Dear Mr Irvine,

Re: Regulation 28 Report to Prevent Future Deaths – Mr Tony Buengo Jackson

Thank you for your Regulation 28 Report dated 23 September 2025 following the inquest into the death of Mr Tony Buengo Jackson. On behalf of Barts Health NHS Trust, I wish to express our sincere condolences to Mr Jackson’s family and to acknowledge the seriousness of the concerns you have raised.

A detailed internal review has been undertaken to ensure the circumstances identified during the inquest are fully understood and that corrective actions are being implemented.

Below I set out our response to each matter of concern and the steps we are taking to prevent similar events in future.

1. Failure to recognise iatrogenic injury and missed opportunity on re-admission

You expressed concern that the iatrogenic bowel injury sustained during the PEG insertion on 19 November 2024 was not recognised until 3 December 2024, despite a CT scan and surgical review on 24 November.

Our review confirmed that the consultant surgeon’s interpretation of the CT scan at that time represented a reasonable differential diagnosis given the available evidence. However, the rationale for this interpretation was not fully documented, limiting retrospective understanding of the decision.

Actions taken

• The case has been reviewed through the Surgical Division’s Morbidity and Mortality (M&M) process and learning shared.

Status: Implemented October 2025; monitored via monthly M&M.

2 & 3. Documentation of best-interest decision-making and availability of clinical records Newham University Hospital Glen Road London E13 8SL

You highlighted concerns regarding the completeness of documentation for best-interest discussions and noted that not all records from the 24 November admission were available. The Trust acknowledges that discussions with Mr Jackson’s family took place over several encounters and were clinically appropriate, but the rationale and outcomes of these discussions were not always documented in a clear and consistent format. We also acknowledge that retrieval of some legacy paper documentation for disclosure was incomplete.

Actions taken:
• The Trust has reinforced the requirement that all best-interest discussions are documented in the patient record, clearly recording: o who was present, o the clinical reasoning and evidence considered, o risks and benefits discussed, o and the agreed outcome. ▪ This reflects Royal College of Physicians and BMA guidance that best- interests’ decisions are iterative and revisited over time, rather than a one- off meeting, and ensures the decision-making process remains transparent and clinically grounded.
• Guidance has been re-issued to consultants and trainees regarding documentation standards for capacity assessments and best-interest decisions. This has been discussed in divisional Clinical Governance meetings and included in Resident Doctor teaching.
• E-consent has been rolled out in endoscopy in the last 12 months and includes a detailed section for consent form 4 and best interests discussions. Currently only a limited number of clinicians have access to this system.

Status: This will be discussed in the Gastroenterology Governance Meeting in December to standardise process and expand the number of users to the Concentric Platform to further reduce the use of paper documentation for consent form 4 with improved integration with the electronic patient record.

4. Governance and incident-reporting failure under the Patient Safety Incident Response Framework (PSIRF)

You highlighted that the case was not identified for investigation under PSIRF and that incident- reporting and governance processes were inadequate.

The Trust acknowledges that a Datix record was not submitted contemporaneously, which represents a missed opportunity for formal learning. An internal review has since strengthened how patient- safety incidents are identified, triaged, and escalated.

Actions taken

• A Trust-wide communication was issued in October 2025 reminding staff that all significant or unexpected complications, including recognised but serious procedural injuries, must be recorded on Datix for PSIRF consideration.

• All deaths that proceed to Coroner’s inquest are now reviewed at the Patient Safety Event Response Meeting (PSERM) to ensure:

o The event is captured on Datix,

o The circumstances are reviewed in a multidisciplinary forum, and

o An appropriate learning response (e.g learning response review, MDT case discussion, thematic review or QI feedback) is agreed and assigned.

• The Endoscopy Governance Meeting is being expanded to include the surgical directorate as a bi-monthly joint forum agenda (within the Gastroenterology Governance Forum) between Surgery and Gastroenterology, with governance and nursing representation, to support shared learning from endoscopy-related adverse events.

• Governance presence is now embedded within Surgical and Gastroenterology M&M meetings to ensure improved linkage between M&M learning, Datix reporting, and PSIRF oversight.

• The Trust is also strengthening the recording of Morbidity and Mortality (M&M) discussions across all divisions. Following a review of M&M processes at the December Quality and Safety Committee, divisions will be supported to embed improved documentation standards and the use of Microsoft Copilot to capture decisions, themes and actions. This will ensure that learning identified at M&M is consistently recorded, traceable, and easily retrievable for follow-up through PSERM and divisional governance structures.

Status: This will be discussed in the Gastroenterology Governance Meeting in December to standardise process

5. Summary and assurance

Barts Health NHS Trust recognises that Mr Jackson’s death resulted from a rare but serious PEG- related complication, and that aspects of documentation and governance did not meet the standard we expect. We have taken decisive steps to strengthen clinical documentation within the electronic patient record , improve governance, and reinforce a culture of proactive incident reporting and shared learning.

Progress will be monitored through the Trust’s Quality & Safety Committee. We believe these measures provide a robust response to the risks identified in your report and will meaningfully reduce the likelihood of similar events recurring.

Dear Mr G Irvine,

Thank you for the Regulation 28 report of 23 September 2025 sent to the Secretary of State for Health and Social Care about the death of Tony Buengo Jackson. I am replying as the Minister with responsibility for patient safety.

I would like to start by saying how saddened I was to read of the circumstances of Mr Jackson’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my apologies for the delay in responding to this matter and thank you for the additional time provided to the department to provide a response to the concerns raised in the report.

The report raises concerns about the care received by Mr Jackson at Newham Hospital relating to the following points: -

• A fatal iatrogenic injury sustained by Mr Jackson on 19th November 2024 went undetected until 3rd December 2024, despite admission, a CT scan and surgical consultation on 24th November 2024.
• Records of, best interest decisions, the Percutaneous Endoscopic Gastrostomy insertion and subsequent treatment were so poor as to impede the court’s investigation.
• The Trust could not provide notes of the 24th November admission.
• A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Incident Response Framework (PSIRF). This omission gives rise to a concern that future deaths may follow due to an inability on the part of the Trust to identify, reflect upon, and remediate sub-optimal practice. In this case the Trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.

In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure that we adequately address your concerns.

NHS England have assured me that all coroner cases at Barts Health NHS Foundation Trust will be discussed at the multi-disciplinary team patient safety event meeting chaired by the Director of Nursing, Medical Director or Divisional Medical Director and attended by each speciality to reduce the likelihood of lack of awareness of patient safety incidents caused in one service but presenting in another.

Following receipt in September of your Prevention of Future Death (PFD) report relating to Mr Jackson, CQC engaged with the leadership team at Newham Hospital, and I believe is now assessing the Trust’s full response to the report CQC have assured me that it will keep monitoring progress and improvement at the hospital and Trust as part of their ongoing engagement.

Regarding the concerns about application of the PSIRF, the Trust is reviewing the mortality and morbidity process across the hospital to ensure better alignment with learning and improvement systems. CQC have raised concerns with the Trust that there is disparity in the effective application of PSIRF across the different hospital’s governance teams. The CQC will review the Trust’s response and decide if any further action is needed.

The Government is committed to fostering a learning culture in the NHS, to minimise harmful events however we also acknowledge that it is not realistic to eliminate all complications in patients undergoing lifesaving high-risk surgery even when all reasonable mitigations are in place.

The changes being made as part of the 10-year Health Plan and report on the patient safety landscape will improve quality and thereby system safety by making it clear where responsibility and accountability sits at all levels of the system. To drive improvements in patient safety, we are ushering in a new era of transparency, a rigorous focus on high-quality care and a renewed focus on patient and staff voice.

Over recent years, the NHS has made significant strides to improve patient safety, including implementing key programmes under the NHS Patient Safety Strategy (2019). The Strategy is now achieving its aim of saving around 1000 lives per year and £100m in care costs per year.

Measures we have taken over the last year include:

• Roll out of Martha’s Rule, which is now being expanded to all acute inpatient sites. From September 2024 to July 2025 more than 260 Martha’s Rule escalation calls required transfers of care to high dependency or intensive care units, enhanced levels of care or to tertiary centres.
• implementing medical examiners on a statutory basis to scrutinise all deaths that are not investigated by a coroner, in order to facilitate learning and improvement locally.

The CQC is also rebuilding its regulatory approach via a data-driven, intelligence-led model to enable the regulator to have a more rounded understanding of the service quality and safety Trusts are delivering. These changes will ensure the safety and learning cultures across the NHS are more consistent.

I hope this response is helpful. Thank you for bringing these concerns to my attention.