Dear Dr Cummings Thank you for sending your “Regulation 28: report to prevent future death” letter to the RCS England, and for giving us the opportunity to respond. We were saddened to read the circumstances of Billy King’s death and we offer our sincere condolences to his family. Your report highlights a number of concerning issues in relation to the shared decision-making process between Billy and the surgical care team, that occurred in the perioperative care of this patient. Although we have no regulatory powers, the College provides extensive advice and guidance to the surgical care team on all aspects of their practice, including matters around consent, communication and team working. With regard to our currently published advice and guidance:

• The College has produced guidance on Consent: Supported Decision-Making which lays out the key principles that underpin the consent process. This guidance emphasises that for the patient’s consent to be considered informed, surgeons must be satisfied that the patient has received and understood full and sufficient information about the proposed treatment and its implications. This includes presenting the various treatment options and discussing their relative risks and benefits side by side. It makes clear that consent should be patient-specific, and that surgeons should communicate the risks that are material to the particular patient and their circumstances. Our guidance also emphasises that surgeons should maintain a written decision-making record that contains contemporaneous documentation of the key points of the consent discussion, including documentation of any discussion around consent with the patient’s supporters and with colleagues.

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• The same principles around the consent process are emphasised in our core standards document, Good Surgical Practice, which was recently updated and published in 2025.

• In collaboration with other Colleges and relevant specialty associations recently (in June 2021) we produced guidance on the Preoperative Assessment and Optimisation for Adult Surgery. This guidance emphasises the need for individualised risk assessment as an essential part of patient selection for surgery to reduce risk of complications and death.

In terms of further actions:

• Advice and guidance: We were concerned to read of the confusion between surgeons and anaesthetists in Billy’s care team around the responsibility for communicating the risks of not placing a nasogastric tube. Although our guidance is clear the surgeon discussing treatment with the patient has the responsibility for communicating the relevant associated risks and complications in the patient’s treatment, we appreciate that, in some cases, some aspects of anaesthetic consent are complex and may require an additional conversation. We are currently in the process of updating our consent guidance to take into account our recent revision of Good Surgical Practice, and we will seek to consult with colleagues at the Royal College of Anaesthetists for coordinated advice in this area.

• Implementation: We have recently consulted with the GMC on the development and publication of practical tools and checklists to assist in the implementation of our guidance on consent. We plan on publishing these additional tools alongside our updated guidance on consent over the coming year. We are also in the process of developing a brief e-learning module on consent based on our guidance which can be used by hospitals to train their teams locally.

• Dissemination of learning: The risks of aspiration in patients with intestinal obstruction being anaesthetised for surgery are well-recognised and are covered in the Intercollegiate Surgical Curriculum Programme (ISCP) general surgery curriculum. We confirm that we will publicise this event to the Association of Surgeons of Great Britain and Ireland (ASGBI), and to the Confidential Reporting System for Surgery

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(CORESS) which publishes anonymised educational vignettes of relevance to surgical teams, in the Journals of the Royal College of Surgeons of England and the Royal College of Surgeons of Edinburgh.

We hope that this response is clear and helpful and provides you with reassurance in relation to the serious consideration we have given to these matters and the actions we shall be taking in response.

Dear Dr Cummings,

Re: Regulation 28: Report to Prevent Future Deaths in the matter of William King

Thank you for sending us a copy of your report regarding the sad death of William King. The information available has been reviewed by our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia- related serious incidents and to share the learning with the specialty across the UK.

Your report highlights your concerns regarding the process and documentation of discussions leading to informed consent regarding the insertion of a nasogastric (NG) tube. Your report outlines that an NG tube was offered to Mr King at different stages of his treatment, but it is not clear whether any of those discussions addressed the risks and benefits of inserting an NG tube that relate specifically to anaesthesia. An NG tube can be one of the components used during rapid sequence induction (RSI) to manage patients with a higher risk of aspiration. Our organisations are shortly to publish a Good Practice guide on the topic of RSI and this addresses considerations about the use of NG tubes and emphasises the need for patients to understand the risks to the airway associated with lack of an NG tube in these circumstances.

The Association of Anaesthetists’ guidance “Consent for anaesthesia 2017” outlines the expectations for the anaesthetic consent process, including the requirements for documentation. One of the key aspects emphasised in this guidance, and in its forthcoming update due to be published in early 2026, is the need for consent discussions to occur prior to patients coming to the anaesthetic room. This is to ensure that patients have the time and space to consider the risks and benefits of the treatment options available and the anaesthetist’s recommended course of action. It is not clear from the report at what stage an anaesthetist spoke to Mr King regarding the anaesthetic procedure and the risks/benefits of the rapid sequence induction (RSI), including the additional considerations of proceeding with or without an NG tube. A discussion between the anaesthetist and a patient regarding the risks/benefits of the anaesthetic should take place as soon as practicable after the decision to list a patient for emergency surgery was made.

The Association guidance recommends that details of the discussion with the patient should be documented, although there is no separate consent form for anaesthetic procedures that are done to facilitate surgery. This documentation should include the risks, benefits and alternatives discussed. As in the General Medical Council’s “Decision Making and Consent” guidance, the guidance is clear that discussions around treatments that the patient refuses should be documented with as much care as those they consent to.

We will disseminate these key learning points through our regular Patient Safety Update publication, which is distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. We will also work with our surgical colleagues to ensure that the shared learning points are shared with members of the Royal College of Surgeons of England and the

Royal College of Surgeons of Edinburgh through the Confidential Reporting System in Surgery (CORESS) reports.

We would be happy to respond to any questions that you might have.

Dear Dr Cummings

Regulation 28 Report following inquest into the death of Mr William (Billy) King

I am writing to you following receipt of the above report dated 08 October 2025. Mr King died following significant aspiration at the time of anaesthetic induction for laparotomy, conservative management for bowel obstruction having failed. Mr King had declined the placement of a Ryle’s tube on admission.

You raised several concerns around:
• the adequacy of the explanation of risks to patients;
• the documentation of consent discussions;
• policy non-compliance; and,
• a lack of clarity over where responsibility sat and which professional led in relation to specific aspects of care.

Your report has led to much reflection and discussion at the Trust, including by the Executive Team and the Trust’s Clinical Board (a regular meeting involving Clinical Directors, senior nurses and allied health professionals from across the organisation). We accept that we could and should have done better in explaining the risks and benefits of various treatment options to Billy such that he could have made a truly informed decision, and that there were gaps in the documentation of the same. I am very sorry that we let Billy down.

However, in the course of our discussions, we have not felt that ‘consent’ is the best lens through which to view this topic. Rather we feel that reinvigorating awareness, knowledge and standard operating procedures (SOPs) around ‘care outside of guidance’ (or ‘management other than as advised by a clinician’) would be a more rational and pragmatic approach. We are conscious that there are already several specific areas where care outside of guidance is well developed from both ethical and operational perspectives: namely, for women who wish to give birth without recommended obstetric or midwifery support, and for patients (including Jehovah’s Witnesses) who do not wish to receive blood or blood products. Whilst documentation in these two scenarios is fairly developed, it would be timely to review this in the context of a move from paper to digital records and - in maternity specifically - the desire to facilitate patient access to the record. We have also taken the opportunity to review the Regulation 28 Report issued by HM Senior Coroner for Manchester North

on 05 November (following inquests into the deaths of Jennifer and Agnes Cahill in the context of a home birth).

We are designing a new form within our electronic patient record (eCare) which will support staff facing such situations in:

• being clear on a patient’s mental capacity;
• articulating their recommended treatment along with its proposed benefits and potential risks;
• articulating alternative treatment options (including both ‘do nothing’ and any intervention preferred by the patient), along with an assessment of benefits (if any) and potential risks;
• reflecting upon the value of high-quality communication (including translation services and independent advocacy where appropriate), multi-disciplinary team working, and second opinions; and,
• ensuring high-quality contemporaneous documentation of valid patient decisions in such complex circumstances.

This electronic form will be generic but will prompt the user to select the specific circumstances which apply (‘maternity care’, ‘blood products’ or ‘other’). In the case of maternity care and blood products, the member of staff accessing the form will be directed to scenario-specific materials and processes (e.g. policies, standard operating procedures and/or bespoke forms). Importantly, use of the form will not be mandated through policy. Rather, it will constitute an aide memoire / decision support to assist colleagues in navigating these challenging discussions with their patients. The form will be one vehicle through which to ensure appropriate documentation. Just as with consent, it is the quality, personalisation and documentation of the discussion and its conclusions – rather than specific piece of paper or electronic form – that is important. The completion of the electronic form may result – subject to further thought and design – in a ‘pop up’ triggered by chart opening for a specified period, alerting users to a ‘care outside of guidance’ discussion having been documented within a relevant timeframe.

The skeleton of the form which we plan to implement in the New Year (following feedback, revision and testing) is attached.