Joan Elizabeth Talbot · Prevention of Future Deaths report

On 6 September 2022, I commenced an investigation into the death of Joan Elizabeth Talbot, aged 74 years. The investigation concluded at the end of the inquest on 24 June 2025 The conclusion of the inquest was that Joan Talbot died on 24 August 2022 at King’s College Hospital, London. The medical cause of death was recorded as

1a Sepsis due to urinary tract infection and proctocolitis
1b Migrated ureteric stent
1c radiation induced scarring in the pelvis and ureters due to previous cervical carcinoma
2 Obesity

I concluded with the following narrative

Recognised long term complications of radiotherapy administered as necessary treatment for cancer

Joan Talbot had a complex past medical history which included cervical cancer for which she had been treated with radiotherapy in 1987 which caused progressive and significant damage over the years initially affecting her bladder causing recurrent urinary tract infections. Her clinical condition began to deteriorate rapidly from March 2022, necessitating three hospital admissions with urinary tract infections, hydronephrosis caused by scarring from the radiotherapy and which required stenting and recurrent bouts of diarrhoea, at times bloody. She was admitted on a fourth and final time to KCH on 14 August 2022 with worsening bloody diarrhoea and a working diagnosis of acute colitis. Whilst waiting for a CT scan to investigate the diarrhoea she developed sepsis and was found to have a dislodged ureteric stent causing hydronephrosis and requiring a nephrostomy as urgent treatment for the sepsis. Her condition continued to deteriorate, and she died despite the nephrostomy and treatment for sepsis. At postmortem the acute colitis was found to be due to ischaemic colitis caused by radiation injury. It was also found that her bladder had been destroyed as a result of recurrent infections, also as a consequence of radiation injury.

1. Mrs Talbot had been admitted on 3 occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team. There were gaps in continuity of care such that the significance of her history of diarrhoea was not fully appreciated resulting in delays in this presentation being investigated. Although the Trust has subsequently introduced a new record system that has the potential to assist with continuity of care, it has not asked itself how this system can be used most effectively to ensure continuity of care in this specific scenario, whether further refinements to the existing systems and processes may be required.