John Ioannou · Prevention of Future Deaths report

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

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.

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.