Lee Eustace

Chief Executive 
University Hospitals Plymouth NHS Trust 
Plymouth PL6 8DH 
Tel. 01752 439084 

Private and Confidential 

09 February 2026  

Ms Louise Wiltshire 
Assistant Coroner, for the coroner area of the County of Devon, Plymouth and Torbay 
County Hall 
Topsham Road 
Exeter 
EX2 4QD 

Dear Ms Wiltshire, 

I am writing in response to your Regulation 28 Report dated the 15th of December 2025 concerning the 
death of Mr Eustace. On behalf of University Hospitals Plymouth NHS Trust (UHP), we would like to 
begin by offering our sincere and heartfelt condolences to Mr Eustace’s family for their profound loss. 

Thank you for clearly setting out the concerns arising from this case. We are sorry that these matters 
required your intervention, and we recognise the seriousness of the issues you have raised. We are 
committed to learning from this incident and taking all necessary steps to strengthen the safety and 
quality of our services to prevent future harm. 

During the inquest, the following matters of concern were identified: 

1.  The jejunostomy feeding protocol in place at the time of Mr Eustace’s death was insufficient and 

not followed. This likely contributed, on the balance of probability, to his death. 

2.  Despite these concerns, an incident was not reported through the Trust’s internal incident 

reporting system, a proportionate investigation did not take place, and Duty of Candour was not 
provided to Mr Eustace’s family. 

3.  There was a failure to disclose these concerns and any associated service improvements to the 

coroner ahead of the inquest hearing (which was subsequently adjourned) in June 2023. 

A full investigation into each of these issues has now been completed, and our response is set out 
below. 

1.  The jejunostomy feeding protocol in place at the time of Mr Eustace’s death was 

insufficient and not followed. This likely contributed, on the balance of probability, to his 
death. 

Mr Eustace was admitted under the care of the Thoracic team on the 27th of April 2022 for an 
upper gastrointestinal endoscopy and two stage Gastro‑Oesophagectomy for squamous cell 

Working in partnership with the Peninsula Medical School 

 
 
 
 
 
 
 
 
  
 
 
 carcinoma of the oesophagus. Postoperatively, and in line with established practice within the 
Thoracic Service Line, he was commenced on jejunostomy feeding at 30ml/hr. 

Mr Eustace subsequently developed abdominal pain. Although the feeding protocol in place at 
that time indicated that feed should not be increased when abdominal pain is present, the rate 
was increased. Over the following 24 hours, Mr Eustace’s abdominal pain and distension 
worsened, his tachycardia increased, his urine output decreased, and he appeared more unwell. 

In the absence of the operating consultant, Mr Eustace was reviewed by a consultant from the 
Oesophagogastric team. The reviewing consultant raised concern for feeding jejunostomy 
syndrome, which is a rare situation, peculiar to patients post upper gastrointestinal surgery, 
where the jejunal feed inspissates in the bowel and causes bowel ischaemia. A CT scan was 
performed which confirmed an ischaemic bowel. Sadly, the extent of ischaemia meant that 
surgery was not an option. Supportive care was provided with input from the Intensive Care 
team, but Mr Eustace’s condition did not improve, and he died on the 1st of May 2022. 

The investigation identified that at the time of Mr Eustace’s death there was variation in post-
operative pathways for patients undergoing a Gastro‑Oesophagectomy between the Thoracic 
and Oesophagogastric teams, including differing approaches to jejunostomy feeding. Although 
jejunostomy feeding post-surgery had been used for many years within the Thoracic Service 
Line, feeding jejunostomy syndrome had not previously been encountered and was not widely 
recognised by staff as a potential complication. The protocol in place did prompt staff to consider 
abdominal pain. However, it did not clearly explain the clinical significance of this finding, how to 
distinguish expected postoperative discomfort from red‑flag symptoms, or the actions required if 
abdominal pain or other concerning symptoms were identified. 

Following Mr Eustace’s death, the jejunostomy feeding protocol (Appendix 1) was revised in 
September 2022. It now includes a daily checklist with explicit instructions regarding abdominal 
pain and other clinical warning signs. In addition, the pathway for all Gastro‑Oesophagectomy 
patients at UHP has since been standardised and feeding jejunostomies are no longer used post-
operatively. This change has removed the risk of feeding jejunostomy syndrome entirely for this 
patient group. 

2.  Despite these concerns, an incident was not reported through the Trust’s internal incident 
reporting system, a proportionate investigation did not take place, and Duty of Candour 
was not provided to Mr Eustace’s family. 

Feeding jejunostomy syndrome is a rare but known complication that is poorly understood. 
However, the Trust acknowledges that an incident did occur during Mr Eustace’s admission 
which met the threshold of a notifiable patient safety incident. This should have triggered an 
incident report, a proportionate investigation, and the provision of both professional and statutory 
Duty of Candour to Mr Eustace’s family. The incident relates to the decision to continue and 
increase the feed in the presence of abdominal pain, which likely contributed to Mr Eustace’s 
death. 

I am sincerely sorry that this did not happen at the time, and that Mr Eustace’s family did not 
receive the openness, involvement, and information they were entitled to until the inquest in 
December 2025. 

The investigation could not establish with certainty why an incident report was not raised, but it is 
possible that staff did not recognise that a patient safety incident had occurred at the time of Mr 
Eustace’s death. In addition, although all deaths within UHP should undergo review, there is no 

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 evidence that Mr Eustace’s death was reviewed or considered at the Thoracic Surgery Morbidity 
and Mortality meeting. As a result, these processes did not identify the incident, the need for it to 
be reported, or the requirement to provide Duty of Candour to Mr Eustace’s family.  

Recognition of the incident occurred only later, when an independent clinician from the 
Oesophagogastric team, who had reviewed Mr Eustace when he became acutely unwell, was 
asked to provide an opinion for the previously adjourned inquest. 

3.  There was a failure to disclose these concerns and any associated service improvements 
to the coroner ahead of the inquest hearing (which was subsequently adjourned) in June 
2023. 

Since Mr Eustace’s death, improvements have been made to UHP’s learning from deaths and 
mortality review processes to strengthen the early identification of concerns in care that may 
have contributed to a patient’s death. These include: 

•  All coroner referrals are now reviewed by the Divisional Quality Team to ensure any concerns 

in care are identified at an early stage. 

•  All adult deaths within surgical services at UHP now undergo a Stage 1 mortality screening 

• 

review, using a standardised tool. 
If any triggers are identified, a Structured Judgement Review (SJR) is undertaken by an 
independent clinician. 

•  Any concerns identified through these processes are reported through the Trust’s incident 
reporting system, ensuring duty of candour is provided, and appropriate investigation and 
learning. 

Copies of the Stage 1 screening tool and the SJR template are included at Appendix 2. 

The Trust apologises that these concerns were not identified and addressed prior to the inquest held in 
June 2023 and again in December 2025 and hopes that this response provides some reassurance that 
we have fully explored the concerns raised, and that we are committed to taking the necessary steps to 
improve the safety of our services. 

If you require any further information or clarification, please do not hesitate to contact me. Once again, 
we extend our deepest condolences to Mr Eustace’s family for their loss. 

Yours sincerely 

Chief Executive Officer  

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 Appendix 1 – Adult Jejunostomy Feeding  

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 Appendix 2 - Mortality Screening Tool

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