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Investigation and inquest
On 18 June 2025 I commenced an investigation into the death of David John Smart aged 79.
The investigation concluded at the end of the inquest on 19 May 2026.
The conclusion of the inquest was that David John Smart died on 14 June 2025 at the Royal Sussex County Hospital, Eastern Road, Brighton from known complications of a treatment to reverse his Rivaroxaban. He needed the reversal in order to receive surgical treatment for a life-threatening rectal bleed which developed on 13 June 2025 following a polypectomy procedure on 5 June 2025.
Circumstances of the death
On 5 June 2025, David John Smart underwent a polypectomy. He was on Rivaroxaban for atrial fibrillation which was stopped prior to the procedure due to the risk of increased bleeding. He underwent the procedure without any immediate complications and was discharged with instructions to resume his Rivaroxaban after 72 hours which he did.
On Friday 13 June 2025 he developed a significant rectal bleed and was advised by the Endoscopy Unit to attend the Emergency Department at the Royal Sussex County Hospital, Brighton which he did that afternoon.
He was assessed in the Emergency Department and a decision was made to attempt conservative management of the bleed but he continued to experience bleeding and a decision was made the next morning that he would undergo surgical intervention to attempt to resolve the same. He was then discussed with the Haematologists as to the implications of the Rivaroxaban and authorised to have the only reversal agent available. There were no complications with the surgery which sealed the bleeding vessels around the site of his polypectomy. The reversal treatment of Andexanet Alfa is known to have recognised complications of thrombosis which Mr Smart sadly suffered after its administration.
He sadly died from the complications resulting from the use of the Andexanet Alfa treatment on 14 June 2025.
Coroner’s concerns
During the inquest I heard evidence that at the of Mr Smart's attendance to the Emergency Department of the Royal Sussex County Hospital, Brighton that there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so. I understand from previous inquests that the area is not designated as a clinical area.
I have heard in other inquests relating to deaths prior to June 2025 that is being taken by University Hospitals Sussex NHS Foundation Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital.
The evidence in this inquest was that, despite these actions, the corridor continues to be used when the Emergency Department reaches capacity.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country.
Prevention of Future Death reports in relation to the use of the corridor for patient care was made during investigations into deaths which occurred in December 2022 and February 2025 and the use of the corridor remains ongoing.
Information checked against the published report and official responses