On 10th November 2020, commenced an investigation into the death of Mr. John Charles LOTT The investigation concluded at the end of the inquest on 29th April,; 2021.The conclusion of the inquest was a Narrative Conclusion: JOHN LOTT DIED FOLLOWING ELECTIVE SURGERY FOR A DEFUNCTIONING ILEOSTOMY. POST-OPERATIVELY THERE WERE TWO MISSED OPPORTUNITIES TO TRANSFER HIM FROM THE PRIVATE HOSPITAL TO AN ADJACENT HOSPITAL WITH LEVEL 2 AND 3 INTENSIVE CARE FACILITIES. HAD HE BEEN TRANSFERRED WHEN HE SHOULD HAVE BEEN IT IS POSSIBLE THAT THE OUTCOME FOR HIM WOULD HAVE BEEN DIFFERENT: CIRCUMSTANCES OF THE DEATH John Lott was a 78 year old man who had a procedure to form a defunctioning ileostomy on 21.10.20. Post-operatively there were two occasions (on the 27th and_the 29tb) when_he_was sufficiently unwell to require transfer from the City -

VERONICA HAMILTON-DEELEY DL, THE CORONER 'S OFFICE LLB_ Her Majesty's Senior Coroner WOODVALE, LEWES ROAD for the of Brighton & Hove BRIGHTON Fax: Brighton (01273) 292047 private hospital where he was; to the acute NHS hospital which had the intensive care facilities which FIND that he needed: He was not transferred on either occasion: He deteriorated rapidly and around the time of transfer, on a background of inadequately treated hypoglycaemia, he suffered myocardial ischaemia and infarction. He did not have the reserves to recover from this and died on 8th November 2020. See Record of Inquest CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you The MATTERS OF CONCERN are as follows_ (1) 27th October 2020, Mr. Lott's NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29th October Mr: Lotts hypoglycaemia was not being managed. He should have been transferred. (3) When the Consultant "in charge" of Mr; Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers? ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 29th July 2021. 1, the Coroner may extend the period . Your response must contain details of action taken or proposed to be taken, out the timetable for action: Otherwise you must explain Why no action is proposed. City On Why days setting

VERONICA HAMILTON-DEELEY LLB THE CORONER 'S OFFICE WOODVALE, LEWES ROAD Majesty' s Senior Coroner for the City of Brighton & Hove BRIGHTON Fax: Brighton (01273) 292047 COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons Wife

John Lott was a 78 year old man who had a procedure to form a defunctioning ileostomy on 21.10.20. Post-operatively there were two occasions (on the 27th and_the 29tb) when_he_was sufficiently unwell to require transfer from the City -

VERONICA HAMILTON-DEELEY DL,