Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0304, written 5 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2026 |
|---|---|
| Reference | 2026-0304 |
| Deceased | Keith Gandy |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. CORONER I am Andrew Walker, HM Senior Coroner for the coroner area of North London. 2. DATE OF REPORT 5th June 2026 3. 3. 4. 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. THIS REPORT IS BEING SENT TO 1. NHS England 2. 3. You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st July 2026. I, the coroner, may extend the period if an appropriate application is made. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 5. SUMMARY OF CORONER’S CONCERN Previous cancer is a red flag and a referral should be made without waiting for further tests. Guidance to GPs where referral for specialist evaluation waiting times are between 6 months to 12 months. 6. 7. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. INVESTIGATION AND INQUEST On 30th October 2025, I commenced an investigation into the death of Keith Richard Gandy aged 65 years. The medical cause of death was 1a. Multiorgan Failure 1b. Radiation-induced osteosarcoma of the pelvis (operated on 13/10/2025) II. Prostate Cancer How, when and where Keith Richard GANDY died in the Royal National Orthopaedic Hospital (Stanmore, London) on the 29th October 2025. Conclusion Keith Richard GANDY died as a consequences of a delay in recognition of a radiation induced osteosarcoma. 8. CIRCUMSTANCES OF DEATH Keith Richard Gandy died in hospital on the 29th October 2025 after a lengthy period of deterioration following first presentation to his surgery following a fall. Mr Gandy had previously had prostate cancer and the focus was on concerns that the cancer had returned or spread together with pain management. The reason that Mr Gandy was in so much pain was discovered when a doctor at the surgery suspected a pubic rami fracture and Mr Gandy was sent to a walk in X-ray centre on the 8th August 2025. Mr Gandy was found to have an osteosarcoma. Mr Gandy was taken to theatre on the 13th October 2025 but despite this failed to recover. This was an extremely rare radiation induced osteosarcoma which, even if caught earlier, is likely to have had a poor outcome. 9. CORONER’S CONCERNS During the course of the inquest I heard evidence 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: There was no guidance to GPs that underlines that previous cancer is a red flag and a referral for a specialist opinion should be made without waiting for further tests. That referral waiting times for specialist evaluation in these circumstances are between 6 months to 12 months 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. NHS England 2. The Gandy family 3. The Royal National Orthopaedic Hospital 4. Bedfordshire Hospital NHS Trust 5. Putnoe Medical Centre I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE HM Senior Coroner Mr Andrew Walker
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.
Mr Andrew Walker
HM Senior Coroner for North London
Barnet Coroner’s Court
29 Wood Street
Barnet
EN5 4BE
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
31st August 2026
Dear Mr Walker,
Re: Regulation 28 Report to Prevent Future Deaths – Keith Richard Gandy who
died on 29th October 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5th
June 2026 concerning the death of Keith Richard Gandy on 29th October 2025. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Mr Gandy’s family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Mr Gandy’s care
have been listened to and reflected upon.
Your Report raised the following concerns:
1. That there is no guidance for GPs highlighting that a previous cancer in a
patient is a red flag, and a referral for a specialist opinion should be made
without waiting for further tests.
2. The referral waiting times for specialist evaluation in these circumstances are
between 6 to 12 months.
A lack of guidance for GPs
National Institute for Health and Care Excellence (NICE) guidance NG12 Suspected
cancer: recognition and referral, advises that clinicians use judgement when
symptoms present in people with higher baseline cancer risk. Whilst it does not
specifically list previous cancer as a red flag, a history of cancer is widely recognised
clinically as such a factor.
GPs should be aware of 1) the risks of cancer recurrence in people who have been
diagnosed with cancer, 2) the carcinogenic risk of some cancer treatments, such as
radiotherapy, which we anticipate they could and would draw on in the management
of patients, even in the absence of specific guidance on this topic.
Based on information in the inquest bundle, it would seem that in this case, the GP did
consider metastatic prostate cancer quite quickly and
investigation
accordingly.
initiated
On treatment-related cancer risks, we would expect any risks of cancer treatment,
such as the risk of radiation-induced subsequent cancers, to be outlined to the patient
at the point of treatment consent and reflected in the consent form.
Referral waiting times
This is primarily a matter for the region and the commissioners and providers in the
locality. However, we would note that in this instance, the patient was seen by the
sarcoma Multi Disciplinary Team very soon after the imaging suggested the diagnosis
of sarcoma. The interval between the raised alkaline phosphatase noted in primary
care and his first admission was 3 weeks, and he went on to the sarcoma service
rapidly thereafter.
Regional response
Central East Integrated Care Board (ICB) have advised that the practise has confirmed
that Mr Gandy’s care was reviewed through a formal Significant Event learning
meeting as part of an internal practice learning session. The practice has confirmed
that its review did not identify any specific patient safety issues requiring further action
by the practice and that, overall, the care provided was considered to have followed
appropriate clinical guidance.
The practice did however, identify additional local learning from the case including the
following:
• The importance of being alert to possible ‘red herrings’ in clinical presentation,
initially appear consistent with
particularly where symptoms may
musculoskeletal injury or another diagnosis.
• The need to carefully examine and reassess the precise anatomical location of
pain to ensure that any imaging or further investigation covers the area of
clinical concern.
• Where a patient is clinically unwell, consideration should be given to whether
hospital admission may be appropriate or required to expedite investigations.
The practice has advised that learning from this case has been disseminated with the
wider clinical team during the Significant Event learning meeting which was attended
by the clinicians working that day.
The ICB have advised that they have been assured that the practice has reviewed the
case through its Significant Event learning process, has considered whether any
patient safety issues were identified and has shared the learning within the practice.
The ICB will also consider the broader learning from this case, particularly around
persistent or evolving pain symptoms, previous cancer history, clinical reassessment
and escalation, can be shared though appropriate primary care quality and patient
safety routes. NHS England will share a copy of our response to your Report with the
ICB to support this.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Mr
Gandy, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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