Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0496, written 8 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Oct 2025 |
|---|---|
| Reference | 2025-0496 |
| Deceased | William King |
| Coroner | Sean Cummings |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Milton Keynes University Hospital 2 Association of Anaesthetists 3 Royal College of Anaesthetists 4 Royal College of Surgeons 1 CORONER I am Sean CUMMINGS, Assistant Coroner for the coroner area of Milton Keynes 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 29 January 2025 I commenced an investigation into the death of William KING aged 32. The investigation concluded at the end of the inquest on 10 September 2025. The conclusion of the inquest was a narrative one. William King, known as Billy King, died on the 26th January 2025 at Milton Keynes University Hospital as a result of an aspiration episode during preparation for emergency laparotomy for bowel obstruction. The cause of death was multi-organ failure due to pulmonary aspiration with sepsis, following laparotomy for small bowel obstruction under general anaesthetic. Billy was admitted with a small bowel obstruction and declined a nasogastric (NG) tube on several occasions. The inquest found that the necessity and risk of declining the NG tube were not sufficiently explained or documented at any stage. Had an NG tube been placed, it is probable in my view that Billy would have survived. 4 CIRCUMSTANCES OF THE DEATH Billy King was admitted to Milton Keynes University Hospital (MKUH) on the 22nd January 2025 with a mechanical small bowel obstruction proven on CT scan of his abdomen. He had previously had both an appendicectomy and then subsequent laparotomy with division of adhesions resulting from the first surgery. He had had a nasogastric tube placed for the first laparotomy and found it unacceptable. He was assessed as being suitable for initial conservative management which I found was acceptable practice. As part of that he was offered but declined a nasogastric tube. There are no notes documenting the first time this was discussed and I was unconvinced by oral evidence that the necessity and risk had been sufficiently explained to him. He initially improved then deteriorated and a decision was made for laparotomy on a daytime list. The night before he had vomited and there is a record of a further discussion of placement of a nasogastric tube. The record is poor and again does not document that the necessity and risk had been properly explained. He was allowed to have food in the form of a yoghurt or jelly and the family report him sending photo's of that. The provision of food was documented in the notes. He was seen by the duty Consultant Emergency Surgeon on the 25th January 2025 prior to surgery. He told me he had offered a nasogastric tube but again did not record what was said and agreed he had not stressed the risk. Billy was taken to the anaesthetic room where he underwent modified rapid sequence induction of anaesthetic. It was admitted that the dose of the Regulation 28 – After Inquest Document Template Updated 30/07/2021 paralysing agent, rocuronium, was lower than it should have been. I found that did not make a material difference to the outcome. During the apnoeic phase of the induction of anaesthesia an oropharyngeal airway was placed, within the 1 minute interval rocuronium apparently takes to paralyse. This caused Billy to vomit. Suction was applied. A CT1 trainee was managing the airway under the direct supervision of a Consultant Anaesthetist. A Cormack grade 1 view (full view of the glottis) was achieved. Gastric contents were visible during the laryngoscopy. This was managed by suctioning the contents. The amount suctioned at induction was 1.2 Litres. The intubation was taken over by the Consultant and achieved. A nasogastric tube was passed. Total volume of fluid suctioned and aspirated via NG tube was in the order of 4.7 litres. During the procedure it became evident that Billy had had a significant aspiration. He was moved promptly following a surgically successful procedure to the ITU where he died. I am of the view that had an NG tube been placed it is probable that Billy would have survived this episode. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving 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 are as follows: (brief summary of matters of concern) i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place since January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary. iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content. iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring. These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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, Regulation 28 – After Inquest Document Template Updated 30/07/2021 namely by December 19, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Milton Keynes University Hospital I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 08/10/2025 Sean CUMMINGS Assistant Coroner for Milton Keynes Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 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.
2nd December 2025 Dear Dr Cummings, Re: Regulation 28: Report to Prevent Future Deaths in the matter of William King Thank you for sending us a copy of your report regarding the sad death of William King. The information available has been reviewed by our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia- related serious incidents and to share the learning with the specialty across the UK. Your report highlights your concerns regarding the process and documentation of discussions leading to informed consent regarding the insertion of a nasogastric (NG) tube. Your report outlines that an NG tube was offered to Mr King at different stages of his treatment, but it is not clear whether any of those discussions addressed the risks and benefits of inserting an NG tube that relate specifically to anaesthesia. An NG tube can be one of the components used during rapid sequence induction (RSI) to manage patients with a higher risk of aspiration. Our organisations are shortly to publish a Good Practice guide on the topic of RSI and this addresses considerations about the use of NG tubes and emphasises the need for patients to understand the risks to the airway associated with lack of an NG tube in these circumstances. The Association of Anaesthetists’ guidance “Consent for anaesthesia 2017” outlines the expectations for the anaesthetic consent process, including the requirements for documentation. One of the key aspects emphasised in this guidance, and in its forthcoming update due to be published in early 2026, is the need for consent discussions to occur prior to patients coming to the anaesthetic room. This is to ensure that patients have the time and space to consider the risks and benefits of the treatment options available and the anaesthetist’s recommended course of action. It is not clear from the report at what stage an anaesthetist spoke to Mr King regarding the anaesthetic procedure and the risks/benefits of the rapid sequence induction (RSI), including the additional considerations of proceeding with or without an NG tube. A discussion between the anaesthetist and a patient regarding the risks/benefits of the anaesthetic should take place as soon as practicable after the decision to list a patient for emergency surgery was made. The Association guidance recommends that details of the discussion with the patient should be documented, although there is no separate consent form for anaesthetic procedures that are done to facilitate surgery. This documentation should include the risks, benefits and alternatives discussed. As in the General Medical Council’s “Decision Making and Consent” guidance, the guidance is clear that discussions around treatments that the patient refuses should be documented with as much care as those they consent to. We will disseminate these key learning points through our regular Patient Safety Update publication, which is distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. We will also work with our surgical colleagues to ensure that the shared learning points are shared with members of the Royal College of Surgeons of England and the Royal College of Surgeons of Edinburgh through the Confidential Reporting System in Surgery (CORESS) reports. We would be happy to respond to any questions that you might have. Yours Sincerely President Royal College of Anaesthetists President Association of Anaesthetists References 1. Association of Anaesthetists of Great Britain and Ireland. AAGBI: Consent for anaesthesia 2017. Anaesthesia 2017; 72: 93-105 (https://anaesthetists.org/Home/Resources- publications/Guidelines/Consent-for-Anaesthesia) 2. General Medical council, Decision and consent, 2020 (https://www.gmc-uk.org/professional- standards/the-professional-standards/decision-making-and-consent)
By email 11 December 2025 Dr Sean Cummings Assistant Coroner for Milton Keynes Dear Dr Cummings Regulation 28 Report following inquest into the death of Mr William (Billy) King I am writing to you following receipt of the above report dated 08 October 2025. Mr King died following significant aspiration at the time of anaesthetic induction for laparotomy, conservative management for bowel obstruction having failed. Mr King had declined the placement of a Ryle’s tube on admission. You raised several concerns around: the adequacy of the explanation of risks to patients; the documentation of consent discussions; • • • policy non-compliance; and, • a lack of clarity over where responsibility sat and which professional led in relation to specific aspects of care. Your report has led to much reflection and discussion at the Trust, including by the Executive Team and the Trust’s Clinical Board (a regular meeting involving Clinical Directors, senior nurses and allied health professionals from across the organisation). We accept that we could and should have done better in explaining the risks and benefits of various treatment options to Billy such that he could have made a truly informed decision, and that there were gaps in the documentation of the same. I am very sorry that we let Billy down. However, in the course of our discussions, we have not felt that ‘consent’ is the best lens through which to view this topic. Rather we feel that reinvigorating awareness, knowledge and standard operating procedures (SOPs) around ‘care outside of guidance’ (or ‘management other than as advised by a clinician’) would be a more rational and pragmatic approach. We are conscious that there are already several specific areas where care outside of guidance is well developed from both ethical and operational perspectives: namely, for women who wish to give birth without recommended obstetric or midwifery support, and for patients (including Jehovah’s Witnesses) who do not wish to receive blood or blood products. Whilst documentation in these two scenarios is fairly developed, it would be timely to review this in the context of a move from paper to digital records and - in maternity specifically - the desire to facilitate patient access to the record. We have also taken the opportunity to review the Regulation 28 Report issued by HM Senior Coroner for Manchester North on 05 November (following inquests into the deaths of Jennifer and Agnes Cahill in the context of a home birth). We are designing a new form within our electronic patient record (eCare) which will support staff facing such situations in: • being clear on a patient’s mental capacity; • articulating their recommended treatment along with its proposed benefits and potential risks; • articulating alternative treatment options (including both ‘do nothing’ and any intervention preferred by the patient), along with an assessment of benefits (if any) and potential risks; reflecting upon the value of high-quality communication (including translation services and independent advocacy where appropriate), multi-disciplinary team working, and second opinions; and, • • ensuring high-quality contemporaneous documentation of valid patient decisions in such complex circumstances. This electronic form will be generic but will prompt the user to select the specific circumstances which apply (‘maternity care’, ‘blood products’ or ‘other’). In the case of maternity care and blood products, the member of staff accessing the form will be directed to scenario-specific materials and processes (e.g. policies, standard operating procedures and/or bespoke forms). Importantly, use of the form will not be mandated through policy. Rather, it will constitute an aide memoire / decision support to assist colleagues in navigating these challenging discussions with their patients. The form will be one vehicle through which to ensure appropriate documentation. Just as with consent, it is the quality, personalisation and documentation of the discussion and its conclusions – rather than specific piece of paper or electronic form – that is important. The completion of the electronic form may result – subject to further thought and design – in a ‘pop up’ triggered by chart opening for a specified period, alerting users to a ‘care outside of guidance’ discussion having been documented within a relevant timeframe. The skeleton of the form which we plan to implement in the New Year (following feedback, revision and testing) is attached. Yours sincerely, Chief Executive Officer Enclosed: Enc. Proposed content for form within eCare
By email
Dr Sean Cummings
Assistant Coroner for the coroner area of Milton Keynes
19 November 2025
Dear Dr Cummings
Thank you for sending your “Regulation 28: report to prevent future death” letter to the RCS
England, and for giving us the opportunity to respond.
We were saddened to read the circumstances of Billy King’s death and we offer our sincere
condolences to his family.
Your report highlights a number of concerning issues in relation to the shared decision-making
process between Billy and the surgical care team, that occurred in the perioperative care of
this patient. Although we have no regulatory powers, the College provides extensive advice
and guidance to the surgical care team on all aspects of their practice, including matters
around consent, communication and team working.
With regard to our currently published advice and guidance:
• The College has produced guidance on Consent: Supported Decision-Making which
lays out the key principles that underpin the consent process. This guidance
emphasises that for the patient’s consent to be considered informed, surgeons must
be satisfied that the patient has received and understood full and sufficient information
about the proposed treatment and its implications. This includes presenting the various
treatment options and discussing their relative risks and benefits side by side. It makes
clear that consent should be patient-specific, and that surgeons should communicate
the risks that are material to the particular patient and their circumstances. Our
guidance also emphasises that surgeons should maintain a written decision-making
record that contains contemporaneous documentation of the key points of the consent
discussion, including documentation of any discussion around consent with the
patient’s supporters and with colleagues.
38-43 Lincoln’s Inn Fields,
London WC2A 3PE
+44 (0)20 7405 3474
info@rcseng.ac.uk
Registered Charity no: 212808
• The same principles around the consent process are emphasised in our core
standards document, Good Surgical Practice, which was recently updated and
published in 2025.
•
In collaboration with other Colleges and relevant specialty associations recently (in
June 2021) we produced guidance on the Preoperative Assessment and Optimisation
for Adult Surgery. This guidance emphasises the need for individualised risk
assessment as an essential part of patient selection for surgery to reduce risk of
complications and death.
In terms of further actions:
• Advice and guidance: We were concerned to read of the confusion between
surgeons and anaesthetists in Billy’s care team around the responsibility for
communicating the risks of not placing a nasogastric tube. Although our guidance is
clear the surgeon discussing treatment with the patient has the responsibility for
communicating the relevant associated risks and complications in the patient’s
treatment, we appreciate that, in some cases, some aspects of anaesthetic consent
are complex and may require an additional conversation. We are currently in the
process of updating our consent guidance to take into account our recent revision of
Good Surgical Practice, and we will seek to consult with colleagues at the Royal
College of Anaesthetists for coordinated advice in this area.
•
Implementation: We have recently consulted with the GMC on the development and
publication of practical tools and checklists to assist in the implementation of our
guidance on consent. We plan on publishing these additional tools alongside our
updated guidance on consent over the coming year. We are also in the process of
developing a brief e-learning module on consent based on our guidance which can be
used by hospitals to train their teams locally.
• Dissemination of learning: The risks of aspiration in patients with intestinal
obstruction being anaesthetised for surgery are well-recognised and are covered in
the Intercollegiate Surgical Curriculum Programme (ISCP) general surgery curriculum.
We confirm that we will publicise this event to the Association of Surgeons of Great
Britain and Ireland (ASGBI), and to the Confidential Reporting System for Surgery
38-43 Lincoln’s Inn Fields,
London WC2A 3PE
+44 (0)20 7405 3474
info@rcseng.ac.uk
Registered Charity no: 212808
(CORESS) which publishes anonymised educational vignettes of relevance to surgical teams,
in the Journals of the Royal College of Surgeons of England and the Royal College of
Surgeons of Edinburgh.
We hope that this response is clear and helpful and provides you with reassurance in relation
to the serious consideration we have given to these matters and the actions we shall be taking
in response.
Yours sincerely
Emeritus Professor of Vascular Surgery & Surgical Education
BSc MSc MD FRCS FEBVS FHEA
University of Bristol, Faculty of Health Sciences
& North Bristol NHS Healthcare Trust,
Southmead Hospital, Bristol, BS10 5NB, UK
Vice President Royal College of Surgeons of England
Royal College of Surgeons of England
38-43 Lincoln's Inn Fields
London WC2A 3PE
38-43 Lincoln’s Inn Fields,
London WC2A 3PE
+44 (0)20 7405 3474
info@rcseng.ac.uk
Registered Charity no: 212808
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