Ellen Taylor

The report

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REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  

1. NHS England 

1 

CORONER 

I am Miss Sarah Middleton, Assistant Coroner, for the Coroner Area of 
Northumberland. 

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  2nd  July  2025  an  investigation  was  commenced  into  the  death  of  Ellen 
Victoria Floyd Taylor aged 69 years. The investigation concluded at the end of 
the inquest on 29th January 2026. 

The narrative conclusion of the inquest was:  

Ms Taylor died from acute peritonitis, an infection that occurred due to her small 
intestine being perforated by the insertion of a nasogastric tube. Although the 
nasogastric tube was inserted appropriately the lack of knowledge of her altered 
anatomy and her previous surgery meant a perforation was not recognised until 
the peritonitis had developed. 

4  CIRCUMSTANCES OF THE DEATH  

Ellen Victoria Floyd Taylor, aged 69 years, had previously undergone gastric 
bypass  surgery  and  as  a  result  her  oesophagus  was  attached  to  her  small 
bowel. She had a history of strokes and was admitted to Northumbria Specialist 
Emergency  Care  Hospital  on  25th  June  2025  where  she  was  found  to  have 
suffered another stroke. The fact that she has previous gastric surgery was not 
known by the treating professionals. A nasogastric feeding tube was inserted 
on 25th June 2025 as there was a clinical need for this. Over the next few days 
Ms Floyd Taylor suffered abdominal pain. A CT scan of her abdomen on 29th 
June 2025 showed the nasogastric tube had perforated her small intestine. This 
was  due  to  her  altered  anatomy  from  the  previous  bypass  surgery.  The 
nasogastric tube could not be placed in her stomach and over the days she has 
had  it  inserted  it  has  caused  the  perforation.  Due  to  the  perforation  acute 
peritonitis  had  developed.  She  was  not  a  candidate  for  surgery  and  so  was 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 managed conservatively and died on 1st July 2025 at Northumbria Specialist 
Emergency Care Hospital, Northumbria Way, Cramlington, Northumberland.  

5  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 MATTERS OF CONCERN are as follows.  

(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this 
her oesophagus was not attached to her stomach but instead attached 
to her small bowel. 
On 25th June 2025 she was admitted to hospital having suffered a stroke 
and was deemed to require a nasogastric tube. 
The fact that she has previous surgery and her anatomy was therefore 
altered  was  not  obvious  from  her  notes.  As  such  when  complications 
began this was not something that was considered and investigations 
about potential perforation were not undertaken initially. 

(2) I heard evidence that the time there were no guidelines about insertion 
of nasogastric tubes in circumstances where someone had had previous 
gastric surgery. 

The Northumbria Healthcare NHS Foundation Trust identified areas of 
learning as a result of the circumstances of Ms Taylor’s death. The key 
finding  from  the  After  Action  Review  was  that  the  previous  gastric 
surgery was not recognised at the time of the nasogastric tube insertion.  

Previous surgery was not a routine consideration and not included within 
the nasogastric tube guideline. Local guidelines have now changed and 
consultation  with  on-call  surgical  team  for  guidance  about  insertion  of 
the tube in these circumstances is now included in the process. Training 
has  taken  place  and  a  clinical  safety  message  circulated  to  increase 
awareness. 

Whilst the local NHS Traut have taken and implemented these steps my 
concern is that there is a wider risk, and these are circumstances that 
are  relevant  to  every  NHS  trust  nationally  and  there  is  a  risk  future 
deaths will occur unless action is taken. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe 
you and your organisation has the power to take such action by ensuring 
thorough safeguarding reviews take place and all parties are notified of the 
conclusion and involved fully in the process. 

7 

YOUR RESPONSE 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You are under a duty to respond to this report within 56 days of the date of 
this report, namely by 4th 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons; the family of Ellen Victoria Floyd Taylor, and Northumbria 
Healthcare NHS Trust. 

I am also under a duty to send the Chief Coroner a copy of your response 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: 9th February 2026 

Sarah Middleton 
HM Assistant Coroner for Northumberland   

3

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