Malcolm Morris · Prevention of Future Deaths report

On 17th July 2024 I commenced an investigation into the death of Malcolm Morris, 63 years.

The investigation concluded at the end of the inquest on 16th August 2025.

The conclusion of the inquest was that Malcolm Morris died on 5th January 2024 at ████████ Northumberland.

A narrative conclusion was recorded.

The medical cause of death was -

1a Pulmonary Embolism
1b
1c
1d
II Lymphoedema complicating right Inguinal Lymph Node Dissection for Squamous Cell Carcinoma plus Obesity

Mr Morris was diagnosed with penile cancer in May 2023 and underwent necessary surgery to remove it, he suffered with repeated infections which required further treatment & surgery to address this. In July 2023 he had a right inguinal node dissection to arrest the spread of the cancer. He was seen to be infection free by November 2023.

He was seen post operatively to develop lymphoedema which is a recognised complication of the surgery.

He was referred for treatment of the lymphoedema. This amongst other treatments required the wearing of compression garments. At an assessment of his lymphoedema on 3rd January 2024 his right thigh was seen to be swollen. On examination the compression garment was not located in a way that applied pressure to his right thigh. He displayed no symptoms suggestive of a deep vein thrombosis including pain.

It is not possible on the evidence to say if a deep vein thrombosis was present at that time.

On 5th January 2024 after complaining of pain in his right thigh he collapsed and died.

His death was due to a pulmonary embolism which is a naturally occurring disease running its full course and resulting in his death.

Mr Morris required various periods of hospital admission in Sunderland for elective and also urgent surgery. This was in part to address his cancer and also to treat recurrent wound infections arising from his surgery.

Sunderland Royal Hospital is a regional centre for the cancer Mr Morris suffered with. He resided in Northumberland which is outside the usual catchment area for the hospital trust.

Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland. They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service.

As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take.

Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible.

This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents.

In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital.

My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services.

Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community.

The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services. Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly.