Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0336, written 2 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2025 |
|---|---|
| Reference | 2025-0336 |
| Deceased | Jason Clemens |
| Coroner | Guy Davies |
| Coroner area | Cornwall & the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: PUBLIC REGULATION 28: REPORT TO PREVENT FUTURE DEATHS IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF JASON JAMES CLEMENS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS , Chief Executive Officer Royal Cornwall Hospital 1 CORONER I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 2 CORONER’S LEGAL POWERS I 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 28 March 2024 I commenced an investigation into the death of 54-year-old Jason James Clemens. The investigation concluded at the end of the inquest on 5 June 2025. The medical cause of death has been established on the evidence as follows 1a Pneumonia 1b Cystic Fibrosis II Renal Failure (on dialysis) The four questions - who, when, where and how – were answered as follows … Jason James CLEMENS died on 23 March 2024 at Royal Cornwall Hospital Truro from complications following cystic fibrosis contributed to by a delay in the administration of antibiotics from the time of prescription. Antibiotics were prescribed to be administered without delay at 18:15 hours on 22 March 2024. There was a 7-hour delay before antibiotics were administered at 01:20 hours on 23 March 2024. Jason became unresponsive at 05:00 hours and died at 06:30 hours on 23 March 2024. 1 Information Classification: PUBLIC There were a number of missed opportunities to identify the requirement to administer antibiotics. This delay likely hastened Jason’s death and more than minimally contributed to Jason’s cause of death. The conclusion of the inquest was as follows Natural causes contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH There were four missed opportunities to administer antibiotics. The inquest found that Jason was a highly vulnerable patient due to his complex medical conditions. Jason suffered a medical episode during the afternoon of 22 March 2024 whilst attending an out-patient appointment at the renal unit of RCHT. Staff took clinical readings and requested a medical review which was completed by a renal registrar at 18:15 hours that day. The registrar gave instructions on Jason’s medical management plan which required a full sepsis screen and the immediate administration of antibiotics. This was reinforced by the registrar completing a without delay prescription of antibiotics on the digital system (known as EPMA). Subsequently there were four missed opportunities to administer antibiotics before they were administered at 01:20 hours following day, 23 March 2024. Jason was found unresponsive at 05:00 and died at 06:30 on that day. The four missed opportunities were as follows 1) The renal registrar did not verbally instruct the nursing team to administer antibiotics at 18:15 hours. 2) The renal unit nurses either disregarded or did not read the registrar review and the management plan and EPMA prescription requiring immediate administration of antibiotics. 3) At 22:15 there was a handover from renal unit to acute medical unit (AMU). The renal unit nurses did not record on the handover notes the requirement to administer antibiotics. 4) On handover the AMU nurses either disregarded or did not check the management plan and EPMA prescription requiring the administration of antibiotics. The error was discovered on registrar review in the AMU at 00:10 hours the next day but there was then a further inexplicable delay. Antibiotics were administered at 01:20 hours, Jason became unresponsive at 05:00 and died shortly thereafter. The court found that these were basic errors and that the delay in the administration of antibiotics likely hastened Jason’s death and more than minimally contributed to Jason’s cause of death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 2 Information Classification: PUBLIC The MATTERS OF CONCERN are as follows. – The hospital accepted that there were failings that contributed to Jason’s death. Measures to address those failings had not been fully implemented at the date of the Inquest. There were no applicable standard operating procedures for worsening patients in the renal unit at the date of Jason’s death and none had been implemented by the date of Inquest. Jason died on 23 March 2024. The inquest was held on 5 June 2025. The court was told that the standard operating procedures are still being drafted in relation to identifying the appropriate pathway for the admission of worsening patients in the renal unit. The clinicians were undecided on applicable processes including whether the emergency department should be the default pathway. The court found on the evidence that moving worsening patients out of the renal unit and onto in-patient facilities is imperative and should be done at the first available opportunity. Such action would reduce the risks of medication and treatment errors and delays such as that which occurred in Jason’s case. Delays due to uncertainties about appropriate pathways raises risks to patients who require the specialist treatment available on in-patient facilities. I note similar concerns have been raised in a previous Regulation 28 Preventing Future Deaths report issued following the death Mr M.R. Jervis, [PFD dated 30.12.2024]. This earlier R28 report noted failings by AMU and other nursing staff to administer antibiotics when clinical observations repeatedly indicated such was required. The Jervis R28 report raised a concern regarding the absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six, including the need to administer antibiotics. It is unclear whether this measure has been introduced and if not, whether a digital alert would have made a difference in Jason’s case. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 August 2025. I, the coroner, may extend the period. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family. I am also 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. He may send a copy of this report to any person who he believes 3 Information Classification: PUBLIC may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 2 July 2025 HMC Guy Davies 4
1 response 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.
Date: 22 July 2025
Tel: 01872 250000
Chief Medical officer’s office
Royal Cornwall Hospital
Truro
Cornwall
TR1 3LJ
Private and Confidential
Mr. Guy Davies
Assistant Coroner for Cornwall and the Isles of Scilly
Pydar House
Pydar Street
Truro
Cornwall
TR1 1XU
Dear Mr Davies,
Re: The Late Jason Clemens – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the
4 July 2025. This was issued following the inquest into the death of Mr Clemens which concluded
on 5 June 2025.
I would like to take this opportunity to express my sincerest condolences to the family of Mr Clemens
for their loss.
During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• A Standard Operating Procedure (SOP) was still outstanding, some 15 months after the
•
death of Mr Clemens
It was unclear for nursing staff as to what pathway unwell patients on the renal unit should
follow
• There is still the absence of a digital alert on hospital software, which could have alerted staff
for the need to implement Sepsis Six.
Please find below the response from the Trust and the detail of the actions being taken in relation to
the above concern.
Standard Operating Procedure (SOP):
This (SOP) is now completed and has been uploaded onto the Trust’s intranet page for all staff to
have access to. A copy of the SOP is attached to the response as ‘Enclosure 1’.
Clinical Guideline for Unwell Patients on Renal Unit:
A Clinical Guideline has been developed to assist staff on the Renal Unit to regarding the relevant
pathway a patient should follow, should they become unwell or deteriorate on the Renal Unit. This
has been shared with staff and has been uploaded on the Trust’s internal Intranet page for all staff
members to review and have access to. A copy of the Clinical Guideline is attached to this response
as ‘Enclosure 2’.
Digital Alert on hospital system to alert to the need to implement Sepsis Six:
Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is
implementing a new e-Care digital electronic patient record (EPR) system and the Sepsis Lead
Nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when
the ‘Sepsis Six’ needs to be actioned.
Additional Actions taken:
Following the death of Mr Clemens, the following actions have also been taken:
1. ESR Sepsis training to be undertaken by all staff on
Complete 100%
the renal unit.
2. Supply of 1st line broad spectrum antibiotic to be kept
Complete
on the renal unit.
3. Acute Sepsis Screening tool 16+ to be kept on renal
unit.
Complete- attached to all
Haemodialysis machines
4. Sepsis screening tool- the Sepsis Six to be available
on the renal unit.
Complete-Nervecentre & paper
5. Sepsis box available on renal unit.
6. Paper News2 charts to be available on the renal unit.
7. Internal transfer telephone handover sheet to be
completed in full for all patients admitted to an
inpatient area from the renal unit.
Complete
Complete
Complete
8. Agree process with renal team for renal patients who
become unwell whilst in dialysis.
Emergency OOHs SOP -
complete
Renal Unit RCHT Practice
Standards for the Deteriorating
Patient: A Clinical Guideline -
complete
Complete- SBAR available for
guidance
Staff attending AIMs course as
available
9. Educate staff on how to ensure escalations of
concerns for patients are heard.
Page 2 of 3
10. Escalation of care stickers to be available on renal unit
to support conversations.
11. Audit of clinical observation recording to be undertaken
by renal unit staff to ensure complete set of clinical
observations are recorded.
12. Share patient safety review with Acute and Emergency
Medicine Care Group Governance team and Head of
Nursing.
Complete
Complete
Complete
To summarise the above, the Trust has taken the following actions:
1. The Standard Operating Procedure has been developed, approved and uploaded onto the
Trust’s intranet.
2. The Clinical Guideline determining the relevant pathway for a deteriorating patient on the
renal unit has been developed and uploaded on the Trust’s intranet.
3. The new E-Care digital electronic patient record will have a flag to alert when Sepsis Six is
triggered. The current, national system (Nervecentre) does not allow for this.
4. The Trust has taken the additional actions listed above following the patient safety review
following the death of Mr Clemens.
I hope that this letter provides both you and Mr Clemen’s family with assurance that the Trust has
taken seriously the matter of concerns you raised in your report and that the Trust has taken
appropriate action to prevent future deaths.
Yours Sincerely
Chief Medical Officer
Royal Cornwall Hospitals NHS Trust
Page 3 of 3
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