“The damage found to Jackson’s liver at post mortem does not appear to be from the tip of…”
Dated 27 Oct 2014, from the coroner for Norfolk. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 22 Dec 2014. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated27 Oct 2014
- Deadline22 Dec 2014
- Published on judiciary.uk27 Oct 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Dec 2014. A reply may have been sent and not yet published. |
| Norfolk and Norwich University Hospitals NHS Foundation TrustNamed in the report as “Norfolk and Norwich University Hospital NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 22 Dec 2014. A reply may have been sent and not yet published. |
| The Queen Elizabeth Hospital, King's Lynn, NHS Foundation TrustNamed in the report as “The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust” | Response publishedPublished on judiciary.uk in October 2014. |
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The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— The damage found to Jackson’s liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it. Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T10 vertebral level. The UVC in this case was found to be in a lower lying position, but one which is presently acceptable to 80% of Doctors. There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period. Extravasation was shown following routine screening of ultra sound scans, although in the study there were no fatalities. Most of the complications in the study occurred with low lying catheters. ' Further investigation is being carried out into the positioning of catheters and problems of extravasation of the fluid from UVC. It is understood NHS England are looking into whether any lessons can be learned from this case. No criticism was expressed at the inquest of any of the medical team involved in the care of Jackson.
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, 2014-0468
- 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
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