Recurring concern

Inadequate guidance for managing oesophageal strictures and transition to stenting

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First reported 10 Feb 2023•Latest report 15 May 2023

Definition

What this concern includes

Includes failures of guidance, protocols, evidence or decision criteria specifically dedicated to managing oesophageal strictures, repeated dilatation, stenting, perforation risk and decisions about when or how to transition between these treatments.

Not included

  • Excludes generic clinical-guidance or evidence deficiencies not specifically concerning oesophageal stricture management.
  • Excludes general oesophageal-cancer treatment failures that do not concern stricture management, dilatation or stenting.
  • Excludes isolated complications or poor outcomes where no deficiency in the stricture-management guidance or decision process is identified.
  • Excludes unrelated procedural guidance, treatment-duration decisions or stenting concerns involving other conditions.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2023–2023

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2
National Institute for Health and Care Excellence1
NHS Greater Manchester Integrated Care Board1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Raymond Lee · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Raymond Douglas Lee had oesophageal cancer treated with radiotherapy, developed an oesophageal stricture, and later had a stent inserted. He was admitted with bleeding and died at Stepping Hill Hospital on 14 September 2021 from complications including an aorta-oesophageal fistula. The report raised concerns about limited national guidance and evidence on treating oesophageal strictures, including uncertainty about when to stop dilatation and consider stenting, and the risks of perforation associated with both procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limited evidence on the risks of stenting oesophageal strictures

    Wider context from the report

    “The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting. The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent. ”

    Source location

    Raymond Lee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of national guidance and evidence-based best practice for treating oesophageal strictures

    Wider context from the report

    “The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting. The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent. ”

    Source location

    Raymond Lee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of evidence on the optimum number of dilatations and when to stop dilatation and consider stenting

    Wider context from the report

    “The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting. The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent. ”

    Source location

    Raymond Lee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Further consider concerns about contraindications for stenting and whether NICE advice should be strengthened.

    Verbatim wording from the response

    “We will log your report and consider further your concerns regarding contraindications for stenting and if we need to strengthen our advice.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop national, evidence-based advice or guidance for managing post-radiotherapy oesophageal stenting cases with AUGIS and NICE.

    Verbatim wording from the response

    “To support a response, I sought the opinion from our clinical advisor within the Cancer Programme of Care at NHS England and they have also spoken to the relevant professional association lead from the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS). In terms of learning from this case, and from other stenting cases previously reviewed, it is clear that these types of cases are clinically difficult to manage; the NICE guidance is not comprehensive and there does not appear to be a guidelines in place covering these sorts of circumstances (i.e., post radiotherapy). We acknowledge this is something that needs to be addressed and we are actively discussing how best to do this in partnership with AUGIS and NICE.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    GM Cancer Alliance, through its Oesophago-Gastric Pathway Board, is responsible for developing the stenting pathway and completing MDT Reform actions.

    Verbatim wording from the response

    “I have also received an update from Greater Manchester Integrated Care Board (ICB) regarding this matter. They have advised that the Greater Manchester (GM) Cancer Alliance will be tasking the Oesophago-Gastric (OG) Pathway Board with developing a clear pathway for the management of oesophageal stenting. The Alliance will also be ensuring that outstanding elements of the Multi-Disciplinary Team (MDT) Reform”

    Source location

    Response from NHS England
    Page 1 · response
    Published 17 May 2023

    Open published response

  2. Manchester South

    AI-generated summary

    Sandra Adina Lomax · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of detailed national guidance on management of oesophageal strictures and when and how to approach stenting

    Wider context from the report

    “1. The inquest heard evidence that the development of oesophageal strictures such as Mrs Lomax’s was a relatively new development as a consequence of advances in chemo/radiotherapy that meant that surgery was not the only option for oesophageal cancer. However the management of these strictures was complicated and there was no detailed national guidance on management of them and in particular when and how stenting should be approached. The development and implementation of detailed National Guidance was the inquest was told key to improving outcomes for patients such as Mrs Lomax across England; ”

    Source location

    Sandra Adina Lomax · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss the Report and updated NICE guidance with the Cancer Clinical Advisory Group before publication to consider immediate actions.

    Verbatim wording from the response

    “NICE are currently consulting on a partial update to their guidance on Oesophago-gastric cancer, with publication expected on/or around 4 July 2023. This includes consideration of treatments offered to patients who have had stents inserted. In response to your Report and the concerns raised, NHS England plans to discuss your Report and the NICE guidance with the Cancer Clinical Advisory Group, in advance of the publication of updated NICE guidance relating to oesophago-gastric cancer, to consider whether any further immediate actions need to be taken. NHS England would be happy to write to the Coroner again in due course to provide an update if she so wishes.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NICE is responsible for developing detailed national guidance on managing oesophageal strictures and stenting.

    Verbatim wording from the response

    “The inquest heard evidence that the development of oesophageal strictures such as Mrs Lomax’s was a relatively new development as a consequence of advances in chemo/radiotherapy that meant that surgery was not the only option for oesophageal cancers. However the management of these strictures was complicated and there was no detailed national guidance on the management of them and in particular when and how stenting should be approached. The development and implementation of detailed National Guidance was the inquest was told key to improving outcomes for patients such as Mrs Lomax across England;”

    Source location

    Response from Greater Manchester Integrated Care
    Page 1 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complex oesophageal cancer cases require individual multidisciplinary team management, so national guidance does not cover every aspect of care.

    Verbatim wording from the response

    “NHS England does not provide guidance covering every aspect of care. This is particularly pertinent for management of complex cases and cancers, such as Sandra’s, which require management on an individual basis with input from a multi-disciplinary team (MDT) within the relevant Trust and NICE does make clear that MDT decision-making is important in these complex cases.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 24 February 2023

    Open published response
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Data last updated 7 September 2026