“The hospital accepted that there were failings that contributed to Jason’s death”

The coroner’s concerns

– The hospital accepted that there were failings that contributed to Jason’s death. Measures to address those failings had not been fully implemented at the date of the Inquest. There were no applicable standard operating procedures for worsening patients in the renal unit at the date of Jason’s death and none had been implemented by the date of Inquest. Jason died on 23 March 2024. The inquest was held on 5 June 2025. The court was told that the standard operating procedures are still being drafted in relation to identifying the appropriate pathway for the admission of worsening patients in the renal unit. The clinicians were undecided on applicable processes including whether the emergency department should be the default pathway. The court found on the evidence that moving worsening patients out of the renal unit and onto in-patient facilities is imperative and should be done at the first available opportunity. Such action would reduce the risks of medication and treatment errors and delays such as that which occurred in Jason’s case. Delays due to uncertainties about appropriate pathways raises risks to patients who require the specialist treatment available on in-patient facilities. I note similar concerns have been raised in a previous Regulation 28 Preventing Future Deaths report issued following the death Mr M.R. Jervis, [PFD dated 30.12.2024]. This earlier R28 report noted failings by AMU and other nursing staff to administer antibiotics when clinical observations repeatedly indicated such was required. The Jervis R28 report raised a concern regarding the absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six, including the need to administer antibiotics. It is unclear whether this measure has been introduced and if not, whether a digital alert would have made a difference in Jason’s case.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0336

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0