Mark Jones · Prevention of Future Deaths report

On 16th November 2020 I commenced an investigation into the death of Mark Jones. The investigation concluded on the 22nd December 2021 and the conclusion was one of Narrative: Died from the complications of necessary surgery. The medical cause of death was 1a Haemorrhage from tongue following surgery for squamous cell carcinoma

Mark Deardon Jones was diagnosed with squamous cell carcinoma of the tongue. He underwent complex surgery to treat his cancer including a left hemiglossectomy of the tongue. He was discharged home on 12th November 2020. On 13th November 2020 he had a catastrophic haemorrhage at the site of the hemiglossectomy and died at his home address ████████

1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months.

2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed.