Terence Clark

Trust Executive Office 
Ground Floor 
Pathology and Pharmacy Building 
The Royal London Hospital 
80 Newark Street 
London E1 2ES 

Telephone: 020 32460641 
Email: 

Group Chief Medical Officer 

www.bartshealth.nhs.uk 

PRIVATE & CONFIDENTIAL 
24 October 2024 

Our Ref: 
Your Ref: 

24 October 2024 

Mr Graeme Irvine 
Area Coroner – East London 
Walthamstow Coroner’s Court 
Queen’s Road 
London 
E17 8QP 

Dear Mr Irvine 

Re:  Regulation 28 Report to Prevent Future Deaths 

I write regarding your letter of regarding your concerns relating to the death of Terence Clark at 
Newham University Hospital.  I hope this letter will provide assurance to you of the steps that we are 
taking to address the concerns you have outlined.   

A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to 
collapse, cream-coloured liquid food was found in Mr Clark's airway at autopsy 
The NG tube, inserted on the day of death had been removed and misplaced 
prior to autopsy. No evidence exists to indicate, when the apparatus was 
removed, by whom, on whose instruction or why. The removal and loss of this 
apparatus impeded the proper investigation of this death. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 B. The Trust conducted a patient safety investigation into the circumstances 
leading to Mr Clark's death, the investigation did not identify the removal of the 
NG tube as a significant factor worthy of scrutiny. Both of these issues raise a 
concern that the Trust can not adequately secure and review evidence relevant 
to governance and coronial investigations, necessary to mitigate risks of future 
fatalities. 

I will respond to these items together as they are interlinked. Mr Clark had an NG tube inserted on 
the 1st November 2023. It was not used prior to the X-Ray being conducted at which point Mr Clark 
had a cardiac arrest and died. The investigation into his death focused on the lack of nursing escort 
and therefore knowledge of Mr Clark’s DNACPR status when he arrested in the department which 
resulted in CPR being commenced. The NG tube was removed by ward staff on the day of Mr 
Clark’s death following a discussion with a doctor and the site manager. At this point a coroners 
referral had not been considered or made. The coroner’s referral was made on the 3rd November 
2023. 
The terms of reference for the concise internal investigation into Mr Clark’s death did not include 
review of the NGT removal as it was not considered to be materially relevant to any care issues 
identified. 

I apologise that the information regarding the timing of the removal of the NGT was not provided at 
the inquest and it was not considered as part of the concise investigation.  

The Barts Health Bereavement – care before, during and after death policy, states that where 
coroners referral has been made, tubes and devices should not be removed and that to contact the 
coroners office if unsure. It also indicates that this can be discussed ahead of death where relevant. 

The current policy differs with regard to removal of tubes and devices according to whether a 
coroners referral has been made. It also states in section 26.4 that: if the cause of death is known 
and the coroner is not going to be involved there should be no concern about removing medical 
tubes and lines. 

Following this case, we are reviewing the Bereavement policy to clarify the guidance around removal 
of tubes, lines and devices. Where a sudden or unexpected death has occurred, the policy will 
mandate that tubes, lines and devices are left in situ until after: 

a.  A discussion with the medical examiner  
b.  A decision has been made about coronial referral  
c.  A death certificate has been issued 

The policy will also be updated to include the role of the medical examiner. Every patient death is 
now reviewed by a Medical Examiner usually within 24 hours and so the need for a coroner referral 
should be clear prior to any removal of equipment from the body and a delay of 2 days, as in this 
case, should be avoided.  

 
 
 
 
 
 
 
 
 This case has already been discussed at our safety huddles, with the senior nursing and site teams 
to underline the above and ensure a lower threshold for discussion with the coroners office should 
there be any doubt about removal of lines etc. Any conversation will be documented in the patient 
record. 
We will be cascading the learning from this incident and embedding this within training across the 
Trust. 

Yours sincerely 

Chief Medical Officer 

Barts Health NHS Trust

Parliamentary Under-Secretary of State for   
Patient Safety, Women’s Health and Mental Health 

39 Victoria Street  
London  
SW1H 0EU  

22 October 2024 

Our ref: 

HM Coroner Graeme Irvine 
East London Coroner’s Court 
Queens Road 
Walthamstow 
London  
E17 8QP 

By email: 

Dear Mr. Irvine, 

Thank you for the Regulation 28 report of 30 August sent to the Secretary of State about the 
death of Terence Harry Clark. I am replying as the Minister for Patient Safety.       

Firstly, I would like to say how saddened I was to read of the circumstances of  Mr. Clark’s 
death, and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. 

The  report raises  concerns  over  poor record  keeping at  the  Trust  around  the  decision  to 
remove  and  the  misplacement  of  the  nasogastric  (NG)  tube  the  day  prior  to  surgery  – 
impeding the investigation. Secondly, the Trust’s investigation did not identify the removal 
of  the  NG  tube as  a  significant factor worthy  of  scrutiny although  there  was nil-by-mouth 
order  for  24  hours  prior.  This  raises  concerns  about  securing  and  reviewing  evidence 
relevant to governance and controls at the Trust. 

In  preparing  this  response,  my  officials  have  made  enquiries  with  NHS  England  and  the 
Care Quality Commission (CQC) to ensure we adequately address your concerns. 

The CQC inform us that actions have taken by the Trust to address the concerns raised by 
the  coroner.  The  CQC  will  monitor  the  Trust  on  the  implementation  of  these  actions  and 
ensure they are embedded for the long term.  

I  have  been  assured  that  as  direct  recipient  of  this  report,  the  Trust  is  considering  the 
concerns carefully and will be responding at length. Appropriate governance is essential for 
the effective running of any organisation, and I look forward to their response to provide the 
detail  behind  the  actions  taken  and  the  learning  from  Mr  Clark’s  sad  case.  It  is  vital  to 
understand the changes made so that the concerns raised in the report around Mr. Clark’s 
death do not recur. 

 
   
 
 
 
 
 
 
 
  
  
 
  
 
 
 
 Patient safety is a top priority for this government  and no one accessing the NHS should 
ever have  to  worry  about  receiving  the  right  care  and  in  the  right hands.  Several reports 
have  identified  shortcomings  in  the  way  patient  safety  incidents  were  investigated  and 
learned from under the previous Serious Incident Framework (SIF). As you might be aware, 
the Patient Safety Incident Response Framework (PSIRF) replaces the SIF. It is part of the 
NHS Patient Safety Strategy and represents a significant shift in how providers must now 
respond and learn from patient safety incidents with a focus on more effective learning and 
engaging families. 

Building an NHS fit for future is a key mission for this government. It is only with our 
continued and joint efforts with partners and stakeholders that we can drive improvements 
in safety and quality.   

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR 
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH