Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0157, written 24 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Mar 2025 |
|---|---|
| Reference | 2025-0157 |
| Deceased | Thomas Glover |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State Department of Health and Social Care. The British Society of Gastroenterology 1 | CORONER | am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 5'" June 2024 | commenced an investigation into the death of Thomas Alexander GLOVER The investigation concluded at the end of the inquest on 10‘ March 2025. The conclusion of the inquest was that the death was the result of:- Naturally occurring strangulation of a hiatus hernia with delayed surgical intervention resulting from an earlier missed opportunity for earlier diagnosis. The medical cause of death was confirmed as: 1a Multi-organ Failure 1b Strangulated Hiatus Hernia and Ischaemic Stomach 4 | CIRCUMSTANCES OF THE DEATH Thomas Glover's death was recognised at 21:00 on 22% May 2024, at the Bloomfield Hospital, Chelmsford, in Essex. Tom had been transferred from the Ipswich Hospital to the Broomfield Hospital on the 16* April 2024, following the delayed presentation of a strangulated hiatus hernia with an ischaemic stomach. Tom underwent a number of emergency surgeries at the Broomfield Hospital, which were ultimately unsuccessful. Tom developed multi-organ failure, and was commenced on end-of-life care until his death on the 22" May 2024. On the 13*" April 2024 Tom had attended the Ipswich Hospital with vomiting symptoms indicative of a gastroenteritis, an inflammation of the stomach and intestines. Tom was admitted onto an assessment unit for observations overnight. On the 14*" April 2024 Tom was reviewed by a Doctor at around 11:00, and was deemed to be clinically well enough for discharge. Tom was discharged at around 17:00 on the 14" April 2024. On the afternoon of 15" April 2024 Tom became acutely unwell and returned to the Ipswich Hospital, where he suffered a cardiac arrest. Once resuscitated he was diagnosed with a strangulated hiatus hernia and transferred by blue light ambulance to Broomfield Hospital. Despite intensive care unit support and emergency surgeries, Tom had suffered irreversible damage to his gastrointestinal system, from which he could not survive. Prior to his discharge on the 14" April 2024, Tom had continued to vomit and looked unwell, but this information was not escalated to the discharging clinician. Had this information been escalated, it is more likely than not that Tom would have not been discharged. Tom’s discharge on the 14" April 2024 led to a missed opportunity to diagnose Tom’s strangulated hiatus hernia at the time it developed, delaying any subsequent treatment. Whether or not an earlier diagnose of Tom’s strangulated hiatus hernia would have prevented the tragic outcome, could not be established on the available evidence. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. — 1. Atinquest it was heard in evidence Tom was suffering from a hiatus hernia, which is a common condition suffered by up to 60% of the population in middle and later life. In the majority of cases a hiatus hernia is asymptomatic, and an individual can be unaware of its presence. Evidence identified there are two types of hiatus hernia. a) Asliding hiatus hernia, which moves up and down through the naturally occurring hole in the diaphragm, and therefore in and out of the chest area, and; b) A para-oesophageal hiatus hernia (also called a rolling hiatus hernia) where part of the stomach pushes up through the hole in the diaphragm next to the oesophagus and stays there. In the population over 80% of those individuals who suffer from this condition have a sliding hiatus hernia, whilst only between 5-15% will have a para-oesophageal hiatus hernia. The difference between the two types of hiatus hernia is import, as the para-oesophageal hiatus hernia is far more likely to develop known complications, and therefore more likely to require surgery. 2. However, it was heard in evidence that in England many non-gastro specialist medical clinicians within the NHS are unaware of the difference in the two types of hiatus hernia, and are therefore unaware of the additional risk posed to the 5-15% of patients with a para- oesophageal hiatus hernia. 3. It was heard in evidence that the NHS England online guidance makes no distinction between the two types of hiatus hernias, whereas the guidance for NHS Scotland does. 4. Asa result, the lack of understanding of the difference between the two types of hiatus hernia within the medical community means that there is no increased vigilance taken when individuals with a para-oesophageal hiatus hernia present with symptoms. 5. In addition, the cohort of individuals who suffer from para-oesophageal hiatus hernia in England, are unaware of the increased risk posed by their condition and are therefore unable to advocate for more testing, or seek a second opinion when worrying symptoms do arise. ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and | believe you or your organisation have the power to take any such action you identify. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 19'" May 2025 I, the Senior Coroner, may extend the period if | consider it reasonable to do so. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- 1. The other Interested Persons in this matter | am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 4 24" March 2025 N Ti Nigel Parsley
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Parliamentary Under-Secretary of State for Public Health and Prevention From 39 Victoria Street London SW1H 0EU Our re: HM Coroner Nigel Parsley Senior Coroner for Suffolk Beacon House Whitehouse Road Ipswich Suffolk IP1 5PB By email: Dear Mr Parsley, 29 May 2025 Thank you for the Regulation 28 report of 24 March sent to the Secretary of State for Health and Social Care about the death of Thomas Alexander Glover. I am replying as the Minister with responsibility for long-term conditions, including gastroenterological conditions. Firstly, I would like to say how saddened I was to read of Mr Glover’s death, and the circumstances of that death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describe are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding and thank you for the additional time provided to the Department of Health and Social Care to provide a response to the concerns you have raised in your report. The report raises concerns over the misdiagnosis of a strangulated hiatus hernia. This was exacerbated by a lack of awareness among clinicians who are not specialists in gastroenterological care about the differences in management between a rolling and a sliding hiatus hernia which delayed subsequent appropriate treatment. Your report referred to online guidance provided by NHS England that does not make the distinction between the two types of hiatus hernia and, as a result, there is a lack of understanding within the medical community of the differences between to the two. Additionally, your report identifies that those patients with a rolling hiatus hernia may be unaware of the increased risk posed by their condition. In preparing this response, my officials have made enquiries with NHS England to ensure that we adequately address your concerns. I have been advised by NHS England that the NHS website for England (NHS.UK) provides members of the public with clear and accurate health information to help them understand what, if any, next steps they need to take with regards to the management of their condition. The guidance on NHS.UK is simple and action-orientated and is designed to help members of the public understand their symptoms and make sure they seek the right help at the right time. NHS.UK covers around 2,000 condition topics, many of which have different sub-types. The primary focus of NHS.UK is on helping people understand when to seek further help by explaining red flag symptoms. This is especially the case where incidence rates of subtypes are low. The NHS.UK website provides general advice for managing a hiatus hernia (https://www.nhs.uk/conditions/hiatus-hernia/), which includes lifestyle changes and, in some cases, medical treatments. Whilst rolling hiatus hernias are a specific type of hernia, the treatment approach is generally the same as for the more common sliding hiatus hernia. The website also provides guidance on recognising symptoms and when to seek further advice or care. Individuals are advised to contact their GP if their symptoms last over a few weeks or worsen. The website contains clear warnings and directs readers to obtain urgent assessment by contacting NHS 111 if they are experiencing symptoms which may indicate urgent assessment and care may be needed. We understand that Mr Glover was diagnosed with gastroenteritis prior to his discharge on 14 April 2024. The symptoms and signs of acute bowel obstruction do not differ according to the type of hiatus hernia. As outlined above, the health information on the hiatus hernia page on NHS.UK directs readers to obtain urgent assessment by contacting NHS 111 if they are experiencing symptoms which indicate urgent assessment and care may be needed. The NHS website does not publish clinical guidelines for use by healthcare professionals. NHS England is not commissioned to provide clinical education to healthcare professionals, which means the information on NHS.UK has not been designed for specialist clinical education or to raise awareness of conditions among the medical community. Clinical guidelines for healthcare professionals are published by institutions such as the National institute for Health and Care Excellence (NICE) and the Royal Colleges. Each Royal College has a curriculum and training programme for clinicians. More generally, continuing professional development (CPD) for doctors is a process of lifelong learning that helps them maintain and improve their skills, knowledge, and attitudes to practice medicine effectively. It involves engaging in various activities, both formal and informal, to stay up to date with advancements in medical knowledge, clinical guidelines and best practice. The responsibility for CPD ultimately rests with the individual doctor. While employers and professional bodies play a role in supporting and facilitating CPD, doctors are accountable for identifying their own learning needs, planning their CPD activities, and documenting their learning. Employers and those contracting doctors' services have a responsibility to ensure their workforce is competent, up-to-date, and able to meet service needs. This may include providing resources, time, and funding for CPD activities. Furthermore, professional bodies, such as the General Medical Council (GMC), offer guidance and standards for CPD, ensuring it aligns with best practice and supports ongoing competence for doctors. CPD is a key component of the revalidation process for doctors, where they demonstrate their continued competence and commitment to professional development. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
14 May 2025 (ref your email 25.03.25) Coroners Office Coroners Service By email only: Dear Sarah BSG Response to Coroners’ Regulation 28 Prevention of Future Deaths Report on Hiatus Hernia Thank you for bringing to our attention the circumstances leading to the death of Mr Thomas Glover. We understand that he was a patient who developed multi-organ failure and died after likely delayed surgical intervention for a para-oesophageal hiatus hernia. Hiatus hernia is a common condition with estimates suggesting that up to a third of people aged over 50 may have a hernia. Whilst the majority of people have the more common, type I or ‘sliding’ type of hiatus hernia, around 5% have a ‘para-oesophageal’ hernia (types II-IV). Hiatus hernias typically cause acid reflux and heartburn. Whilst severe complications are still rare, para-oesophageal hernias are at significantly higher risk of developing complications such as strangulation, bleeding or incarceration. Patients with these complications may present acutely and may need prompt surgical intervention. This matter has been discussed within the Oesophageal section of the BSG, including both surgical and medical colleagues. Following consideration of the Regulation 28 Report, the stated concerns around Mr Glover’s care appear to centre around: - • Lack of awareness amongst non-gastroenterology specialists of the two different types of hiatus hernia and the relative risks posed, • Paucity of NHS England patient information regarding the symptoms and potential complications of para-oesophageal hiatus hernia, • Lack of awareness amongst affected patients of their increased risk of complications. The British Society of Gastroenterology (“The Society”) currently has no published guidance on the diagnosis and treatment of Hiatus Hernia. Nor was the Society consulted on the referenced patient information provided by NHS England. However, it is the view of the Society that hospital emergency staff, especially non-GI specialists should be aware of the potential for hiatus hernias (of any kind, as the differentiation between sliding and para-oesophageal hernias is often not made at diagnosis) to develop complications such as ischaemia or strangulation and patients with a known hiatus hernia presenting with concerning symptoms should be reviewed by an appropriate specialist as a matter of urgency. British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 The Coroner may be minded to send a Regulation 28 Prevent of Future Deaths report to the Royal College of Emergency Medicine (RCEM). The Coroner may also be minded to send a Regulation 28 Prevent of Future Deaths report to NHS England concerning the content of its website guidance. The Society agrees that patients diagnosed with a hiatus hernia of any kind, but especially a para-oesophageal hernia, are told to be aware of potential symptoms indicating a complication such as strangulation or ischaemia. These symptoms might include: - o Significant Chest pain o Significant Epigastric pain o Dysphagia o Shortness of breath o Significant early satiety Whilst The Society is not a patient-facing Charity, we will work with Guts UK, a national charity for the digestive system, to develop a patient information leaflet for hiatus hernia, highlighting the need for extra vigilance following diagnosis of a para-oesophageal hernia. Thank you for bringing this matter to our attention. Yours sincerely President of the British Society of Gastroenterology Professor of Gastroenterology Consultant Gastroenterologist Population Health Sciences Institute Newcastle University Centre for Cancer Faculty of Medical Sciences Newcastle University Consultant Gastroenterologist Clinical Lead for Gastroenterology West Hertfordshire Teaching Hospitals NHS Trust British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61
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