Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0325, written 10 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2026 |
|---|---|
| Reference | 2026-0325 |
| Deceased | Glen Jay |
| Coroner | Jyoti Gill |
| Coroner area | Essex |
| Organisation named | Mid and South Essex NHS Foundation Trust |
| Source | judiciary.uk record |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England 1 CORONER I am Jyoti Gill, assistant coroner, for the coroner area of Essex 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 14 March 2025 an investigation into the death of Glen Edward Robert Jay commenced. The investigation concluded at the end of the inquest on 27 February 2026. The conclusion of the inquest was a narrative conclusion which stated that Glen Edward Robert Jay died of complications arising from a necessary surgical procedure. 4 CIRCUMSTANCES OF THE DEATH Glen Edward Robert Jay was admitted to Broomfield Hospital on 10 February 2025 as part of planned preoperative preparation for abdominal wall reconstruction. Mr Jay had a history of adhesional small bowel obstruction. During this admission an emergency laparotomy was performed to address a small bowel obstruction with suspected associated ischaemia and a further resection of the bowel followed by an anastomosis and an abdominal wall closure. Mr Jay was admitted to the intensive care unit on 24 February 2026. Following surgery on 26 February 2026 Mr Jay did not regain consciousness and his condition deteriorated following severe sepsis. Sadly, Mr Jay died at Broomfield Hospital (Heybridge Ward) on 8 March 2025. 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 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 are other clinics nationally who may be offering patients Preoperative Progressive Pneumoperitoneum (PPP) to patients who have a history of adhesional small bowel obstruction (ASBO). Mid & South Essex NHS Foundation Trust have updated their protocol to include a prior history of recurrent ASBO, as a contraindication to PPP. This is because it can induce ASBO due to stretching of any intra-abdominal or hernia sac adhesions and consequent obstruction of involved loops of small bowel. 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. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 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 (wife and next of kin of Mr Jay) Chief Executive of Mid & South Essex 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 other 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. 9 DATED: 10 May 2026 Assistant Coroner for Essex 2
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.
Ms Jyoti Gill
Assistant Croner
Essex and Thurrock Coroner’s Service
Essex County Council
Seax House
Victoria Road South
Chelmsford
CM1 1QH
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
25th June 2026
Dear Ms Gill,
Re: Regulation 28 Report to Prevent Future Deaths – Glen Edward Robert Jay
who died on 8 March 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10 May
2026 concerning the death of Glen Edward Robert Jay on 8 March 2025. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Glen’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Glen’s care have been listened
to and reflected upon.
Your Report raised concerns that clinics may be offering Preoperative Progressive
Pneumoperitoneum (PPP) to patients who have a history of recurrent adhesive small
bowel obstruction (ASBO).
Progressive Preoperative Pneumoperitoneum (PPP) is only performed at a handful of
specialist centres prior to complex abdominal wall reconstruction in England. It is
reserved for very large incisional hernias where there is no alternative operative
strategy.
Botox injections are more widely used in many centres throughout England prior to
abdominal wall reconstruction and are typically given 6 weeks before surgery.
The evidence base and literature on this area is limited. Two recently published PPP
protocols [i, ii] do not mention prior bowel obstruction as a contraindication.
From reading the Report and accompanying inquest bundle, it appears that Glen had
a fairly aggressive regimen of PPP with high volumes of air introduced at each setting.
Most published protocols for PPP suggest omitting further insufflation or deflation if
the patient has significant pain. Further insufflation was omitted when Glen developed
pain, but deflation did not take place in this case, and there seems to have been a
significant delay in instigating emergency surgery when Glen deteriorated.
3
As a result of the concerns, raised NHS England plans to compile a warning notice to
Chief Medical Officers/Medical Directors of all Trusts currently providing or considering
PPP to state:
1.
2.
3.
There should be an enhanced governance framework around the provision
of Preoperative Progressive Pneumoperitoneum (PPP) before abdominal
wall reconstruction which should include formal Trust approval to carry out
the procedure, a detailed written local protocol for PPP and enhanced
consent.
All patients being considered
for PPP must be discussed at a
Multidisciplinary Team (MDT) meeting and the result of the MDT discussion
documented in the patient record.
Local protocols and MDT discussion should include:
a. Consideration of previous acute small bowel obstruction as a relative
contraindication to PPP
b. Provision to stop or reverse PPP in the event of the patient experiencing
severe pain
c. Provision for immediate surgical intervention in the event that bowel
ischaemia or perforation is suspected.
4.
Local teams should audit their results following PPP and report any
episodes of patient harm using local patients safety reporting systems.
NHS England plans to work with the British Hernia Society to disseminate the warning
notices.
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 Glen,
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
i
Preoperative progressive pneumoperitoneum: insights on implementation in an ambulatory care setting. How I do it?
ii A structured protocol for Preoperative Progressive Pneumoperitoneum (PPP) in Complex Abdominal Wall Reconstruction
(CAWR): our York protocol - PMC
4
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