John Stephen England · Prevention of Future Deaths report

On 30/4/25, I concluded the inquest into the death of John Stephen England who died in Royal Cornwall Hospital on 15/3/23.

I recorded the cause of death as:

1a) Aspiration;

1b) Ileus;

1c) Sigmoid volvulus (operated 12/3/23)

II) Transient ischaemic attack; hypertension

I recorded a Narrative conclusion that Mr England died from natural causes. It is more likely than not that the delays in conveyance to hospital and in definitive medical intervention contributed to the development of a post operative ileus and Mr England’s death more than minimally.

Mr England lived in Gloucester. In 2018, a CT at Gloucester Royal Hospital revealed he had a very long redundant sigmoid loop which it was recognised left him very prone to a volvulus. Between February 2020 and February 2023, he had five separate presentations to hospital with a sigmoid volvulus, four of which required medical intervention to resolve.
In March 2023, Mr England came to Cornwall on holiday. In the early hours of 12/3/23, he developed abdominal pain with increasing distention. He rang for an ambulance at 01:37 reporting to the call handler that he suspected he had a twisted bowel. Owing to operational pressures, there was delay in the arrival of an ambulance. Mr England arrived at Royal Cornwall Hospital at 08:05. There was delay transferring Mr England from the ambulance and into hospital.
An x-ray and CT scan were performed. Both supported a diagnosis of sigmoid volvulus.
The CT scan was reported at 10:48 but not brought to the attention of the locum consultant surgeon until approximately 15:30. A rigid sigmoidoscopy was performed at approximately 16:00 but due to concerns over the appearance of the bowel and whether it was ischaemic, a flexible sigmoidoscopy was performed at approximately 18:00 which confirmed ischaemic/infarcted tissue. A laparotomy was performed at approximately 20:30 when a gangrenous section of bowel was removed and a stoma formed.
At a ward round on 15/3/23, Mr England was found to be short of breath and with a distended abdomen. A post-operative ileus was diagnosed and a direction given for a naso-gastric tube to be placed. During the course of its placement, Mr England became distressed and suffered an acute collapse. He could not be resuscitated and died in Royal Cornwall Hospital on 15/3/23.

1) At the time of the initial call to South West Ambulance Service Trust, Mr England reported that he thought he had a ‘twisted bowel.’ This had happened to him on five previous occasions in Gloucester when medical intervention had been required four times to decompress a sigmoid volvulus.
The call handler, using the MDPS system, reached a Category 5 disposition. Two experts who gave evidence at inquest, ████████, a Consultant Surgeon, and ████████, a Consultant Gastroenterologist, both felt Mr England needed to be conveyed to hospital within two hours which I believe would have required a Category 3 disposition.
As both the fact of a delay and its causative relevance were admitted by the Trust, the detail of the call and the questions asked to reach a disposition were not enquired into at inquest. Evidence was heard, however, that upon audit it was felt the call handler had achieved a high degree of compliance with expected standards.
This raises a concern whether the system is sufficiently nuanced to distinguish between different types of abdominal complaints and to ensure that those who need to be recognised as a surgical emergency receive a disposition resulting in a patient being conveyed to hospital within an appropriate timeframe.