“(brief summary of matters of concern) i) Failure to document consent discussions - The…”

The coroner’s concerns

(brief summary of matters of concern) i) Failure to document consent discussions - The record of discussions with Billy about the NG tube was poor. Despite the Trust having a "Policy & Guidelines for Consent to Examination or Treatment" in place since January 2020 (reviewed February 2024), there was a failure to comply with these guidelines in Billy's case. The policy required clear documentation, but this was not followed in Billy's case. The Trust’s subsequent assertion in submissions that policy and training are sufficient is undermined by the fact that the policy was in place but not followed ii) Inadequate explanation of risks to patients - I found that the necessity and risks of declining the NG tube were probably not sufficiently explained to Billy at any stage. There was certainly no supporting evidence to suggest the contrary. iii) Policy non-compliance - Despite a comprehensive policy being in place, there was a failure to implement it in practice, suggesting a gap between policy and practice that may affect other patients. The existence of a policy is not sufficient if it is not followed in practice. The inquest demonstrated a failure of implementation, not of policy content. iv) Absence of clear responsibility - There appeared to be a disconnect in terms of who was actually responsible for ensuring the need for an NG tube was explained to Billy. The assessing anaesthetists thought he needed an NG tube and the surgeons thought he needed an NG tube, but neither took ultimate responsibility for ensuring that this was adequately and, if needed, strongly explained and implemented. No one professional led on this vital aspect of his care. I conclude that, since the policy was not followed despite being in place, there remains a risk of recurrence unless there is assurance of effective implementation and monitoring. These concerns are likely to manifest and be replicated across England and Wales requiring me to send this report to the Royal Colleges and Association of Anaesthetists.

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, 2025-0496

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