Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0560, written 5 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Nov 2025 |
|---|---|
| Reference | 2025-0560 |
| Deceased | Vivian Nolan |
| Coroner | Paul Appleton |
| Coroner area | Teesside and Hartlepool |
| 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.
This document was classified as: OFFICIAL Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The President of the British Society of Gastroenterology 1 CORONER I am Mr Paul Appleton, Assistant Coroner for the coroner area of Teesside and Hartlepool. 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 12 May 2025 I commenced an investigation into the death of Vivian Joan Tuddenham NOLAN, aged 84. The investigation concluded at the end of the inquest on 31 October 2025. I recorded the following narrative conclusion: Due to recognised complications arising from and following a diagnostic colonoscopy procedure. 4 CIRCUMSTANCES OF THE DEATH Vivian was referred to secondary care by her GP due to iron deficiency anaemia and a positive FIT test. Following review by the Gastroenterology Service, Vivian was listed for a diagnostic colonoscopy (the risks discussed as part of the consent process for the diagnostic colonoscopy included colonic perforation and need for emergency surgery). The diagnostic colonoscopy was performed on 31 March 2025 and following the colonoscopy, Vivian was diagnosed to have a colonic perforation. Despite medical and surgical treatment, Vivian deteriorated and sadly died on 10 May 2025. I recorded Vivian’s medical cause of death to be the following: 1a) Hospital acquired pneumonia and Covid infection 1b) Colonic perforation 1c) Diagnostic colonoscopy procedure to investigate iron deficiency anaemia 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) 1. During the course of the inquest hearing, I heard evidence from the Consultant Surgeon who performed the diagnostic colonoscopy. Their evidence included that, in their view, there ought to be a higher clinical threshold for offering diagnostic colonoscopies to patients aged over 80 given the associated, increased risks. Their This document was classified as: OFFICIAL evidence included that there is a higher clinical threshold in other countries for offering this diagnostic investigation to the 80+ age group. My concern is that there is a lack of knowledge amongst, and lack of clinical guidance available to, clinicians as to the potential increased risks of diagnostic colonoscopies in the 80+ age group. 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, namely by December 30, 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: 1. Vivian’s Family. 2. South Tees Hospitals NHS Foundation Trust. 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. 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. 9 Dated: 05.11.2025 Mr Paul Appleton Assistant Coroner for Teesside and Hartlepool
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.
10 December 2025 Mr Paul Appleton Assistant Coroner for Teesside and Hartlepool Teesside & Hartlepool Coroner’s Service Middlesbrough Town Hall Albert Road Middlesbrough TS1 2QJ Dear Mr Appleton Regulation 28 prevention of future death report V J T Nolan Thank you for bringing to our attention the circumstances leading to the death of Vivian Joan Tuddenham Nolan. We understand that she was a patient who underwent a colonoscopy for iron deficiency anaemia and a positive FIT test in March 2025 and sadly died following the procedure. Amongst the medical causes of death was “Colonic Perforation”. The British Society of Gastroenterology (BSG) would like to place on record our condolences to the family of Ms Nolan. We have been asked to address concerns raised during the deceased’s inquest, specifically: - 1. There should be a higher clinical threshold for offering diagnostic colonoscopy to patients over the age of 80 given the associated increased risks; 2. The general lack of awareness amongst clinicians of the potential increased risks of diagnostic colonoscopy in the over 80s age group; 3. There is a higher clinical threshold in other countries. Data provided by the NHS Getting it Right First Time (GIRFT) Model Health System reveals that 5.8% of all colonoscopies performed in England are carried out on those over 80 years of age. Whilst it is accepted that risks associated with any procedure increase with age, all patients should be appropriately consented prior to the procedure being carried out, with any risks, benefits and alternatives to the procedure personalised to the individual patient, taking into account, inter alia, concurrent comorbidities and frailty as well as the age of the patient. The NHS GIRFT Programme National Specialty Report states “Trusts may need to look at whether they are appropriately vetting and pre-assessing colonoscopy referrals, to defer or divert any that are not suitable for colonoscopy. For example, with more frail patients they may want to consider replacing colonoscopy with CTVC or CT…, or to discuss a more conservative approach with these patients.” (1) The British Society of Gastroenterology published guidance on this individualised approach to informed consent in 2023.(2) In April 2025, the BSG also published guidance on the Management of Colorectal Polyps in Patients with Limited Life Expectancy.(3) This document includes careful advice about patient selection for diagnostic colonoscopy. British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 Specifically, it states: - “…patients with a limited life expectancy should only undergo diagnostic colorectal investigations if the outcome of the investigation has the potential to benefit the patient and that the patient or their representative should be involved in any decision to investigate.” Furthermore: - “…if investigation is deemed appropriate for prognostication in a patient unfit for intervention, to reduce harm from overdiagnosis or overtreatment of irrelevant benign polyps, that CT abdomen/pelvis is undertaken rather than colonoscopy or CT colonography (CTC).” And finally: - “…prior to a diagnostic procedure in all patients with frailty or a limited life expectancy, a clear threshold for therapy is set and discussed with the patient or their representative as part of the informed consent process.” This guidance and that contained in the GIRFT 2021 report reflects the BSG view that thresholds should not be set on the basis of age alone (nor indeed that patients are discriminated against on the basis of their age) but rather should be part of a wide-ranging assessment of the patient. Factors to be considered would include both the strength of the indication for colonoscopy as well as individual patient risk factors. This guidance has been published in Gut, the foremost journal for gastroenterology practitioners and widely publicised to BSG members in newsletters, podcasts and webinars since publication. We have no evidence to suggest that this practice is not being followed nor of evidence to suggest that clinicians are not considering these factors prior to undertaking colonoscopy. The Coroner may be minded to also seek the opinion of the Association of Coloproctology of Great Britain and Northern Ireland (ACPGBI) whose members mainly comprise colorectal surgeons who also carry out colonoscopy, should he consider that raising awareness amongst this group of practitioners would be best served here. We note the suggestion that there is a higher clinical threshold in other countries. Our understanding is that recommendations from other health systems (USA and Europe) are similar to that in the UK in that any decision to undertake a colonoscopy should be individualised to the patient. If you are aware of evidence to the contrary, then we would be happy to review it. Colonoscopy is an important procedure for the investigation and management of gastrointestinal diseases, carrying significant benefits for patients. Whilst the BSG recognises that the risks of any invasive procedure are greater in people who are older, more frail or more comorbid, it is important that the decision to perform a colonoscopy is an informed one, balancing risks and benefits. There is a risk of significant patient harm if the risk of colonoscopy is overstated and not balanced alongside its potential benefits. Therefore, it is essential that these risks and benefits are explained by those who understand them, so that patients are not deterred from undergoing the investigation when it would be in their best interests. British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61 We thank you for bringing this matter to our attention. Yours faithfully President, British Society of Gastroenterology 1. 2. 3. Oates B. Gastroenterology GIRFT Programme National Specialty Report 2021 [Available from: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/10/Gastroenterology-Oct21v.pdf. Burr NE, Penman ID, Griffiths H, Axon A, Everett SM. Individualised consent for endoscopy: update on the 2016 BSG guidelines. Frontline Gastroenterol. 2023;14(4):273-81. Rutter MD, Ranjan R, Westwood C, Barbour J, Biran A, Blackett H, et al. BSG/ACPGBI guidance on the management of colorectal polyps in patients with limited life expectancy. Gut. 2025;74(10):1551-60. British Society of Gastroenterology: Company No. 8124892 Charity No. 1149074 / VAT No. 347 4214 61
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