Source · Prevention of Future Deaths

Jacqueline Aarons

Ref: 2025-0576 Date: 10 Nov 2025 Coroner: Andrew Walker Area: North London 2 responses identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raised concerns about the need for a lower threshold for hospital admission for patients with learning disabilities, requiring face-to-face doctor consultations. Post-consultation, written instructions including safety netting advice should be provided in an accessible format for non-medically trained staff.

Date 10 Nov 2025
56-day deadline 5 Jan 2026 est. estimated from the report date
Responses identified 2 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
The coroner raised concerns about the need for a lower threshold for hospital admission for patients with learning disabilities, requiring face-to-face doctor consultations. Post-consultation, written instructions including safety netting advice should be provided in an accessible format for non-medically trained staff.
View full coroner's concerns
Concern that there should be a recognised lower threshold for hospital admission for patients with learning disability There should be a fact to face consultation by a doctor. Following any consultation there should be written instructions including safety netting advice, set out in such a way that they may be understood and acted upon by staff who may not be medically trained.

Responses

2 respondents

Department for Health and Social Care

Central Government
Letter dated 12 Jan 2026 PDF
AI-classified response stance Noted

No AI summary available.

View full response
Dear Andrew Walker

Thank you for the Regulation 28 report of 13 November 2025 sent to the Department of Health and Social Care about the death of Jacqueline Aarons. I am replying as the Minister with responsibility for disabilities.

Firstly, I would like to say how saddened I was to read of the circumstances of Miss Aarons’ death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns about the threshold at which patients with learning disability are admitted to hospital; the requirement for in-person consultations with a doctor; and the provision of safety netting advice for those with caring responsibilities who are not medically trained.

In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.

I hope this response is helpful.

NHS England

NHS / Health Body
Letter dated 8 Apr 2026 PDF
AI-classified response stance Noted
AI-generated response summary

• NHS England stated that a lower threshold for hospital admission for patients with a learning disability is warranted, consistent with existing guidance and tools. • NHS England acknowledged the importance of face-to-face clinical assessment by a doctor for patients with a learning disability. • NHS England confirmed that clear, accessible written instructions and safety netting advice should be provided following consultations, with workforce capability supported by initiatives such as the Oliver McGowan Mandatory Training.

Report sections

Investigation and inquest
On the 21 November 2024 commenced an investigation into the death of, Jacqueline Aarons, aged 60. The investigation concluded at the end of the inquest on 29 October2025. The conclusion of the inquest was Consequences of an unrecognised but symptomatic umbilical hernia.. The medical cause of death was 1a Aspiration, 1b Strangulated umbilical hernia, 1c Downs Syndrome.
Circumstances of the death
On the 19th November 2024 Jacqueline Aarons died at her Care Home from the consequences of a strangulated umbilical hernia. Miss Aaron had become unwell with symptoms of vomiting after breakfast on the 17th November 2024. The staff, none of whom were medically trained, called 111 and an Out of Hours doctor called the care home, felt that the patient had gastroenteritis and gave advice for better management of the patient. The Care Home doctor spoke to the staff the next morning and arranged for a Rapid Response nurse who attended and was reassured that Miss Aarons appeared to be settling. The nurse spoke to a doctor at the surgery before providing written advice to the staff when they may need to contact 999 Miss Aarons become more unwell, and an ambulance was called and attended on the morning of the 19th of November 2024. The cause of the vomiting after breakfast on the 17th November 2024 is likely to be a partial obstruction related to the hernia which is likely during the early hours of the 19th November 2024 to have progressed to a complete obstruction leading to aspiration of stomach contents. Had Miss Aaron been admitted to hospital at any point from when the vomiting started to the point at which she collapsed and stopped breathing at the Care Home it is likely that she would have survived.

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Report details

Reference
2025-0576
Date of report
10 November 2025
Coroner
Andrew Walker
Coroner area
North London

Responses identified

Responses identified 2 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Jan 2026 (estimated from the report date).

Sent to

Department of Health and Social Care

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