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Investigation and inquest
On 3rd November 2025 evidence was heard touching the death of Mr Barry Clive Loxston. He had died at St George’s Hospital on 30th July 2023 aged 67 years.
Medical Cause of Death
Ia Electrolyte and metabolic abnormality with acute n chronic diarrhoea
Ib Delayed renal transplant graft function ( transplant performed on 8/7/2023),
Clostridium Difficile infection (treated) and chronic pancreatic insufficiency
II Hypertensive heart disease.
How, when and where the deceased came by her death.
Mr Loxston suffered with dialysis dependent renal failure secondary to long term use of indomethacin for ankylosing spondylitis. He was admitted for renal transplant surgery on 8/7/2023 to St George’s Hospital. This went ahead despite failures to recognise that he was unfit for surgery due to malabsorption causing low albumin from chronic diarrhoea by his nephrology team in St Helier Hospital and the transplant team at St George’s. These were serious failures that contributed to Mr Loxston’s death. The surgery was initially successful, however post operatively he developed complications due to low albumin contributing to circulatory failure, electrolyte imbalance, and delayed graft function. From 29/7/2023 his potassium was dangerously low. This was not treated until 30/7/2023 in part due to workload acuity. On 30/7/2023 he arrested and was initially resuscitated but died shortly after.
Conclusion of the coroner as to the death:
Mr Loxston died as a result of serious failures to recognise that he was unfit for renal transplant surgery
Circumstances of the death
This section does not appear in the published report.
Coroner’s concerns
1. That poor patient handling and allowing patients to lie for hours in their own excrement is detrimental to patient wellbeing and may contribute to deaths.
2. That leaving medication with patients for them to take in their own time rather than supervise the taking of medication by the patient causes drug maladministration issues that may cause or contribute to deaths of patents.
3. That lack of investigation of the matter outlined in 2 increases the risk to patients of the concern outlined in 2.
4. That all relevant blood tests, including albumin level since low albumin may be associated with significant post operative complication risk, are not reviewed prior to surgery and considered as part of the risk/benefit analysis of surgery and the consenting process.
5. That there is no system mandating suitability to remain on the transplant list by the local nephrologist at each nephrology review.
6. That there is no system recommending direct contact with the local on call nephrology team by the transplant team to check whether there are clinically relevant matters in relation to the patient and their suitability for transplant that the local team are aware of and the transplant team are not, such as active other chronic illness or abnormal test results.
Information checked against the published report and official responses