Michael Thompson

29 January 2025 

Mrs Louise Hunt 
Senior Coroner for Birmingham & Solihull. 

BY EMAIL TO: 

Dear Mrs Hunt 

Inquest touching the death of Michael John Thompson - Response to Regulation 28 Report to Prevent 
Future Deaths  

I am writing in response to your report issued pursuant to Regulation 28, following the conclusion of the 
inquest on the 5th of December 2024 into the death of Mr Michael John Thompson. 

We have carefully considered the matters of concern raised within your report to prevent future deaths, 
and summarise these as: 

1.  Surgery Complication: A defect in the peritoneum occurred during surgery and was repaired, but 

2. 

this was not recorded in the operation note, raising concerns about record keeping. 
Investigation Focus: The Patient Safety Incident Investigation (PSII) under the Patient Safety 
Incident Response Framework (PSIRF) process only addressed resuscitation efforts and did not 
address the peritoneal defect, raising concerns about the adequacy of the Trust's investigations and 
its ability to learn from deaths. 

Matter of Concern 1 - record keeping  

In response to this concern, the Trust acknowledges and accepts that the operation note did not document 
the management of the peritoneal tear when the tumour was removed. We also accept and acknowledge 
that this omission was not identified as part of our PSIRF investigations. 

In terms of immediate learning, the Trust has taken steps to ensure there has been professional reflection 
around delegation and documentation at individual and team level. The Chief Medical Officer has discussed 
this notice and the importance of clear documentation with the clinical body at the Trust’s Audit, Morbidity 
and Mortality meeting. 

To further address this concern, and to ensure that learning is embedded, the Trust has commissioned an 
audit into the standard and accuracy of operation notes, as part of the monitoring of documentation audit 
programme overseen by the Trust’s Heath Records Advisory Group (HRAG). The completion of the audit, 
any actions arising from the audit and progress toward completion, will be monitored via HRAG as well as 
at bi-weekly divisional governance meetings and a monthly Executive Governance meeting. 

We will also undertake a thematic review of past patient safety incident investigations where gaps and 
omissions in documentation and record-keeping were observed. Any identified themes and learning will be 
addressed through a quality improvement action plan. 

Our PSIRF response plan will be updated to include a requirement for a review of the quality of 
documentation, and in particular the operation note, for all incident investigations that relate to 
complications of surgery. 

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 Additionally, this case will be represented, with the context of your notice included, at the Trust’s Clinical 
Audit meeting to remind clinicians of the importance of capturing key information related to surgery within 
the operation note. The presentation will take place in February 2025. 

The case and this concern will be discussed at all our quality & safety huddles,  serving as a reminder to 
clinical and nursing staff of the importance of the accuracy of record keeping and documentation. 

Matter of Concern 2 – adequacy of investigations and learning from deaths 

In response to this concern, we would like to illustrate the Trust’s response under the Patient Safety 
Incident Response Framework (PSIRF) and explain the approach we took to applying our PSIRF Response 
Plan to the circumstances relating to the death of Mr Thompson. To aid with this please find enclosed a 
copy of our PSIRF Policy, which also includes our PSIRF Response Plan. You will be aware that the NHS 
guidance on responding proportionately to patient safety incidents was released in 2022, which the Trust 
has adopted as required. In line with this guidance, organisations are supported to respond to incidents in a 
way that maximises learning and improvement rather than basing responses on arbitrary and subjective 
definitions of harm. Organisations are directed to explore patient safety incidents relevant to their context 
and the populations they serve rather than exploring only those that meet a certain nationally defined 
threshold. 

PSIRF Response to the vascular bleed complication and subsequent emergency transfer out of the Trust. 

Our PSIRF response began prior to Mr Thompson’s death and immediately following the intraoperative 
vascular bleed that led to the post operative transfer out of Mr Thompson to the ITU department at 
University Hospitals Birmingham (UHB). 

Patient safety incidents relating to emergency transfers were identified as a local priority in our PSIRF 
response plan (see section 7 of the enclosed PSIRF Response Plan). In accordance with this priority, and 
following discussion at our divisional governance meeting, a decision was made to commission a 
Multidisciplinary Team (MDT) Review. The method of investigation was chosen due to the involvement of 
several internal and external services (e.g. ROH theatres and anaesthetics departments as well as regional 
Acute Critical Care Co-ordination and Transfer Service ((ACCOTS) team and UHB ITU department) in 
responding to the vascular bleed and the subsequent transfer out.  

A Multi Disciplinary Team (MDT) roundtable meeting was held with key representatives from internal and 
external stakeholders to discuss the surgical complications and identify any areas of learning and 
improvement. The MDT concluded that the vascular bleed was well managed and the emergency transfer 
out was appropriate and well handled. Minor learning recommendations were made to further improve the 
standard of our care in such circumstances, but no significant actions were needed as no gaps in care were 
identified. 

PSIRF response to the cardiac arrest and subsequent death of Mr Thompson 

Section 6 of our PSIRF response plan states that a PSII is required where a patient death is thought, more 
likely than not, to be attributed to potential problems in care. The PSII is therefore done to identify learning 
opportunities to prevent recurrence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Following discussion at our divisional governance meeting, a PSII was commissioned. The terms of 
reference for the PSII related to the standard of our critical care response to the cardiac arrest and to 
whether there were signs or symptoms of deterioration that if acted upon sooner, could have prevented 
the arrest from occurring. 

The PSII concluded that there were no obvious or significant signs of clinical deterioration or that the 
patient would have a cardiac arrest in the hours before the event. There was no evidence that a lack of care 
contributed to the cardiac arrest or that any actions could have prevented it. However, the investigation 
did identify aspects of the cardiac arrest management that could provide learning opportunities for future 
events. 

PSII response to the conclusion of the Post Mortem report 

Following receipt of the postmortem report, it was decided that no separate PSII into the cause of death 
was required based on our application of the PSIRF guidance issued by NHS England (NHSE). The risk of a 
peritoneal tear during such major complicated surgery is well known and the outcome, whilst rare, was a 
foreseen possibility and did not indicate there had been any surgical error. 

Pursuant to this guidance, PSIRF and its supported activities (such as PSIIs), explicitly exclude and are 
insulated from activities that apportion blame, determine culpability, assess preventability, or identify the 
cause of death. 

While we did not investigate the death further under PSIRF for the reasons given above, we did undertake a 
separate, additional review following the receipt of the postmortem report to assist with the coronial 
investigation. This process of investigation is explored further below. 

Response to the coronial investigation and inquest 

In response to disclosure requests received as part of the investigation and inquest process, we provided 
statements from key clinicians involved in the care and treatment of Mr Thompson. We also provided a 
copy of the PSII report. 

, Consultant Orthopaedic Surgeon, was considered key evidence. It included a 

The statement of 
chronological summary of the surgery, detailing the vascular bleed, the transfer out and the peritoneal 
tear. The statement was informed by the postmortem report and included reflections on the significance of 
the peritoneal tear and the decision to repair it during surgery, in light of the cause of death. 

Additionally, we conducted a further review in response to coronial enquiries relating to causation and of 
how the defect in the peritoneum likely occurred. This review also explored whether there were any signs 
or symptoms of the defect repair failing causing small bowel herniation before Mr Thompson collapsed. 
This review resulted in an additional statement authored by 
Associate Medical Director, specifically addressing these points. 

, Consultant Anaesthetist and 

The review concluded that there were no specific signs or symptoms that would have indicated a defect in 
the peritoneum, or small bowel obstruction, that could have been secondary to the small bowel herniating 
through the defect.  

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 Identified Learning & Improvements 

We have carefully considered the points raised in the Regulation 28 report and reflected on the Trust’s 
implementation of PSIRF. The Trust acknowledges there are difficulties posed by the move away from 
Serious Incident (SI)/ Root Cause Analysis (RCA) reports. The Trust further acknowledges there is a need to 
ensure it provides sufficient information to satisfy its duty to assist the coroner with investigations.  
The Trust accepts that the overall presentation of our evidence did not provide a clear narrative, explaining 
the approach the Trust took to the investigation of Mr Thompson’s death, the rationale and scope of the 
PSIRF investigations we undertook and the additional review we undertook based on the postmortem 
report and cause of death. 

In order to better assist the coroner with future investigations and inquests, in addition to the standard 
disclosure of statements and copies of investigation reports, we propose to provide an overarching position 
statement. It is envisaged that the statement will summarise and explain our PSIRF response; the rationale 
and scope of our PSIRF investigations; the learning and actions arising from our PSIRF investigations; the 
outcome of reviews undertaken as part of our learning from deaths process; and any additional 
investigations undertaken as a result of postmortem reports and/or further requests from the coroner. 

We would welcome the opportunity to further discuss this proposal should you feel it necessary to do so as 
the Trust seeks to ensure it is completely fulfilling its duty to assist the coroner in their investigations.  

Yours sincerely 

Interim Chief Executive