Neil John Clarke · Prevention of Future Deaths report

On 1st March 2024 an investigation was opened into the death of Neil John Clarke aged 81 years. The investigation concluded at the end of the inquest on 1st May 2025. Sitting without a jury I made a determination that Neil John Clark died as a result of hypoxic encephalopathy, aspiration pneumonia and infarcted bowel arising as a consequence of aspiration secondary to vomiting which precipitated a cardiac arrest following a right hemicolectomy.

Neil Clarke was a fit 81 year old who was investigated by way of colonoscopy following reports of bowel discomfort. A colonoscopy and polypectomy were carried out on 12th December 2022. Two polyps were removed and were benign. A repeat colonoscopy on 29th August 2023 showed recurrence of a polyp in the caecum. Endoscopic mucosal resection polypectomy failed. A discussion in MDT took place and the consensus was to proceed with a right hemicolectomy. The options provided to Mr Clarke were conservative management, further polypectomy or a right hemicolectomy. The latter was advised as the most appropriate option by clinicians as it would involve one invasive procedure rather than two and provide clarity as to the nature of the polyps being cancerous or benign. The surgery carried out on 12th February 2024 at Stepping Hill Hospital was uneventful save for some post operative bleeding. Once stabilised he was transferred to ward D5 on 15th February 2024. He felt unwell that afternoon and vomited. His ward lights were turned out at 23:00 and he was made comfortable. At 02:00 on 16th February he was agitated and then violently vomited before suffering a cardiac arrest. CPR was administered and he was taken to the intensive care unit where he was treated and monitored. Sadly, he had suffered a hypoxic encephalopathy following aspiration secondary to vomiting. He went on to develop aspiration pneumonia and an infarcted bowel which in conjunction with his hypoxic encephalopathy resulted in his death at Stepping Hill Hospital on 26th February 2024.

The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.