“Mr Teesdale’s care was compromised by the isolated position and associated lack of…”

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.

1. Mr Teesdale’s care was compromised by the isolated position and associated lack of facilities and other sub-speciality medical and surgical clinical personnel able to assist in the investigation and management of Mr Teesdale at Queen Victoria Hospital, East Grinstead. More particularly: 2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery, thereby requiring oral maxillo-facial surgeons of _ variable and unclear experience to undertake the procedure peri-operatively. 3. Written guidance by the surgeons for insertion of PEG’s was not followed with little reflection as to whether this was an acceptable procedure given Mr Teesdale’s previous extensive surgery at or around the point where the PEG was inserted with concomitant poor gastroscopic trans-illumination. 4. No risk assessment was undertaken as to whether a PEG insertion would have been appropriate, given that a non-invasive alternative of a feeding tube for enteral feeding was available. 5. No formal ‘training’ programme for the insertion of PEG or independent competency based assessment. 6. The post-operative management of Mr Teesdale did not follow the written guidance for the management of abdominal pain after PEG insertion. This resulted in a delay in seeking appropriate advice, timely intervention and optimal treatment of this complication. ‘s 4 i \ Me AS, LE oO et ET RMIMON Die” 7. Mr Teesdale’s transfer was delayed because of a reluctance to transfer in the immediate post operative period complicated by the associated logistical difficulties of doing so given his major surgery. 8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications. As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’. 9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial surgeon with unknown general surgical experience who did not recognise or manage the severity of a surgical complication. 10. There was no recognition of how unwell Mr Teesdale was on the consultant surgical ward round at or around 0900 on the 19" October 2016, despite considerable evidence present at the time that Mr Teesdale had developed multi-organ failure. 11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day. 12. There are no haematology or biochemistry services at QVH. A courier service is required for emergency laboratory tests. This has the potential to either not request ‘bloods’ and/or a delay in obtaining results. Similarly, there is no ‘out of hours’ radiology service and there is no CT scanner on site to assist in a diagnosis (which was required as part of the management guidelines prepared by QV#H).

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, 2017-0202

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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