The health trust that runs Plymouth’s Derriford Hospital has been criticised over the death of a 61-year-old man at the hospital in 2022.

In a hard-hitting report, Devon’s assistant coroner Louise Wiltshire says an ‘insufficient’ protocol probably contributed to the death of Lee Eustace. She also says there is a risk of deaths occurring in the future due to a lack of proper incident investigation.

The University Hospitals Plymouth (UHP) NHS Trust says it is carefully assessing the concerns raised by the report.

Mr Eustace died at Derriford on May 1 2022 from a rare complication of being fed through a tube which by-passed his stomach.

Ms Wiltshire’s report, which follows an inquest hearing in December, says there were ‘multiple opportunities’ to recognise that Mr Eustace was suffering from this rare complication, and an opportunity to provide effective treatment.

Unfortunately, she says, these were missed and Mr Eustace developed an ‘ischemic’ bowel, meaning that blood flow was restricted or blocked. By the time this was recognised, it could not be reversed.

The medical causes of death were bowel ischaemia; the rare feeding syndrome; oesophageal cancer and heart disease.

The ‘Prevention of Future Deaths’ report says feeding was increased when it should have been stopped due to the abdominal pain Mr Eustace was experiencing.

It goes on: “Had the feed been stopped, on balance of probabilities, Mr Eustace would not have died when he did.”

The report goes on to say there is a risk that future deaths will occur unless action is taken. The feeding protocol at the time was insufficient and, in part, not followed, says Ms Wiltshire.

“This on balance, likely contributed to his death.”

As a result a new protocol was brought in later in 2022.

A ‘Datix’ online report was never raised and a ‘Duty of Candour’ letter of apology and explanation was not sent to the family in accordance with regulations. Some information was not provided to the coroner despite requests.

The report sums up: “I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths.

“In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.”

The trust has until February 9 to respond with details of any action taken or proposed, along with a timetable.

A UHP spokesperson said: “First and foremost we want to share our condolences with the family of Lee Eustace. We understand how distressing his death has been and we are extremely sorry for their loss.

“We are now carefully accessing the concerns that have been raised and we will be responding to the coroner in due course. While we are reviewing the report it would be inappropriate to comment further at this stage.”