores, for all patients.  

We also recognise there are improvements required around monitoring response times to 
pain team referrals and evaluating impact. We will undertake a service review of the pain 
team by May 2024, led by the head of nursing for Surgery and Cancer Board, to understand 
gaps in the service and to identify systems and processes for improvement. This review will 
report to the pain steering group by July 2024. 

4. At night, her buzzer was taken away from her and her door was shut. 

Overnight on 14 June 2023 it was documented that Ms Chappell had called her Mum, 

 as she could not locate/see her buzzer. A staff nurse gave Ms Chappell her buzzer 

and apologised over the phone to 
removed from her but at times she did have trouble locating it in her bed. Ms Chappell’s door 
was closed when undertaking personal care but was not routinely kept shut.  

 at that time. Ms Chappell’s buzzer was not 

Whilst we were responsive to Ms Chappell’s concern about her buzzer we recognise that 
vulnerable patient groups may require enhanced levels of care and observation to ensure 
easy access to communication aids. In January 2024 we convened a mental health and 
enhanced observations programme board, chaired by the chief nurse. This group provides 
assurance to the nursing & midwifery board and senior directors team that the assessment, 
delivery and evaluation of care meets the needs of people requiring enhanced care.  

To supplement the
between April-September 2023. This training is designed to improve understanding of 
hospital passports and the care needs of people with a learning disability. Furthermore, ADD-
Vance, an external provider, delivered 8 commissioned sessions between April-June 2023 for 
100 staff on “Understanding Autism and ADHD”. Feedback from staff was extremely positive.  

 training we have delivered  bespoke training to 612 staff 

In January 2024 we launched patient stories via video to share patient experiences and 
improve staff understanding of different patient populations and care needs. The first story we 
co-produced focussed on the experience of a patient with a learning disability. This was 
presented at the trust board in January 2023.  

5.  The management of the nasogastric tube that was crucial in attempting to avoid a 

fatal aspiration was inappropriate. The tube in situ that was operating effectively 
was removed approximately ten days before her death. Her abdomen became 

5/7 

 
 
 
 
 extremely distended. A further tube placement was not attempted until the day 
before she died. When this proved beyond the nurses’ skillset, a doctor was not 
called to assist until the following afternoon. By then, two experienced doctors 
were unable to insert a tube and, as they were attending her (with her mother 
present), their patient suffered a massive aspiration and died shortly afterwards. I 
was told at inquest that if the nasogastric tube had been passed at an earlier point, 
this would have been done successfully and the fatal cardiac arrest would have 
been avoided. 

Actions: 

Ms Chappell was admitted to UCLH with a nasogastric (NG) tube from PRUH on 1st June 
2023. The NG tube was removed on 10th June 2023 due to low drainage volume which is 
appropriate practice. A NG tube can be uncomfortable for patients and prolonged placement 
can cause inflammation of the oesophagus. We therefore remove them if they are not 
required. Following a scan on 22nd June there was a request for a new, larger NG to be 
inserted. Nasogastric tube insertion can be difficult and not predictable as to which in which 
patients such insertion may not succeed. However, we recognise there were multiple 
attempts to insert the larger NG tube and that there were failings in the escalation of a difficult 
NG tube insertion.  

We will update our policy on NG insertion to include a section on the placement of NG tubes 
in the context of surgical drainage and the escalation process for difficult/unsuccessful NG 
tube placement. This will be completed by March 2024.  

We will also update our bowel obstruction flow chart by March 2024 to ensure it includes 
escalation procedures and timelines.  

6.  This death occurred almost six months ago, but no proper trust investigation has 

taken place, no change in policies or procedures has been agreed, and the systems 
at UCLH remain largely what they were on the day that Sarah Chappell died. 

Actions: 

A 72 hour cardiac arrest rapid review was undertaken on 3rd July 2023. This culminated in an 
after-action review with a robust and detailed action plan. There was a delay to producing the 
action plan (October 2023) and we recognise this as a concern.  

In January 2023 we instigated a process as part of our mortality surveillance group to review 
all patients with a learning disability who die at UCLH. This group is chaired by the corporate 
medical director and attended by multi-professional group including the learning disability 
team, quality & safety team and structured judgement review leads. 

In October 2023 we convened a weekly, multi-professional trust wide incident review group 
that reviews moderate harm incidents, allowing us to better identify and disseminate learning 
following the introduction of the Patient Safety and Incident Response Framework (PSIRF).  

In June 2023 we actively promoted Learning Disability Awareness Week with support from 
the learning disability nurses, chief nurse and chief executive. Newly published hospital 
communication support books were handed out across the trust with very positive feedback. 

6/7 

 
 
 
 
 An online version is available on the intranet for staff to access. The safeguarding team will 
evaluate the effectiveness of the books and share with the learning disability steering group. 

In addition, a subgroup of the Learning Disability Steering Group will be convened in 
February 2024 to review all incidents involving patients with a learning disability, including 
those resulting in no harm. The subgroup aims to improve learning and inform improvements 
at an individual, team, organisational and system level, with quarterly reporting of key themes 
to the nursing & midwifery board and senior directors team.   

This response has been prepared by 

, Deputy Chief Nurse on behalf of the chief nurse 

Date of response 

5th February 2024 

7 

8 

Yours sincerely, 

Chief Nurse 

cc:  

, Director for Quality and Safety, UCLH 

, Claims & Inquests Manager, UCLH 

7/7