John Tompkins · Prevention of Future Deaths report

John Tompkins (date of birth 11/9/50) died on 25 July 2024 at Royal Free Hospital (RFH), following treatment received for a diagnosis of hepatocellular carcinoma.

Mr Tompkins had been admitted to Royal Free Hospital in July 2024 and underwent a hepatic artery embolisation and right-sided portal vein embolisation. These were requested to be undertaken sequentially, following a multi-disciplinary team (MDT) meeting. However, owing to how the requests had been received, they were undertaken at the same time. Before the procedures were undertaken, attempts were made to discuss the MDT plan with the surgical Consultant. However, he was on leave and not contactable.

Mr Tompkins subsequently developed acute-on-chronic liver failure and sadly died from consequential multiorgan failure on 25 July 2024.

I heard the inquest into his death on 6 December 2024 and reached a narrative conclusion as follows:

Mr Tompkins died from a recognised complication, arising from necessary medical procedures. These procedures were undertaken simultaneously, rather than sequentially, as had initially been intended. This simultaneous approach more than minimally contributed to his death.

At the inquest there was limited evidence as to what steps had been taken by RFH to address the risk of future deaths occurring in similar circumstances, including issues with how requests for procedures were undertaken, whether consent for these procedures included the risk of death and how novel procedures are considered by RFH before they are implemented.

Following the inquest I received a response from RFH which predominantly addressed the points raised (attached entitled ‘Procedure Requesting Process’). Additional recommendations were raised in this response, regarding the National safety standards for invasive procedures (NatSSIPS2), a standard which was not highlighted at the inquest.

Subsequent to receipt of the RFH response, Mr Tompkins’ family raised concerns (attached entitled ‘Appendix 1’) that, inter alia, the Trust had not followed the NatSSIPS2 standards whilst undertaking the two procedures.

See box 3.

1. I am concerned that there was limited internal review of the circumstances of Mr Tompkins’ death, following identification that the procedures were undertaken at the same time;
2. Further and linked to the above, I am concerned that the Trust seemingly did not consider the NatSSIPS2 standards either when undertaking the procedures, nor in detail as part of its review following the inquest.