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Investigation and inquest
On 27th December 2024, this court commenced an investigation into the death of Tony Buengo Jackson aged 57. The investigation concluded at the end of the inquest on 22 September 2025. The court returned a narrative conclusion.
“Tony Buengo Jackson (Known as Jackson) died in hospital on 13th December 2024. He died of peritonitis caused by intestinal content slipping into his abdomen from a bowel perforation caused by a misplaced Percutaneous Endoscopic Gastrostomy apparatus fitted in hospital on 19/11/24.”
Mr Tony Buengo-Jackson’s medical cause of death was determined as;
1a Peritonitis
1b Perforation of Transverse Colon by Percutaneous Endoscopic Gastrostomy (Peg) Tube
1c Multiple Sclerosis
Circumstances of the death
Tony Buengo-Jackson was 57, he lived in a nursing home due to progressive MS.
In the final year of his life, he sustained frequent chest infections attributable to aspiration.
On 9/11/24 admitted to Newham General Hospital with pneumonia. To mitigate the risk of further episodes of aspiration, a best interests decision was made to fit a Percutaneous Endoscopic Gastrostomy (“PEG”) to provide nutrition.
On 19/11/24 a nurse endoscopist under supervision of consultant gastroenterologist, carried out the PEG insertion procedure, apparently without incident. An iatrogenic injury occurred that went undetected. the Peg tube was passed through the stomach and then straight through the transverse colon and out through the peg port in the skin.
Tony Buengo-Jackson was discharged to his care home on 20/11/24.
In the following week concerns were raised intermittently by Care home of abdominal distention - concerns are escalated to 111, community care response.
On 24/11/24 taken hospital by ambulance, a CT scan showed bubbles of gas in Tony Buengo-Jackson’s abdomen and was reported on by a consultant radiologist as being probably due to a bowel perforation. The report went on to recommend a surgical consultation for a potential resection of the bowel. The findings were interpreted by the attending consultant surgeon as being attributable to an air-leak caused by the Peg apparatus not pressing the stomach wall tightly to inside of abdominal wall. A surgeon retracted the peg to press against interior abdominal wall and Jackson was again discharged on 27/11/24.
On 3/12/24 was admitted to the ED by ambulance with sepsis and a distended abdomen. Jackson was again referred to the surgical team and his peg was again withdrawn and re-fixed. A repeat CT scan confirmed that the PEG insertion had transfixed his colon. Tony Buengo-Jackson was palliated and died on 13/12/24.
Coroner’s concerns
1. A fatal iatrogenic injury caused to Tony Buengo-Jackson on 19th November 2024 went undetected until 3rd December 2024, despite admission, CT scan and surgical consult on 24th November 2024.
2. Records of, best interest decisions, the PEG insertion and subsequent treatment were so poor as to impede the court’s investigation.
3. The Trust could not provide notes of the 24th November admission.
4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
Information checked against the published report and official responses