PFD report

Mr Graham Edgar White · Prevention of Future Deaths report

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Issued 18 Jul 2022•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns: 3
Recipients: 3
Responses found: 3
Stated actions: 11

Recipients and published responses

Barking, Havering and Redbridge University Hospitals NHS TrustResponse found Department of Health and Social CareResponse found The British Association of Urological Surgeons LimitedNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 20th August 2021 I commenced an investigation into the death of Mr Graham Edgar White aged 72 years. The investigation concluded at the end of the inquest on 13th July 2022. I made a determination of a narrative conclusion incorporating a finding of neglect;

Mr Graham Edgar White died in hospital on 18th August 2021 following surgery to remove a antegrade ureteric stent of his right ureter.

The stent was inserted in November 2019 and should have been removed after three months. The stent deteriorated causing a urinary tract infection and a right peri-nephric abscess.

On multiple occasions in a 20-month period the deterioration of the stent was observed but no action was taken to remove it.

Mr White’s death was contributed to by neglect.

Mr White’s medical cause of death was determined as;

1a Sepsis
1b Right Perinephric Abscess
1c Urinary tract infection in relation to longstanding ureteric stent inserted for ureteric stone
II Ischaemic Heart Disease

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

Lack of a registry of patients fitted with stents for monitoring and recall
Failure to identify and escalate deaths through governance procedures as serious incidents for investigation
Part of recurring concern: Inadequate safety incident investigations Part of recurring concern: Unreliable formal safety-incident management processes
Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 5

Action
Implement and operate an electronic ureteric stent register with automated population, overdue warnings and weekly monitoring.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed
Action
Complete a retrospective review of stent insertions from 1 April 2019 to 5 August 2022 to identify missed patients and tracking gaps.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed
Action
Review governance procedures for detecting potential incidents and emphasise internal incident reporting within clinical divisions.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed

Respondent positions 4

Position
Delayed stent removal should largely be addressed through individual NHS trust clinical governance systems, led by trust medical directors.
Stated by British Association of Urological SurgeonsRedirects responsibility

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 6

1
Progress approval of the third Urology Consultant’s job description to support additional specialist capacity.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progress
2
Introduce a lithotripsy service by commencing staff training to reduce reliance on urological stent insertion.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated planned
3
Publish an updated stent patient leaflet covering symptoms, complications, intended dwell time, discharge completion fields and clinical-team contact details.
Stated by British Association of Urological SurgeonsStated completed
4
Discuss with the Medical Device Safety Programme team how temporary-device safety will be incorporated into its work.
Stated by British Association of Urological SurgeonsStated planned
5
Incorporate stent information into the BAUS Endourology/NHS GIRFT acute stone pathway and disseminate the pathway through BAUS professional meetings.
Stated by British Association of Urological SurgeonsStated completed
6
Consider carrying out an audit of contemporary stent-management practices to identify tracking approaches and quantify delayed removals.
Stated by British Association of Urological SurgeonsStated planned

Recipient positions 1

1
The encrusted stent issue does not fully lie within BAUS’s remit or the GIRFT Urology programme.
Stated by British Association of Urological SurgeonsOutside remit

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised3

Lack of a registry of patients fitted with stents for monitoring and recall

Failure to identify and escalate deaths through governance procedures as serious incidents for investigation

Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

Actions described in response 5

Respondent positions 4

Recipient-stated actions 6

Recipient positions 1