Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0160, written 19 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2026 |
|---|---|
| Reference | 2026-0160 |
| Deceased | Graham Oxley |
| Coroner | Carl Fitch |
| Coroner area | South Yorkshire |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: SHEFFIELD TEACHING HOSPITAL NHS FOUNDATION TRUST CORONER I am Carl J Fitch, His Majesty's Assistant Coroner for the coroner area of South Yorkshire West. 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 23 June 2025 I commenced an investigation into the death of Graham Ian OXLEY. The investigation concluded at the end of the inquest on 19th March 2026. The conclusion of the inquest was - Graham Ian Oxley died on 22nd February 2025 at the Northern General Hospital, Sheffield after suffering serious side effects from pembrolizumab immunotherapy given following kidney cancer surgery. The treatment caused inflammation affecting his heart, muscles and nerves, which led to worsening problems with his breathing and heart. He was treated in hospital, but his condition continued to decline and life support treatment was stopped. The cause of death was established as: 1a. Myositis, myocarditis and myasthenia gravis 1b. Complication of pembrolizumab immunotherapy II. Renal cancer CIRCUMSTANCES OF THE DEATH Mr Graham Ian Oxley was diagnosed with renal cell carcinoma and underwent radical nephrectomy in October 2024. His Post-operative recovery included wound infection and persistent numbness around the surgical site. Follow-up imaging showed no metastatic disease and he was offered adjuvant pembrolizumab immunotherapy to reduce the risk of cancer recurrence. Pembrolizumab was administered on 9 January 2025, and within days, Mr Oxley developed symptoms including diarrhoea, fatigue, breathlessness, weakness and later neuromuscular impairment. He made repeated attempts to obtain advice via oncology emergency contact numbers, without success. He attended emergency care but was left without diagnosis. 1 2 3 4 On 28 January 2025 he was admitted to Weston Park Hospital, appearing jaundiced with neuromuscular weakness. He rapidly deteriorated requiring intensive care. He was diagnosed with immunotherapy-related toxicity. He received escalating aggressive immunosuppressive treatment including steroids, IVIG and abatacept. Despite treatment, his condition progressed to multi-organ failure. Following discussion with his wife and clinicians, life-sustaining treatment was withdrawn. CORONER'S CONCERNS 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 investigation has identified that immunotherapy is being used more frequently and there are concerns about the reliable operation of systems intended to support early recognition, escalation and access to specialist care for patients experiencing serious immunotherapy toxicity. The MATTERS OF CONCERN are as follows. - [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Urgent oncology advice - The Trust describes access to urgent oncology advice through a queue-based triage system and accepts that delays may occur. The response does not demonstrate how time-critical immunotherapy toxicity is reliably prioritised or escalated when delays arise. (2) Immunotherapy alert card pathway - Patients are issued with an immunotherapy alert card intended to signal urgent risk. The Trust's response does not show that possession or presentation of an alert card triggers a distinct fast-track or priority pathway, instead linking it to the same triage arrangements. These matters create a risk of future deaths where patients experiencing immunotherapy toxicity may encounter delay in accessing specialist advice and where urgent risk signals do not result in priority assessment. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you SHEFFIELD TEACHING HOSPITAL NHS FOUNDATION TRUST 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 20th May 2026. 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 SHEFFIELD TEACHING HOSPITAL NHS FOUNDATION , the wife of the deceased. TRUST and 5 6 7 8 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. 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. 19 March 2026 9 Signature Carl J Fitch H.M Assistant Coroner for
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.
Clocktower Northern General Hospital Herries Road SHEFFIELD S5 7AU 21 May 2026 Mr C J Fitch Assistant Coroner Office of H.M Coroner The Medico-Legal Centre Watery Street Sheffield S3 7ES Dear Mr Fitch Prevention of Future Deaths Report Mr Graham Ian Oxley We are writing to respond formally to your Prevention of Future Deaths (PFD) Report dated 19 March 2026, following the very sad death of Mr Graham Oxley. We are very saddened sincerely sorry for the distress and upset this will have caused his family, particularly Mrs Oxley. death, and I am In your investigation you identified that immunotherapy is being used more frequently, and you raised concerns about the reliable operation of systems intended to support early recognition, escalation, and access to specialist care for patients experiencing serious immunotherapy toxicity. We have reviewed the actions identified in your report and our response is as follows: Access to urgent oncology advice As you heard in evidence, patients receiving immunotherapy receive an alert card which advises them to contact the Weston Park Cancer Centre Assessment Unit triage line. The telephone triage service provides a 24-hour, 7-day-a-week telephone assessment and advice line for patients receiving cancer treatment under the care of Weston Park Cancer Centre. Its purpose is to ensure timely, safe, and evidence-based assessment of symptoms related to cancer and its treatments, and to direct patients to the most appropriate care setting. The phone line is staffed as follows: - - - 07:00-19:30 - At least 2 nurses; where possible, this role is rotated between a number of staff members over the period of the shift to minimise fatigue. 09:00-13:00 - An additional nurse supports the triage line to reduce morning call wait times. 19:00-07:30 - One Band 6 nurse. The nurses who staff the triage line are all experienced cancer nurses who have completed the UK Oncology Nursing Society (UKONS) Systemic Anti-Cancer Therapy competency package, which is a national, standardised framework for training and assessing nurses and practitioners handling, administering, and educating patients on Systemic Anti-Cancer Therapy (SACT). PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST Staff answering the calls use the UKONS triage tool to assess patients symptoms and identify risks; this assessment supports staff to advise on appropriate action which may include: - Referral to A&E for clinically very urgent cases - Urgent attendance at the Weston Park Assessment Unit for medical assessment - Booking for attendance at a rapid assessment outpatient clinic. received by the triage line. On review it became apparent that patients were using the triage line number because they either did not have the correct phone number or were unable to get a response on the alternative number provided. These calls led to increased waiting times for patients needing to access specialist advice and support. , we recognised that there was an increasing number of calls being In response, we have reviewed and redesigned how patients and service users contact Weston Park Cancer Centre. We have reduced the amount of contact numbers in circulation and put in place arrangements to ensure the numbers that are publicised are answered by the right team who can assist with the query. As part of this change, patients contacting the triage line are presented with three options: Option 1: Urgent medical advice Option 2: Appointments (including Radiotherapy and Chemotherapy) Option 3: Transport and Secretarial Teams This aims to ensure that patients not requiring the specialist support offered by the triage line are re-directed to a more appropriate team. This process was introduced in April 2026 and the team supporting this change are meeting weekly to review performance and address any issues following the go-live date. In response to your report, we have further reviewed the arrangements for the triage line and have identified that patients may still wait some time for their call to be answered. We have put in place call-handling escalation arrangements whereby if call wait times exceed 12 minutes, staff on the triage line escalate immediately to the inpatient matron, who will take action to arrange further cover. Where patients wait over 12 minutes, staff will incident report this, creating a clear record of any instances where the escalation process is enacted. This escalation process was introduced in early May, and we plan to audit the impact of these changes in three time. Immunotherapy alert card pathway As detailed above significant action has been taken to ensure that patients are able to access specialist advice via the telephone triage line and be provided with appropriate care. However, we acknowledge that there may be times that patients, such as Mr Oxley, present at our Accident and Emergency (A&E) Department. As I am sure you are aware there is significant pressure on A&E Departments and therefore all patients are triaged to ensure that the most clinically urgent are prioriti reviewed regularly to ensure that any change in presentation is identified, and care can be escalated as appropriate. We are aware of the risk presented by long waits experienced by patients in A&E and there is Trust wide work championed by me, as Chief Executive Officer, alongside the Chief Operating Officer to address challenges including the increased use of patient streaming to ensure patients are seen in the most appropriate locations, whilst reducing pressure on A&E, and real-time reviews of delays to inform collaborative pathway improvements. The department has a comprehensive plan aimed at reducing waiting times to see a clinician PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST and we have work underway to reduce the time patients wait for admission and overall time spent in the department. In Mr increased risk and as such he was placed appropriately in a side room. There is a clear process following medical review in A&E for patients to receive a specialist oncology review which would, where appropriate, lead to an admission to Weston Park Cancer Centre. In response to your concerns, we will review this pathway and consider if any changes are required. In addition, as you have acknowledged, cancer therapy is rapidly expanding and changing field and the oncology team is therefore providing update teaching to the entire trust, including people who work in acute and emergency care focusing on a variety of topics including immunotherapy toxicity, and rare complications of treatment such as MMM (Myocarditis, Myositis, and Myasthenia Gravis) as occurred in Mr Oxley's case. Having outlined the actions we are taking in response to your report, I hope that I have been able to convey how seriously we have viewed this matter. We are absolutely committed to learning from and implementing these actions. Furthermore, we intend Inquest to present the actions set out in this letter and to give the family the opportunity to raise any outstanding concerns not addressed at the Inquest. death Finally, I hope that my response has addressed the concerns and actions you identified in your Report. Please contact me if you have any queries or points of clarification. Yours sincerely Chief Executive PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST
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