Tony Jackson

East London Coroners Court 
124 Queens Road  
Walthamstow 
E17 8QP 

Newham University Hospital 
Glen Road 
London 
E13 8SL 

Dear Mr Irvine, 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Tony Buengo Jackson 

Thank you for your Regulation 28 Report dated 23 September 2025 following the inquest into the 
death of Mr Tony Buengo Jackson. On behalf of Barts Health NHS Trust, I wish to express our 
sincere condolences to Mr Jackson’s family and to acknowledge the seriousness of the concerns you 
have raised. 

A detailed internal review has been undertaken to ensure the circumstances identified during the 
inquest are fully understood and that corrective actions are being implemented. 

Below I set out our response to each matter of concern and the steps we are taking to prevent similar 
events in future. 

1. Failure to recognise iatrogenic injury and missed opportunity on re-admission 

You expressed concern that the iatrogenic bowel injury sustained during the PEG insertion on 19 
November 2024 was not recognised until 3 December 2024, despite a CT scan and surgical review 
on 24 November. 

Our review confirmed that the consultant surgeon’s interpretation of the CT scan at that time 
represented a reasonable differential diagnosis given the available evidence. However, the rationale 
for this interpretation was not fully documented, limiting retrospective understanding of the decision. 

Actions taken 

•  The case has been reviewed through the Surgical Division’s Morbidity and Mortality (M&M) 

process and learning shared. 

Status: Implemented October 2025; monitored via monthly M&M. 

2 & 3. Documentation of best-interest decision-making and availability of clinical records 

 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 You highlighted concerns regarding the completeness of documentation for best-interest discussions 
and noted that not all records from the 24 November admission were available. 
The Trust acknowledges that discussions with Mr Jackson’s family took place over several 
encounters and were clinically appropriate, but the rationale and outcomes of these discussions were 
not always documented in a clear and consistent format. We also acknowledge that retrieval of some 
legacy paper documentation for disclosure was incomplete. 

Actions taken: 

•  The Trust has reinforced the requirement that all best-interest discussions are documented in 

the patient record, clearly recording: 

o  who was present, 
o 
o 
o  and the agreed outcome. 

the clinical reasoning and evidence considered, 
risks and benefits discussed, 

▪  This reflects Royal College of Physicians and BMA guidance that best-

interests’ decisions are iterative and revisited over time, rather than a one-
off meeting, and ensures the decision-making process remains 
transparent and clinically grounded. 

•  Guidance has been re-issued to consultants and trainees regarding documentation standards 
for capacity assessments and best-interest decisions. This has been discussed in divisional 
Clinical Governance meetings and included in Resident Doctor teaching. 

•  E-consent has been rolled out in endoscopy in the last 12 months and includes a detailed 

section for consent form 4 and best interests discussions. Currently only a limited number of 
clinicians have access to this system.  

Status: This will be discussed in the Gastroenterology Governance Meeting in December to 
standardise process and expand the number of users to the Concentric Platform to further reduce the 
use of paper documentation for consent form 4 with improved integration with the electronic patient 
record. 

4. Governance and incident-reporting failure under the Patient Safety Incident Response 
Framework (PSIRF) 

You highlighted that the case was not identified for investigation under PSIRF and that incident-
reporting and governance processes were inadequate. 

The Trust acknowledges that a Datix record was not submitted contemporaneously, which represents 
a missed opportunity for formal learning. An internal review has since strengthened how patient-
safety incidents are identified, triaged, and escalated. 

Actions taken 

•  A Trust-wide communication was issued in October 2025 reminding staff that all significant or 
unexpected complications, including recognised but serious procedural injuries, must be 
recorded on Datix for PSIRF consideration. 

•  All deaths that proceed to Coroner’s inquest are now reviewed at the Patient Safety Event 

Response Meeting (PSERM) to ensure: 

o 

The event is captured on Datix, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o 

The circumstances are reviewed in a multidisciplinary forum, and 

An appropriate learning response (e.g learning response review, MDT case 

o 
discussion, thematic review or QI feedback) is agreed and assigned. 

•  The Endoscopy Governance Meeting is being expanded to include the surgical directorate as a 

bi-monthly joint forum agenda (within the Gastroenterology Governance Forum) between 
Surgery and Gastroenterology, with governance and nursing representation, to support shared 
learning from endoscopy-related adverse events. 

•  Governance presence is now embedded within Surgical and Gastroenterology M&M meetings 
to ensure improved linkage between M&M learning, Datix reporting, and PSIRF oversight. 

•  The Trust is also strengthening the recording of Morbidity and Mortality (M&M) discussions 

across all divisions. Following a review of M&M processes at the December Quality and Safety 
Committee, divisions will be supported to embed improved documentation standards and the 
use of Microsoft Copilot to capture decisions, themes and actions. This will ensure that learning 
identified at M&M is consistently recorded, traceable, and easily retrievable for follow-up 
through PSERM and divisional governance structures. 

Status: This will be discussed in the Gastroenterology Governance Meeting in December to 
standardise process 

5. Summary and assurance 

Barts Health NHS Trust recognises that Mr Jackson’s death resulted from a rare but serious PEG-
related complication, and that aspects of documentation and governance did not meet the standard 
we expect. We have taken decisive steps to strengthen clinical documentation within the electronic 
patient record , improve governance, and reinforce a culture of proactive incident reporting and 
shared learning. 

Progress will be monitored through the Trust’s Quality & Safety Committee. We believe these 
measures provide a robust response to the risks identified in your report and will meaningfully reduce 
the likelihood of similar events recurring. 

Yours sincerely, 

Chief Medical Officer

Parliamentary Under-Secretary of State for 
Health Innovation and Safety 

39 Victoria Street 
London 
SW1H 0EU 

    19th December 2025 

Mr G Irvine – Senior Coroner  
East London Coroner’s Court 
124 Queens Road Walthamstow, 
E17 8QP 

Dear Mr G Irvine,  

Thank you for the Regulation 28 report of 23 September 2025 sent to the Secretary of State 
for Health and Social Care about the death of Tony Buengo Jackson. I am replying as the 
Minister with responsibility for patient safety.       

I would like to start by saying how saddened I was to read of the circumstances of Mr 
Jackson’s death, and I offer my sincere condolences to his family and loved ones. The 
circumstances your report describes are concerning and I am grateful to you for bringing 
these matters to my attention. Please accept my apologies for the delay in responding to 
this matter and thank you for the additional time provided to the department to provide a 
response to the concerns raised in the report. 

The report raises concerns about the care received by Mr Jackson at Newham Hospital 
relating to the following points: - 

•  A fatal iatrogenic injury sustained by Mr Jackson on 19th November 2024 went 

undetected until 3rd December 2024, despite admission, a CT scan and surgical 
consultation on 24th November 2024. 

•  Records of, best interest decisions, the Percutaneous Endoscopic Gastrostomy 
insertion and subsequent treatment were so poor as to impede the court’s 
investigation. 

•  The Trust could not provide notes of the 24th November admission. 
•  A failure in governance at the Trust meant that this case was not identified as an 
incident worthy of investigation through the Patient Safety Incident Response 
Framework (PSIRF). This omission gives rise to a concern that future deaths may 
follow due to an inability on the part of the Trust to identify, reflect upon, and 
remediate sub-optimal practice. In this case the Trust’s Datix incident reporting 
system, morbidity and mortality meeting process and PSIRF procedure were 
inadequate.  

 
 
 
 
 
 
 
 
 
 
  
  
 
     
 
  
  
  
  
  
  
 In preparing this response, my officials have made enquiries with NHS England and the 
Care Quality Commission (CQC) to ensure that we adequately address your concerns. 

NHS England have assured me that all coroner cases at Barts Health NHS Foundation 
Trust  will be discussed at the multi-disciplinary team patient safety event meeting chaired 
by the Director of Nursing, Medical Director or Divisional Medical Director and attended by 
each speciality to reduce the likelihood of lack of awareness of patient safety incidents 
caused in one service but presenting in another. 

Following receipt in September of your Prevention of Future Death (PFD) report relating to 
Mr Jackson, CQC engaged with the leadership team at Newham Hospital, and I believe is 
now assessing the Trust’s full response to the report CQC  have assured me that it will 
keep monitoring progress and improvement at the hospital and Trust as part of their 
ongoing engagement. 

Regarding the concerns about application of the PSIRF, the Trust is reviewing the mortality 
and morbidity process across the hospital to ensure better alignment with learning and 
improvement systems. CQC have raised concerns with the Trust that there is disparity in 
the effective application of PSIRF across the different hospital’s governance teams.  The 
CQC will review the Trust’s response and decide if any further action is needed. 

The Government is committed to fostering a learning culture in the NHS, to minimise 
harmful events however we also acknowledge that it is not realistic to eliminate all 
complications in patients undergoing lifesaving high-risk surgery even when all reasonable 
mitigations are in place.  

The changes being made as part of the 10-year Health Plan and 
the patient safety landscape will improve quality and thereby system safety by making it 
clear where responsibility and accountability sits at all levels of the system. To drive 
improvements in patient safety, we are ushering in a new era of transparency, a rigorous 
focus on high-quality care and a renewed focus on patient and staff voice.  

 report on 

Over recent years, the NHS has made significant strides to improve patient safety, including 
implementing key programmes under the NHS Patient Safety Strategy (2019). The Strategy 
is now achieving its aim of saving around 1000 lives per year and £100m in care costs per 
year.  

Measures we have taken over the last year include:  

•  Roll out of Martha’s Rule, which is now being expanded to all acute inpatient sites. 
From September 2024 to July 2025 more than 260 Martha’s Rule escalation calls 
required transfers of care to high dependency or intensive care units, enhanced 
levels of care or to tertiary centres.  
implementing medical examiners on a statutory basis to scrutinise all deaths that are 
not investigated by a coroner, in order to facilitate learning and improvement locally. 

• 

The CQC is also rebuilding its regulatory approach via a data-driven, intelligence-led model 
to enable the regulator to have a more rounded understanding of the service quality and 
safety Trusts are delivering. These changes will ensure the safety and learning cultures 
across the NHS are more consistent. 

 
 
  
  
  
  
  
  
  
  
  
 I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

Parliamentary Under-Secretary of State  
for Health Innovation and Safety