Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0410, written 4 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Aug 2025 |
|---|---|
| Reference | 2025-0410 |
| Deceased | John Bell |
| Coroner | Simon Tait |
| Coroner area | South Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: CORONER'S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS Tel: (01302) 737135 Fax: (01302) 736365 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Bassetlaw Teaching Hospitals NHS Foundation Trust 1. CORONER , Chief Executive, Doncaster and I am Simon Tait Assistant Coroner for South Yorkshire East 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 21 February 2025 I commenced an investigation into the death of John Bell. The investigation concluded at the end of the inquest . The conclusion of the inquest was a narrative conclusion that: The deceased died as a result of recognised complications of a wound infection following appropriate spinal surgery. If the spinal surgeons had been aware of the prior diagnosis of a renal tumour, surgery to treat the renal tumour would have been prioritised and spinal surgery not undertaken at that time. This in turn would have avoided the spinal surgical wound infection and the deceased would not have died when he did. The Medical Cause of death was: 1a Right upper lobe pneumonia 1b 1c II Infected spinal surgery wound, ischaemic heart disease, localised left renal carcinoma 4. CIRCUMSTANCES OF THE DEATH Mr Bell died at St John's Hospice Doncaster on 10 February 2025. His death was caused by right upper lobe pneumonia which was contributed to by an infected spinal surgery wound, ischaemic heart disease and localised left renal carcinoma. On 25 October 2024 he underwent spinal surgery. At the time of that surgery, the spinal surgeon was not aware that Mr Bell had recently been diagnosed with a renal tumour which required curative surgical treatment. If the spinal surgeon had been aware of that diagnosis, spinal surgery would not have been undertaken at this time and surgery on the renal tumour would have been prioritised. Following the spinal surgery, Mr Bell was started on heparin to treat a renal thrombus which was a complication of the renal tumour. Heparin would not normally have been given following spinal surgery due to the increased risk of bleeding, however, the renal thrombus necessitated the administration of heparin in Mr Bell's case. The heparin in turn caused a wound haematoma which became infected. Despite treatment Mr Bell deteriorated and died on 10 February 2025 as a result of complications of the wound infection. On the balance of probability, if the spinal surgery had been delayed to treat the renal tumour, Mr Bell would not have developed the haematoma and spinal wound infection and would not have died when he did. 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. The MATTERS OF CONCERN are as follows. 1. Renal investigations were undertaken following a fast track cancer referral in September 2024. Investigations were undertaken and on 16 October 2024 a renal MDT reviewed CT scans and recommended that Mr Bell be considered for left nephrectomy to treat a renal tumour. Although the MDT note was apparently in the electronic records, the spinal surgeons were not aware of the renal findings at the time of the spinal surgery on 25 October 2024. Had they been aware, spinal surgery would not have been undertaken at this stage with the renal surgery being prioritised. I am concerned that critical clinical information was not available to and/or considered by, the spinal surgeons before the spinal surgery took place. 2. The issue in the previous paragraph came to light shortly after the spinal surgery in October 2024. However, no investigation of the incident was undertaken by the Trust. At the time of the inquest no Datix report had been submitted. The witnesses accepted at inquest that a Datix would have been good practice. I am concerned that some 8 months after the incident no formal investigation had taken place and no consideration of any learning had occurred. 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 the 29th September 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 following Interested Persons: . 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 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. 4 August 2025 9 Signature Simon Tait Assistant Coroner for South Yorkshire East
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.
Interim Executive Medical Director Medical Director – Operations , Interim Medical Director - Workforce Associate Medical Director – Clinical Safety , Associate Medical Director – Professional Standards Clinical Governance & Professional Standards Co-ordinator (642149) 23 September 2025 STRICTLY CONFIDENTIAL – ADDRESSEE ONLY Mr S Tait Assistant Coroner for South Yorkshire East Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Mr Tait John Bell (deceased) I write to you with respect to the Regulations 28 Report issued on the 6 August 2025 to Chief Executive of Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest into the death of John Bell concluded on the 30 July 2025. The report was received by the Chief Executive’s office and forwarded to me in order to provide a response. I have been assisted in constructing this response by Safety; Orthopaedic Surgeon & Divisional Director; and , Associate Chief Nurse for Patient Safety & Quality; , Associate Medical Director for Clinical , Consultant , Divisional Nurse for Surgery. I would respond to the matters of concern referred to within the PFDR as follows: 1. Renal investigations were undertaken following a fast track cancer referral in September 2024. Investigations were undertaken and on 16 October 2024, a renal MDT reviewed CT scans and recommended that Mr Bell be considered for left nephrectomy to treat a renal tumour. Although the MDT note was apparently in the electronic records, the spinal Surgeons were not aware of the renal findings at the time of the spinal surgery on 25 October 2024. Had they been aware, spinal surgery would not have been undertaken at this stage with renal surgery being prioritised. I am concerned that critical clinical information was not available to and/or considered by, the spinal surgeons before the spinal surgery took place. I would like to take this opportunity of assuring you and Mr Bell’s family that the Trust has undertaken a full review of this case as part of a thematic analysis. The prolonged waiting times and lack of standardised pre- operative processes raised concerns around patient safety, pathway efficiency, and equity of access. Immediate safety actions agreed - all patients with a TCI (“to come ‘in’ date”) now have a clinically appropriate pre-operative assessment, within a reasonable timescale, and the patient is reviewed by both the operating surgeon and anaesthetist on the day of surgery to establish if there has been any deterioration/change that would necessitate a change in clinical plan. This is documented in the patient’s notes, team brief and operation notes. The longer term plan is to formulate a comprehensive action plan to address the following: i) Pathway & Process Improvements Review how patients are listed and allocated for surgery. Define timeframes for additional investigations. Standardise referral into pre-operative assessment and high-risk anaesthetic clinics (template/letter). Introduce electronic referral forms (ICE or similar) to replace yellow waiting list forms. Ensure compliance with the national clinical prioritisation programme, so that all patients have a clinical prioritisation code recorded on the Patient Tracking List (PTL), that the clinical prioritisation code is in line with FSSA guidance (Federation of Surgical Specialty Association) and that clinical reviews are undertaken at the required intervals for each clinical prioritisation code Review the theatre booking and scheduling processes to ensure this is in line with national best practice Ensure robust PTL management processes are in place, in line with best practice i) Pre-operative Optimisation Review and enhance pre-habilitation offerings. Improve timeliness and mechanisms for referring into pre-operative assessment. Introduce a morbidity scale for orthopaedic surgery risk stratification. ii) Consent and Safety Review consent processes (digital consent, EIDO) with Consent Lead. Explore Venous Thrombosis Embolism (VTE) prescribing integration via VTE forum. Strengthen Surgical Site Infection (SSI) reporting and culture appropriateness with Infection Prevention & Control (IPC). iii) Governance & Oversight Review Mortality & Morbidity (M&M) processes across the division. Maintain oversight of prioritisation work within orthopaedics through Divisional Leadership Team. 2. The issue in the previous paragraph came to light shortly after the spinal surgery in October 2024. However, no investigation of the incident was undertaken by the Trust. At the time of the Inquest, no DATIX report had been submitted. The witnesses accepted at Inquest that a DATIX would have been good practice. I am concerned that some 8 months after the incident no formal investigation had taken place and no consideration of any learning had occurred. I can confirm that a DATIX incident form was completed on 30 July 2025, and the investigation remains ongoing as part of a broader thematic analysis. A comprehensive thematic review and associated actions are currently being drafted for presentation to the Executive Team. While the patient safety culture within the Trust is strong, it is recognised that incident reporting for learning purposes is predominantly undertaken by nursing colleagues. Significant work is underway across the Trust – through clinical governance meetings and patient safety events – to enhance incident reporting by medical staff. Further awareness has also been raised through the World Patient Safety programme, with a dedicated session held on 17 September 2025. Conclusion By implementing the proposed recommendations, the Trust has an opportunity to standardise care, enhance pre-operative optimisation, and strengthen governance oversight. A coordinated, multidisciplinary approach will be essential to ensure that patients are not only listed appropriately but also supported to “wait well” and undergo surgery safely and effectively. I trust this information provides reassurance that learning from Mr Bell’s case, along with other cases identified in the thematic review, will lead to improvements in pathways and processes, ultimately strengthening patient safety. Yours sincerely Acting Executive Medical Director Cc: , Chief Executive , Associate Medical Director for Clinical Safety Associate Chief Nurse for Patient Safety & Quality , Consultant Orthopaedic Surgeon & Divisional Director for Surgery , Divisional Nurse for Surgery
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