You are under a duty to respond to this report within 56 days of the date of this report, namely by 22.9.26. I, the coroner, may extend the period if an appropriate application is made.

I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided.

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The conclusion of the inquest was a Narrative as follows:
Eunice lived alone independently, with family support. She had a background history of hypertension, Type 2 Diabetes Mellitus, CKD, and reflux in association with a large Hiatus Hernia.

The Hiatus Hernia was troublesome at times, causing episodes of pain and nausea due to food not passing from the stomach, relieved by drinking and then vomiting.

Unfortunately, the Hiatus Hernia was not amenable to elective surgery as the procedure was thought to be high risk in light of her age, and other comorbidities.

The Hiatus Hernia became incarcerated, and partially twisted, such that Eunice developed severe and persistent vomiting and severe and worsening abdominal pain from 3.9.25.

She was admitted to Bassetlaw Hospital on that day, and the obstruction secondary to the incarcerated hernia with partial gastric volvulus, was not recognised.  This  untreated  condition  led  to  her  clinical  deterioration,  with compromise to stomach blood supply and then to a perforation of her stomach, and then to her death.

Had the issues with the Hiatus Hernia, and its blockage and twisting, been recognised as they should have been, Eunice would have had a nasogastric tube placed on admission, or in the days prior to her death, and on balance she would not have died when she did.
Eunice’s death was contributed to by neglect

Eunice continued to deteriorate throughout her admission from an undiagnosed incarcerated Hiatus Hernia, likely with volvulus. This was not recognised and led to compromised blood supply to her stomach and to a gastric perforation, and to her death.

There are issues of care during her final admission that have probably caused, or made a more than minimal, negligible or trivial contribution to her death as follows:
a)  There was no Emergency Department or Acute Medicine Consultant review during her admission, until she was in extremis on the morning of 8.9.25, some 3-4 hours prior to her death
b)  There was no surgical review during her admission, or throughout, until the morning of 8.9.25.
c)  There was inadequate monitoring of fluid input and output, most
particularly the lack of recording of the large volumes of vomit
d)  The Trust Adult Pain guideline was not followed, with inadequate pain relief provided, and a lack of escalation to the medical team for review of worsening pain.
e)  There was no recognition of Eunice’s deterioration, on 6.9.25 and no senior review on that day
f)   There was uncertainty as to how to obtain an urgent surgical review on 7.9.25 (a Sunday), such that it did not occur
g)  The family, who continued to articulately raise their concerns as to
Eunice’s deterioration, were not listened to or believed
h)  No Consultant opinion, or Critical Care Outreach team opinion, was offered on 7.9.25 when this was requested by the family
i)   No nasogastric tube to achieve stomach drainage was placed on
admission, or throughout, until attempts were made to pass a tube when she was dying on the morning of 8.9.25

The MATTERS OF CONCERN are as set out in Box 6 above.

I also may send a copy of the report to any other person who I believe may find it useful or of interest.

I can confirm I have sent the report to:
[please do not use individual’s names, but instead roles/titles]
·    Family
·    Doncaster and Bassetlaw Teaching Hospitals NHS Foundation
Trust
·    Care Quality Commission
·    Nottingham and Nottinghamshire Integrated Care Board

I also have a duty to send a copy of the report to the Chief Coroner.

You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy  (2026). Any representations will be sent to the Chief Coroner alongside the  report. Please refer to box 4 above for additional information relating to the  publication of reports and responses.