Stephen Francis WALKER · Prevention of Future Deaths report

On 21 April 2021, I commenced an investigation into the death of Stephen Walker, aged 79 years. The investigation concluded at the end of the inquest earlier today.

Dr Walker's medical cause of death was:
1a aspiration pneumonia and acute pulmonary oedema
1b small bowel ileus and ischaemic small bowel
1c leostomy reversal
2 aortic incompetence

I made a determination at inquest that Stephen Walker died from the complications of medical treatment, being an ileus following an ileostomy reversal. Earlier placement of a nasogastric tube would have improved his chance of survival, because it would have reduced the risk of vomiting and so of aspiration.

Dr Walker was admitted to the Royal Free Hospital for an ileostomy reversal on 1 April 2021. He began vomiting on the morning of 5 April and felt extremely unwell, but a nasogastric tube was not placed until that evening, at which point 2 litres was aspirated. He was then admitted to the intensive care unit, but died the following day.

1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression.

However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination, no subsequent early medical review was fixed and no nasogastric tube was passed.

2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this.

3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased.

4. At inquest, I asked the colorectal surgeon with care of Dr Walker to check matters in the online medical records before him. However, he said that he was in difficulty because they were so confusing in the way that they were laid out and completed.

If the records are so confusing that a consultant cannot read them easily, then that is obviously sub optimal in terms of care.

I am aware that the chair of the panel that has already considered the circumstances in which Dr Walker died, the consultant surgeon ████████
████████, intends to conduct a more in depth review of the medical records.

I write this report partly in the hope that my concerns will feed into ████████
████████ review. As such, I should be grateful if a copy of my PFD report could be forwarded to him before he completes any such review.