Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0438, written 22 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 | 22 Aug 2025 |
|---|---|
| Reference | 2025-0438 |
| Deceased | Lee Stammers |
| Coroner | Louise Slater |
| Coroner area | South Yorkshire (East) |
| 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.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: hmc.doncaster@doncaster.gov.uk CORONER’S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS Tel: (01302) 737135 Fax: (01302) 736365 Date: 22 August 2025 Case: NJM / 28445208 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 THIS REPORT IS BEING SENT TO: Doncaster Royal Infirmary CORONER , Chief Executive, I am Louise Slater, Area Coroner for South Yorkshire East 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 INVESTIGATION and INQUEST On 12 March 2025 I commenced an investigation into the death of Lee James STAMMERS. The investigation concluded at the end of the inquest on the 22nd August 2025. The medical cause of death was : 1a Acute Cardiac Event 1b Lung Infection, Myocardial Ischaemia, Pericardial Effusion II Haemorrhage from punctured right and left ventricles from pericardiocentesis The inquest concluded with a narrative conclusion as follows:- Mr Lee Stammers died as a result of an acute cardiac event which developed due to the combined effects of infection, myocardial ischaemia, and pericardial effusion, and occurred on a background of recognised complications of pericardiocentesis during resuscitation efforts. CIRCUMSTANCES OF THE DEATH 4 Mr Lee Stammers, 47 year old, attended Doncaster Royal Infirmary at 12:06 hours on the 10th February 2025 with chest pain, shortness of breath and nausea. He was treated for infection, with intravenous fluids and antibiotics. At 19:15 hours, Lee suffered a cardiorespiratory arrest and despite prolonged resuscitation attempts he was pronounced deceased at 20:00 hours. During Mr Stammers admission, there were missed opportunities for the myocardial ischemia to be identified prior to his collapse. Electrocardiography was incomplete, not reported, or repeated. Blood tests were not performed as requested. If these actions had occurred, his clinical management would have been different. Although, it is not possible to determine if the cardiac arrest would have been avoided and/or the ultimate outcome would have been different, if his cardiac ischaemia had been identified earlier and managed sooner but it would have given Mr Stammers the best possible chance of survival. 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) Poor documentation, Communication, and systems– There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For example, the medical records indicated blood had been obtained and collected by the laboratory and the result was awaited. When blood had not been obtained. 5 Inaccurate information in the medical records and poor communication, led to a failure of urgent tests being undertaken. A comparable situation occurred, in relation to confusion regarding the performance of the electrocardiogram. Poor communication, documentation, and systems allowed tests/actions to be cancelled by student nurses, temporary staff and locum clinicians, who can also access the system and cancel tests without any rationale, accountability or identifying themselves in the records. These individuals were referred to as “unknown” at the inquest and have not been identified. Finally, there was clear and consistent evidence of poor documentation throughout the medical records, from admission to the emergency department continuing through to the resuscitation attempts. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17th October 2025. I, the coroner, may extend the period. 7 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Secretary of State Health. 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. She 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. 22 August 2025 9 Signature Louise Slater Area 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.
Acting 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 ( 14 October 2025 STRICTLY CONFIDENTIAL – ADDRESSEE ONLY Miss L Slater Area Coroner for South Yorkshire East Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Miss Slater Lee James Stammers (deceased) I write to you with respect to the Regulations 28 Report issued on the 22 August 2025 to Mr Richard Parker, Chief Executive of Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest into the death of Lee James Stammers concluded on the 22 August 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; Marie Hardacre, Associate Chief Nurse for Patient Safety & Quality and Nurse for Urgent & Emergency Care (UEC). Associate Medical Director for Clinical Divisional I would respond to the matters of concern referred to within the PFDR as follows: 1. There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For example, the medical records indicated blood had been obtained and collected by the laboratory and the result was awaited. When blood had not been obtained. Inaccurate information in the medical records and poor communication, led to a failure of urgent tests being undertaken. A comparable situation occurred, in relation to confusion regarding the performance of the electrocardiogram. Poor communication, documentation, and systems allowed tests/actions to be cancelled by student nurses, temporary staff and locum clinicians, who can also access the system and cancel tests without any rationale, accountability or identifying themselves in the records. These individuals were referred to as “unknown” at the Inquest and have not been identified. Finally, there was clear and consistent evidence of poor documentation throughout the medical records, from admission to the emergency department continuing through to the resuscitation attempts Mr Stammers’ case was formally presented to the Learning from Patient Safety Events (LFPSE) Panel with the declaration of a Patient Safety Incident Investigation (PSII). During this meeting, Immediate Safety Actions were identified and shared with the relevant division to ensure prompt implementation. In relation to Mr Stammers’ case, the panel noted several Immediate Safety Actions, particularly concerning communication and documentation practices. These actions were communicated to the division to support timely improvements and mitigate the risk of recurrence. In response to the concerns raised, the Emergency Department promptly implemented the identified Immediate Safety Actions. The majority of these actions were overseen by a named senior doctor within Emergency Medicine, ensuring accountability and compliance with the require safety improvement. I can confirm that the Patient Safety Incident Investigation (PSII) Report is now complete and scheduled for review and approval at the next Trust Executive Patient Safety Oversight Group. Once approved, this report will be shared with Mr Stammers’ family. Safety Recommendation 1 - The Emergency Department (ED) should review their departmental procedure regarding the frequency of Monitoring Observations and Escalation of Care in the Emergency Department and ensure this is clearly communicated to all staff. Once implemented, audit the effectiveness of the procedure. Part 1 of the recommendation was completed June 2025. Part 2 of the recommendation is targeted for completion by October 2025. Safety Recommendation 2 - The ED should develop Standing Operating Procedure (SOP) to ensure standardised care within the ED when patients present with chest pain. This should include expectations of the clinical assessment and investigation required. Once implemented, this should be followed by education and training for all ED staff. This will be discussed in Divisional Clinical Governance and is targeted for completion and implementation by 30 November 2025. Safety Recommendation 3 - Symphony user access to be reviewed and permissions changed to prevent user changes to prescribed care errors. Urgent & Emergency Care to consider how locum access can be strengthened to ensure traceability and an audit trail. Recommendation completed in respect of restrictions in place for all student nurses. Locum doctors must enter their full name and GMC number upon first login to Symphony – this step is mandatory. Safety Recommendation 4 – The ED to introduce a local quality improvement initiative focusing on enhancing communication and contemporaneous documentation in both emergency and non-emergency situations. Target date for recommendation 4 is 1 December 2025. I trust that the above information reassures you that learning from Mr Stammers’ case will improve communication and documentation in the Trust’s Emergency Department to enhanced patient safety. Yours sincerely Acting Executive Medical Director Cc: , Chief Executive , Associate Medical Director for Clinical Safety , Associate Chief Nurse for Patient Safety & Quality Divisional Nurse for UEC
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