“During the inquest I heard evidence that the jejunostomy feeding protocol in place at the…”

The coroner’s concerns

– During the inquest I heard evidence that the jejunostomy feeding protocol in place at the time of Lee's admission was insufficient and, in part not followed. This on balance, likely contributed to his death. As a result a new jejunostomy feeding protocol was implemented in September 2022. Despite this a Datix was never raised and a Duty of Candour letter was not sent to the family in accordance with Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the "Regulations"). Furthermore, information about the identification of this clearly relevant issue was not provided to the Coroner ahead of the inquest hearing (which was subsequently adjourned) on 30 June 2023, or in response to any further requests for evidence. It was only when a specific question was put to the Trust by the Coroner in relation to the existence of a protocol and whether it was followed that this information was provided. This was in September 2025, two years after the new protocol had been introduced in direct response to Lee's death. I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations; has not provided relevant documentation to the Coroner in 2 accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA"); and has not investigated this incident in accordance with the requirements to do so under Datix. I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths. I would like to understand the governance processes in place at the Trust to ensure that: 1. Incidents are properly investigated via the Trust's internal processes; 2. Regulation 20 - Duty of Candour is complied with; and, 3. Disclosure duties under Schedule 5 CJA are properly adhered to.

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, 2025-0626

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