Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0333, written 8 Jul 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jul 2026 |
|---|---|
| Reference | 2026-0333 |
| Deceased | Marie Bell |
| Coroner | Abigail Combes |
| Coroner area | Sunderland |
| Organisation named | South Tyneside and Sunderland 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.
David Place Senior Coroner for the City of Sunderland REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 1. CORONER I am Abigail Combes, His Majesty’s Assistant Coroner for the City of Sunderland. 2. DATE OF REPORT This 8th day of July 2026 3. 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. 4. THIS REPORT IS BEING SENT TO: NHS England You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd September 2026. I, the Coroner, may extend the period if an appropriate application is made. 5. 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. 6. SUMMARY OF CORONER’S CONCERN Marie Bell underwent a FIT test in January 2025. The result was a positive result, which she was made aware of in February 2025 and sent for a colonoscopy. Unfortunately due to imminent hip surgery she was unable to get into the positions required for the administration of the colonoscopy, and it would appear that she was then deemed to have declined further testing from the Screening Service. She still had symptoms, but these were not recognised as being significant until July 2025, when she was referred for a CT scan which identified a mass within the abdomen. This mass was ultimately found to be cancerous following a surgical procedure and, although the mass had not significantly increased in size, the delay between February and July for the surgery meant that Marie’s abdomen was distended, and the surgery was more complicated as a result. Ultimately Marie died as a result of an error in the surgery, which was not caused by the delay, however there will be cases where the delay is of significant impact on patient outcome. The primary concern is that there seems to be an erroneous view that Marie had declined testing from the Screening Service due to a physical condition, which meant she could not have the test which was offered. There is no evidence that an alternative, such as a CT scan, was offered which would have offered an earlier diagnosis. 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 you have the power to take such action. 8. INVESTIGATION AND INQUEST On 7th August 2025 I commenced an Investigation into the death of Marie Bell, aged 58 years. The Investigation concluded at the end of the Inquest on 7th July 2026. The medical cause of death was confirmed as: - Ia Faecal Peritonitis Ib Latrogenic Small Bowel Perforation (operated) Ic Obstructing Sigmoid Bowel Cancer (operated) On 25 July 2025 Marie Bell underwent a procedure to remove a bowel obstruction. There were no noted complications within that surgery however it would appear that during the procedure the diathermy implement has made contact with the small bowel causing a scorch and subsequent perforation which was not noted during the surgery. This perforation was not noted until Marie deteriorated on 27 July 2025 and despite surgery to repair the perforation on 28 July 2025 it was unsurvivable and she died at hospital on 29 July 2025. I gave the following narrative conclusion: - ‘On 25 July 2025 Marie Bell underwent a procedure to resolve a bowel obstruction. Unfortunately she suffered a perforation of her small bowel as a consequence of the surgery and went on to develop faecal peritonitis resulting in her death on 29 July 2025.’ 9. CIRCUMSTANCES OF DEATH On 25 July 2025 Marie Bell underwent a procedure to remove a bowel obstruction. There were no noted complications within that surgery, however, it would appear that during the procedure the diathermy implement had made contact with the small bowel causing a scorch and subsequent perforation which was not noted during the surgery. This perforation was not noted until Marie deteriorated on 27 July 2025 and, despite surgery to repair the perforation on 28 July 2025, it was unsurvivable and she died at hospital on 29 July 2025. Page 2 of 3 The obstruction was directly related to a tumour, located within Marie’s bowel, which had been present in February 2025 when Marie had a positive FIT test, and therefore could have been diagnosed earlier and surgery performed earlier. The reason for not diagnosing cancer in February 2025 is that Marie was physically unable to undergo a colonoscopy due to imminent hip surgery, and the Screening Service deemed her to therefore be declining investigations rather than identifying alternative methods of investigation. This did not make a difference to the outcome for Marie but may for others. 10. 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:- Where one means of investigation is not suitable for a patient due to comorbidities or conditions this does not mean that the patient is declining all investigations and an alternative should be explored. I shall be glad to be told of any learning arising from Marie’s death and timescales and results of your review. 11. 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: • Family and their Solicitors and Counsel • South Tyneside and Sunderland NHS Foundation Trust 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 Prevention of Future Deaths Reports 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 His Majesty’s Assistant Coroner for the City of Sunderland Page 3 of 3
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 Abigail Combes
HM Assistant Coroner for the City of Sunderland
Office of HM Coroner for Sunderland
and HM Coroner’s Courts
City Hall
Plater Way
Sunderland
SR1 3AA
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
24th August 2026
Dear Ms Combes,
Re: Regulation 28 Report to Prevent Future Deaths – Marie Bell who died on
29th July 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th July
2026 concerning the death of Marie Bell on 29th July 2025. In advance of responding
to the specific concerns raised in your Report, I would like to express my deep
condolences to Marie’s family and loved ones. NHS England is keen to assure the
family and yourself that the concerns raised about Marie’s care have been listened to
and reflected upon.
Your Report raised concerns that alternative screening tests were not offered when
Marie was unable to tolerate the planned colonoscopy procedure due to her
comorbidities. This was then incorrectly marked as her having declined the test.
NHS England can confirm that there is existing published national guidance which sets
out the Bowel Cancer Screening pathway requirements which includes actions
required regarding colonoscopy or other diagnostic tests.
The guidance stipulates that ‘screening centres must have systems in place to:
• Provide clinic appointments with Specialist Screening Practitioners (SSP) who
are trained in accordance with Specialist Screening Practitioners education and
training requirements to assess fitness for colonoscopy (or other diagnostic tests)
and discuss the procedure.
• Make sure individuals offered colonoscopy are fully aware of what the procedure
entails (including possible benefits and risks), and accurately document their
consent.
• Undertake screening colonoscopies in line with programme guidelines on
colonoscopy, using screen accredited colonoscopists (guidance on accreditation
is available from the Bowel Cancer Screening Accreditation (BCSA) website.
• Offer computed tomographic colonography (CTC) where an individual is
medically unsuitable for colonoscopy.
• Contact patients the day after colonoscopy to check there are no complications
following the procedure and to confirm when to expect results’
There is also published national guidance which covers the scenarios of individuals
being unfit for colonoscopy and where there is an incomplete colonoscopy. The
guidance states as follows:
‘2. Patients unfit for colonoscopy
For patients with significant comorbidities the risks of colonoscopy may outweigh the
benefits. In these situations, a clinical decision should be made by a BCSP accredited
colonoscopist in conjunction with the patient, to discuss if any screening intervention
is appropriate.
In cases where a patient is unfit for colonoscopy and the clinical condition will not
improve, the patient can be ceased from screening following discussion with the
patient. This should be documented within the patient’s episode notes on the bowel
screening IT system (BCSS) (refer to Bowel Cancer Screening Consent and Ceasing
Guidance).
Some patients who are currently unfit for colonoscopy may have a condition that is
likely to clinically improve or be on medication such as anticoagulants that should not
be stopped for a diagnostic procedure. In these situations, a clinical decision should
be made referring to relevant guidance (e.g. BSG and ESGE anticoagulation
guidance 2021) as well as seeking external advice from specialist clinicians if
to assess
appropriate (e.g. haematologist/cardiologists/alcohol
suitability for colonoscopy. Options should then be discussed with the patient on when
and how to proceed. All patients on anticoagulants alone with a history of prior
coronary stents must be either switched to aspirin or discussed with an interventional
cardiology consultant first (refer to Addendum to BSG anticoagulation guidance issues
3 June 2024).
teams)
liaison
Alternative options may include:
• A computed tomography colonoscopy (CTC) for those that meet the criteria for
a colonoscopy but who are assessed as medically unfit for the procedure (refer
to BCSP Guidelines for CTC Imaging). This includes those with complex, severe
co-morbidities, with medication or mobility needs making the risks or difficulties
of colonoscopy unacceptable, those with significant neurological, cardiovascular
or respiratory co-morbidities which might compromise the safety of the
procedure and those that are deemed too frail to undergo standard laxative
bowel preparation.
• A diagnostic colonoscopy.
• Or to delay the colonoscopy.
A subsequent plan for management of any pathology identified must be agreed with
the patient.
These decisions must be documented and episode notes entered onto BCSS to
ensure that all reports and alerts are acted upon to ensure timely progression and
closure of a patient episode.
Under the Equality Act 2010, screening providers have a legal duty to make
reasonable adjustments to make sure services are accessible to people with learning
and physical disabilities. NHS bowel cancer screening: identifying and reducing
inequalities provides more information on identifying and reducing inequalities.’
‘4. Colonoscopy procedure
In the case of an incomplete colonoscopy, it is at the discretion of the BCSP accredited
colonoscopist to request a repeat procedure, possibly by an alternative BCSP
accredited colonoscopist or with an alternative bowel preparation, or to request a
BCSP computed tomography colonoscopy (CTC)’.
In line with published guidance, where one means of investigation is not suitable for
an individual due to comorbidities, we would expect a clinical discussion to have taken
place and be documented regarding next steps, rather than there being an assumption
the individual has declined all investigations without exploring alternatives.
The National Bowel Cancer Screening programme team at NHS England will work
with local services to ensure the published national guidance is understood and
implemented. A message was sent from the screening quality assurance service as a
reminder of the guidance in July and an update will be included at the next national
colonoscopy network meeting in Quarter 3 of 2026/27.
Regional Response
North East and Yorkshire regional colleagues have advised that North East and North
Cumbria Integrated Care Board (ICB) will ask the Trust for a review of their criteria for
patients referred for Faecal Immunochemical Tests (FIT) but who are unable to
undergo a colonoscopy. They will establish the criteria for when deeming a patient to
have ‘declined’ treatment, what their mitigations are and whether they have consultant
oversight. The ICB have advised that they will use the learning from this Report to
highlight this as a system risk.
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 Marie,
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 Director of Patient Safety
NHS England
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