John Loannou
PFD Report
No Identified Response
Ref: 2026-0137
Coroner's Concerns (AI summary)
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with a profoundly learning disabled patient.
View full coroner's concerns
1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored.
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored.
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
Sent To
- Barts Health NHS Trust
- Department of Health and Social Care
Response Status
Linked responses
0 of 2
56-Day Deadline
5 May 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 24th June 2025, this court commenced an investigation into the death of John Ioannou aged 61 years The investigation concluded at the end of the inquest on 9th March 2026.
The inquest concluded with a Narrative conclusion, “John Ioannou died at home on 24th June 2025 having sustained a cardiac arrest brought about by peritonitis. The source of his peritonitis was an infection in his stomach and small intestine caused by a Percutaneous Endoscopic Gastrostomy (PEG) apparatus.
Mr Ioannou’s medical cause of death was determined as;
1a Peritonitis 1b Infected Peg Tube II Congenital Cerebral Palsy
The inquest concluded with a Narrative conclusion, “John Ioannou died at home on 24th June 2025 having sustained a cardiac arrest brought about by peritonitis. The source of his peritonitis was an infection in his stomach and small intestine caused by a Percutaneous Endoscopic Gastrostomy (PEG) apparatus.
Mr Ioannou’s medical cause of death was determined as;
1a Peritonitis 1b Infected Peg Tube II Congenital Cerebral Palsy
Circumstances of the Death
John Ioannou was a 61-year-old, non-verbal man who received 24-hour care in a residential care home in East London. Mr Ioannou was fed a liquid diet through a piece of apparatus called a Percutaneous Endoscopic Gastrostomy (PEG).
On the afternoon of 23rd June 2025, Mr Ioannou attended an outpatient appointment at Whipps Cross Hospital to resolve a problem with his PEG. It was believed that the apparatus had become adhered to the lining of his stomach a process called a “buried buffer”. The apparatus was manipulated, under force, to push the buffer into the void of the stomach and then to rotate the apparatus to free it from the stomach lining. In the early evening he was discharged back to his care home. No written discharge summary was provided to Mr Ioannou’s carers.
In the hours that followed, John experienced pain and became agitated. At approximately 06.45 on 24th June 2025 John sustained a cardiac arrest, despite the best efforts of the emergency services he could not be resuscitated.
An autopsy identified that an infection, the seat of which was the PEG site, had spread from John’s stomach, into his small intestine and had caused peritonitis in his abdomen.
On the afternoon of 23rd June 2025, Mr Ioannou attended an outpatient appointment at Whipps Cross Hospital to resolve a problem with his PEG. It was believed that the apparatus had become adhered to the lining of his stomach a process called a “buried buffer”. The apparatus was manipulated, under force, to push the buffer into the void of the stomach and then to rotate the apparatus to free it from the stomach lining. In the early evening he was discharged back to his care home. No written discharge summary was provided to Mr Ioannou’s carers.
In the hours that followed, John experienced pain and became agitated. At approximately 06.45 on 24th June 2025 John sustained a cardiac arrest, despite the best efforts of the emergency services he could not be resuscitated.
An autopsy identified that an infection, the seat of which was the PEG site, had spread from John’s stomach, into his small intestine and had caused peritonitis in his abdomen.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.