“On 13 January 2024 acute Trust Hospital ward staff noted a split in the lumen of the…”
Dated 12 Dec 2024, from the coroner for Essex. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 6 Feb 2025.
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; a reply may have been sent and not yet published.
- Report dated12 Dec 2024
- Deadline6 Feb 2025
- Published on judiciary.uk18 Dec 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mid and South Essex NHS Foundation TrustNamed in the report as “Mid & South Essex NHS Trust” | Response publishedPublished on judiciary.uk in December 2024. |
The coroner’s concerns
– (1) On 13 January 2024 acute Trust Hospital ward staff noted a split in the lumen of the Hickman Catheter and this was clamped and dressed. (2) The incident was escalated for urgent medical review due to the significant risk of infection, however no Datix was raised for the split Hickman Catheter as required by the acute Trust protocol. (3) Mr Burroughs had a jejunal extension to his PEG on 15 January 2024. Advice was received that the Hickman Catheter should be removed as soon as possible if it was not being used. (4) Mr Burroughs was tachycardic and spiked a temperature on 19 January 2024 with no apparent symptoms of recurrent aspiration and the Hickman Line remained in situ. (5) The Hickman Catheter was surgically removed on 30 January 2024.
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, 2024-0685
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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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