Mr. John Charles LOTT · Prevention of Future Deaths report

On 10ᵗʰ November 2020, I commenced an investigation into the death of Mr. John Charles LOTT. The investigation concluded at the end of the inquest on 29ᵗʰ April, 2021. The conclusion of the inquest was a Narrative Conclusion:-

“JOHN LOTT DIED FOLLOWING ELECTIVE SURGERY FOR A DEFUNCTIONING ILEOSTOMY. POST-OPERATIVELY THERE WERE TWO MISSED OPPORTUNITIES TO TRANSFER HIM FROM THE PRIVATE HOSPITAL TO AN ADJACENT NHS HOSPITAL WITH LEVEL 2 AND 3 INTENSIVE CARE FACILITIES. HAD HE BEEN TRANSFERRED WHEN HE SHOULD HAVE BEEN IT IS POSSIBLE THAT THE OUTCOME FOR HIM WOULD HAVE BEEN DIFFERENT.”

John Lott was a 78 year old man who had a procedure to form a defunctioning ileostomy on 21.10.20. Post-operatively there were two occasions (on the 27th and the 29th) when he was sufficiently unwell to require transfer from the private hospital where he was, to the acute NHS hospital which had the intensive care facilities which I FIND that he needed. He was not transferred on either occasion. He deteriorated rapidly and around the time of transfer, on a background of inadequately treated hypoglycaemia, he suffered myocardial ischaemia and infarction. He did not have the reserves to recover from this and died on 8th November 2020.

See Record of Inquest

(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield.
(2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred.
(3) When ████████ the Consultant “in charge” of Mr. Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support. Why not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers?