Dear Mr. Irvine,

Thank you for the Regulation 28 report of 30 August sent to the Secretary of State about the death of Terence Harry Clark. I am replying as the Minister for Patient Safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr. Clark’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over poor record keeping at the Trust around the decision to remove and the misplacement of the nasogastric (NG) tube the day prior to surgery – impeding the investigation. Secondly, the Trust’s investigation did not identify the removal of the NG tube as a significant factor worthy of scrutiny although there was nil-by-mouth order for 24 hours prior. This raises concerns about securing and reviewing evidence relevant to governance and controls at the Trust.

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

The CQC inform us that actions have taken by the Trust to address the concerns raised by the coroner. The CQC will monitor the Trust on the implementation of these actions and ensure they are embedded for the long term.

I have been assured that as direct recipient of this report, the Trust is considering the concerns carefully and will be responding at length. Appropriate governance is essential for the effective running of any organisation, and I look forward to their response to provide the detail behind the actions taken and the learning from Mr Clark’s sad case. It is vital to understand the changes made so that the concerns raised in the report around Mr. Clark’s death do not recur.

Patient safety is a top priority for this government and no one accessing the NHS should ever have to worry about receiving the right care and in the right hands. Several reports have identified shortcomings in the way patient safety incidents were investigated and learned from under the previous Serious Incident Framework (SIF). As you might be aware, the Patient Safety Incident Response Framework (PSIRF) replaces the SIF. It is part of the NHS Patient Safety Strategy and represents a significant shift in how providers must now respond and learn from patient safety incidents with a focus on more effective learning and engaging families.

Building an NHS fit for future is a key mission for this government. It is only with our continued and joint efforts with partners and stakeholders that we can drive improvements in safety and quality. I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Mr Irvine

Re: Regulation 28 Report to Prevent Future Deaths

I write regarding your letter of regarding your concerns relating to the death of Terence Clark at Newham University Hospital. I hope this letter will provide assurance to you of the steps that we are taking to address the concerns you have outlined.

A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr Clark's airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death.

Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES

Telephone: 020 32460641 Email:

Group Chief Medical Officer

B. The Trust conducted a patient safety investigation into the circumstances leading to Mr Clark's death, the investigation did not identify the removal of the NG tube as a significant factor worthy of scrutiny. Both of these issues raise a concern that the Trust can not adequately secure and review evidence relevant to governance and coronial investigations, necessary to mitigate risks of future fatalities.

I will respond to these items together as they are interlinked. Mr Clark had an NG tube inserted on the 1st November 2023. It was not used prior to the X-Ray being conducted at which point Mr Clark had a cardiac arrest and died. The investigation into his death focused on the lack of nursing escort and therefore knowledge of Mr Clark’s DNACPR status when he arrested in the department which resulted in CPR being commenced. The NG tube was removed by ward staff on the day of Mr Clark’s death following a discussion with a doctor and the site manager. At this point a coroners referral had not been considered or made. The coroner’s referral was made on the 3rd November
2023. The terms of reference for the concise internal investigation into Mr Clark’s death did not include review of the NGT removal as it was not considered to be materially relevant to any care issues identified.

I apologise that the information regarding the timing of the removal of the NGT was not provided at the inquest and it was not considered as part of the concise investigation. The Barts Health Bereavement – care before, during and after death policy, states that where coroners referral has been made, tubes and devices should not be removed and that to contact the coroners office if unsure. It also indicates that this can be discussed ahead of death where relevant.

The current policy differs with regard to removal of tubes and devices according to whether a coroners referral has been made. It also states in section 26.4 that: if the cause of death is known and the coroner is not going to be involved there should be no concern about removing medical tubes and lines.

Following this case, we are reviewing the Bereavement policy to clarify the guidance around removal of tubes, lines and devices. Where a sudden or unexpected death has occurred, the policy will mandate that tubes, lines and devices are left in situ until after:
a. A discussion with the medical examiner
b. A decision has been made about coronial referral
c. A death certificate has been issued

The policy will also be updated to include the role of the medical examiner. Every patient death is now reviewed by a Medical Examiner usually within 24 hours and so the need for a coroner referral should be clear prior to any removal of equipment from the body and a delay of 2 days, as in this case, should be avoided.

This case has already been discussed at our safety huddles, with the senior nursing and site teams to underline the above and ensure a lower threshold for discussion with the coroners office should there be any doubt about removal of lines etc. Any conversation will be documented in the patient record. We will be cascading the learning from this incident and embedding this within training across the Trust.