Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0524, written 20 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 | 20 Oct 2025 |
|---|---|
| Reference | 2025-0524 |
| Deceased | John Rust |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
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THIS REPORT IS BEING SENT TO:
CHIEF EXECUTIVE OF UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
CORONER
I am Adam Hodson, Area Coroner for Birmingham and Solihull
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.
INVESTIGATION and INQUEST
On 10 April 2025 I commenced an investigation into the death of John Christopher RUST. The
investigation concluded at the end of the inquest. The conclusion of the inquest was that John died
due to an uncontrolled CSF leak following elective thoracic aortic replacement surgery
CIRCUMSTANCES OF THE DEATH
On 25/03/25, John was admitted to the Queen Elizabeth Hospital for a elective thoracic
aortic replacement, having been diagnosed with a Type B aortic dissection in October 2019.
On 26/03/25 he had a cerebrospinal fluid ('CSF') catheter inserted to minimise post-
operative risks of paraplegia that is common with the type of surgery. On 27/03/25, the
surgery went ahead without major complications, and he was transferred to ITU to recover.
On 28/03/25, there was over-drainage of the CSF drain, and there were concerns raised
about a possible CSF leak, which were not acted upon. John's neurological status started to
deteriorate which was put down to side effects of medication. At 20.32 hours, Johns' CSF
drain was noted to have become disconnected which had resulted in him having a period of
unmonitored and uncontrolled CSF loss, and sadly which caused him to suffer a
catastrophic and unsurvivable brain injury. He was kept comfortable, and he passed away
at 18:36 on 29/3/25, following which John made the generous gift of organ donation. The
evidence is that that John’s death was avoidable had concerns surrounding the CSF leak
been acted upon sooner.
Based on information from the Deceased’s treating clinicians the medical cause of death was
determined to be:
1a Intracerebral haemorrhage
1b Excess CSF drainage
1c Lumbar drain, replacement of thoracic-abdominal aortic aneurysm
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II Chronic Type B Dissection, Hypertension.
CORONER’S CONCERNS
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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. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made
that "All clinical staff (medical and nursing) using automated CSF drainage systems such as
Liquoguard must have completed adequate training to ensure that they are familiar with the
functionality of the device prior to use..."
2. The evidence at inquest was that this training was not mandatory at present, and that at the
time of the inquest, approximately 55% of the relevant staff have received the training. This
has been slowed down somewhat due to a representative of the company being off sick,
but further training sessions have been planned.
3. However, the evidence of
(author of the PSII report and consultant
neurosurgeon) indicated that it was his view that the training should be mandatory, and that
consideration must be given to ensuring this is rolled out in a "sustainable" way to staff -
both current and future - as opposed to a "knee-jerk reaction" where training is only given to
a limited number of staff following an incident.
4. There was no evidence before the court that there was any plan to embed this training and
ensure that it is carried out in a "sustainable" way, with a particular focus on ensuring that
future staff are adequately and properly trained. This was particularly concerning given the
apparent high rotation and through-put of staff in the ITU department. It became apparent
to me that the training being offered was the type of "knee-jerk reaction" that
fearful of.
was
5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not
receive adequate training on equipment.
6. As Coroner, it is not my role to advise what action needs to be taken - that is a matter for
your organisation.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
15 December 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
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Mr Rust's next of kin
I have also sent it to the Medical Examiner who may find it useful or of interest.
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 she 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.
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20 October 2025
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Signature:
Adam Hodson
Area Coroner for Birmingham and Solihull
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.
NHS University Hospitals Birmingham NHS Foundation Trust Trust Headquarters Level 1 Queen Elizabeth Hospital Birmingham Mindelsohn Way Edgbaston Birmingham B15 2GW Monday 15 December 2025 Pe For the attention of Mr Adam Hodson Area Coroner for Birmingham and Solihull Dear Mr Hodson Inquest touching the death of John Rust Response to Regulation 28 Report to prevent future deaths | am writing in response to the Regulation 28 notice issued following the conclusion of the Inquest on 2 October 2025 touching the death of Mr Rust who died on 29 March 2025 at the Queen Elizabeth Hospital Birmingham (part of University Hospitals Birmingham NHS Foundation Trust (UHB)). The Trust was deeply saddened by Mr Rust’s tragic death, which occurred as a consequence of an intracerebral bleed caused by excessive cerebrospinal fluid (CSF) drainage via a lumbar drain inserted for cardio-thoracic surgery. Following Mr Rust’s death, the Trust protocol for the care of aortic surgical patients was updated and we introduced an automated, electronic monitoring system (Liquoguard) for patients requiring lumbar drains after cardio-thoracic surgery. The automated system replaced manual monitoring and drainage via a gravity-based manometer which was the system in use at the time of Mr Rust’s surgery. At the inquest, we were not in a position to fully outline our plans for a sustainable and comprehensive programme to train staff in the cardiac critical care unit and cardiac operating theatres to use the automated system. We have now carefully considered the concerns raised in your report and provide the following update: 1. Automated electronic monitoring is now in place for all CSF drains in the cardiac critical care unit (Critical Care D) and cardiac theatres. 2. To date, 91 out of 122 (75%) of relevant staff have completed training on the Liquoguard system, including both medical and nursing staff. 3. Training for the remaining 31 staff is scheduled for completion by 31 January 2026. 4. Enhanced training has been developed for nursing staff who choose to specialise further in cardiac critical care; these individuals will act as core trainers for new staff. 5. There are currently nine core trainers, comprising senior educators, Band 7 nurses, and Advanced Critical Care Practitioners, ensuring sustainability of training delivery including for new staff rotating into the service. 6. The cohort of trained staff is now sufficient to ensure that whenever these devices are used (approximately 10-12 times per year), appropriately trained personnel are present. Chair: Dame Yve Buckland Chief Executive: Jonathan Brotherton 7. Areference guide for nursing and medical staff has been developed and will be kept at the bedside for all patients requiring automated CSF drainage. 8. Training in the use of the Liquoguard system is now a core competency within the cardiac critical care unit and is mandatory for all new staff. We trust this demonstrates the steps taken to address the concerns raised and our commitment to patient safety. Yours sincerely Deputy CEO and Chief Medical Officer University Hospitals Birmingham NHS Foundation Trust Chair: Dame Yve Buckland Chief Executive: Jonathan Brotherton
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