DAVID ARTHUR SHARP BATEMAN · Prevention of Future Deaths report

On 30 July 2024 I commenced an investigation into the death of 76-year-old David Arthur Sharp BATEMAN, known as Dave to family and friends. The investigation concluded at the end of the inquest on 15 May 2025.

The medical cause of death was found as follows

1a Frailty Syndrome
1b Progressive Deconditioning following Recurrent Admissions for Pelvic Collections
1c Laparoscopic Pan Proctocolectomy and Ileostomy (3/9/2023)

The four questions - who, when, where and how – were answered as follows ...

David Arthur Sharp BATEMAN died on 22 July 2024 at Pengower House Care Home Liskeard Cornwall from recognised complications following an elective operation, namely a Laparoscopic Pan Proctocolectomy and Ileostomy performed at University Hospital Plymouth on 3 September 2023.

The conclusion of the inquest was as follows

David Arthur Sharp BATEMAN died as a result of recognised complications of an elective operation.

Dave opted for an elective surgical procedure due to high-risk cancerous colon polyps which had developed following a lengthy period of ulcerative colitis.

The surgery was performed on 3 September 2023 at Derriford University Hospital Plymouth (UHP) and was uneventful. However, following that initial procedure, Dave suffered significant post operative complications which required multiple admissions to Derriford and interventions/treatments for a pelvic collection and urethral injury.

Dave had a final operation to try and deal with these complications on 24 December 2023.

It was found that before the operation on 3 September 2023 that Dave was fit, active and relatively healthy. However, by 24 December 2023 Dave had physically deconditioned and developed significant cognitive impairment.

It was found that Dave’s deconditioning led to the development of dementia such that he was no longer able to care for himself and had entered a period of irreversible decline after the final operation on 24 December 2023, that led to his death from frailty syndrome on 22 July 2024.

The court found evidence of poor nursing care on Derriford UHP Wolf Ward, particularly during the immediate post-operative period, from 3 September to 24 December. The poor nursing care contributed to Dave’s deconditioning in the following:

• Ineffective support for taking nutrition, leading to significant weight loss. The medical records indicated that Dave’s weight dropped from 86 kilos on 7.9.23, down to 64.8 kilos on 2 Dec 2023, amounting to approximately 25% weight loss
• Insufficient monitoring of weight
• Inadequate physiotherapy
• Repeatedly found to be lying in a soiled bed
• Frequently in an unwashed condition
• Frequently with a split stoma bag

The court found on the basis of evidence from the hospital’s treating consultant that this poor care and treatment from September to December 2023 amounted to a missed opportunity to rehabilitate Dave following the operation. The treating consultant stated that such poor care raised a mortality risk for other patients.

There were three witnesses from UHP giving evidence before the court, a consultant and two nursing witnesses. They were unable to assist the court upon whether these issues of poor care have been addressed.

1. The finding of poor nursing care and treatment that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients.
2. There was no evidence before the court that these concerns have been addressed and remedied.