Source · Prevention of Future Deaths

Jason Clemens

Ref: 2025-0336 Date: 2 Jul 2025 Coroner: Guy Davies Area: Cornwall & the Isles of Scilly Responses identified: 1 / 1 View PDF

The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.

Date 2 Jul 2025

56-day deadline 27 Aug 2025 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Information Classification: PUBLIC

The hospital accepted that there were failings that contributed to Jason’s death. Measures to address those failings had not been fully implemented at the date of the Inquest. There were no applicable standard operating procedures for worsening patients in the renal unit at the date of Jason’s death and none had been implemented by the date of Inquest. Jason died on 23 March 2024. The inquest was held on 5 June 2025.

The court was told that the standard operating procedures are still being drafted in relation to identifying the appropriate pathway for the admission of worsening patients in the renal unit. The clinicians were undecided on applicable processes including whether the emergency department should be the default pathway.

The court found on the evidence that moving worsening patients out of the renal unit and onto in-patient facilities is imperative and should be done at the first available opportunity. Such action would reduce the risks of medication and treatment errors and delays such as that which occurred in Jason’s case. Delays due to uncertainties about appropriate pathways raises risks to patients who require the specialist treatment available on in-patient facilities.

I note similar concerns have been raised in a previous Regulation 28 Preventing Future Deaths report issued following the death Mr M.R. Jervis, [PFD dated 30.12.2024]. This earlier R28 report noted failings by AMU and other nursing staff to administer antibiotics when clinical observations repeatedly indicated such was required. The Jervis R28 report raised a concern regarding the absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six, including the need to administer antibiotics. It is unclear whether this measure has been introduced and if not, whether a digital alert would have made a difference in Jason’s case.

Responses

1 respondent

Royal Cornwall Hospitals NHS / Health Body

22 Jul 2025 PDF

Action Taken

The Trust has completed a Standard Operating Procedure and a Clinical Guideline, both uploaded to the Trust's intranet. A new digital patient record system will have a flag to trigger Sepsis Six, and additional actions listed following a patient safety review have been completed. (AI summary)

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Dear Mr Davies,

Re: The Late Jason Clemens – Regulation 28 PFD Report and Response

I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the 4 July 2025. This was issued following the inquest into the death of Mr Clemens which concluded on 5 June 2025. I would like to take this opportunity to express my sincerest condolences to the family of Mr Clemens for their loss. During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• A Standard Operating Procedure (SOP) was still outstanding, some 15 months after the death of Mr Clemens
• It was unclear for nursing staff as to what pathway unwell patients on the renal unit should follow
• There is still the absence of a digital alert on hospital software, which could have alerted staff for the need to implement Sepsis Six. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern. Standard Operating Procedure (SOP): This (SOP) is now completed and has been uploaded onto the Trust’s intranet page for all staff to have access to. A copy of the SOP is attached to the response as ‘Enclosure 1’.

Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 01872 250000

Clinical Guideline for Unwell Patients on Renal Unit: A Clinical Guideline has been developed to assist staff on the Renal Unit to regarding the relevant pathway a patient should follow, should they become unwell or deteriorate on the Renal Unit. This has been shared with staff and has been uploaded on the Trust’s internal Intranet page for all staff members to review and have access to. A copy of the Clinical Guideline is attached to this response as ‘Enclosure 2’. Digital Alert on hospital system to alert to the need to implement Sepsis Six: Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is implementing a new e-Care digital electronic patient record (EPR) system and the Sepsis Lead Nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the ‘Sepsis Six’ needs to be actioned. Additional Actions taken: Following the death of Mr Clemens, the following actions have also been taken:
1. ESR Sepsis training to be undertaken by all staff on the renal unit. Complete 100%
2. Supply of 1st line broad spectrum antibiotic to be kept on the renal unit. Complete
3. Acute Sepsis Screening tool 16+ to be kept on renal unit. Complete- attached to all Haemodialysis machines
4. Sepsis screening tool- the Sepsis Six to be available on the renal unit. Complete-Nervecentre & paper
5. Sepsis box available on renal unit. Complete
6. Paper News2 charts to be available on the renal unit. Complete
7. Internal transfer telephone handover sheet to be completed in full for all patients admitted to an inpatient area from the renal unit. Complete
8. Agree process with renal team for renal patients who become unwell whilst in dialysis. Emergency OOHs SOP - complete Renal Unit RCHT Practice Standards for the Deteriorating Patient: A Clinical Guideline - complete
9. Educate staff on how to ensure escalations of concerns for patients are heard.

Complete- SBAR available for guidance Staff attending AIMs course as available

To summarise the above, the Trust has taken the following actions:
1. The Standard Operating Procedure has been developed, approved and uploaded onto the Trust’s intranet.
2. The Clinical Guideline determining the relevant pathway for a deteriorating patient on the renal unit has been developed and uploaded on the Trust’s intranet.
3. The new E-Care digital electronic patient record will have a flag to alert when Sepsis Six is triggered. The current, national system (Nervecentre) does not allow for this.
4. The Trust has taken the additional actions listed above following the patient safety review following the death of Mr Clemens.

I hope that this letter provides both you and Mr Clemen’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.

Report sections

Investigation and inquest

On 28 March 2024 I commenced an investigation into the death of 54-year-old Jason James Clemens. The investigation concluded at the end of the inquest on 5 June 2025.

The medical cause of death has been established on the evidence as follows

1a Pneumonia 1b Cystic Fibrosis II Renal Failure (on dialysis)

The four questions - who, when, where and how – were answered as follows …

Jason James CLEMENS died on 23 March 2024 at Royal Cornwall Hospital Truro from complications following cystic fibrosis contributed to by a delay in the administration of antibiotics from the time of prescription. Antibiotics were prescribed to be administered without delay at 18:15 hours on 22 March 2024. There was a 7-hour delay before antibiotics were administered at 01:20 hours on 23 March 2024. Jason became unresponsive at 05:00 hours and died at 06:30 hours on 23 March 2024. Information Classification: PUBLIC There were a number of missed opportunities to identify the requirement to administer antibiotics. This delay likely hastened Jason’s death and more than minimally contributed to Jason’s cause of death.

The conclusion of the inquest was as follows

Natural causes contributed to by neglect.

Circumstances of the death

There were four missed opportunities to administer antibiotics.

The inquest found that Jason was a highly vulnerable patient due to his complex medical conditions.

Jason suffered a medical episode during the afternoon of 22 March 2024 whilst attending an out-patient appointment at the renal unit of RCHT. Staff took clinical readings and requested a medical review which was completed by a renal registrar at 18:15 hours that day. The registrar gave instructions on Jason’s medical management plan which required a full sepsis screen and the immediate administration of antibiotics. This was reinforced by the registrar completing a without delay prescription of antibiotics on the digital system (known as EPMA).

Subsequently there were four missed opportunities to administer antibiotics before they were administered at 01:20 hours following day, 23 March 2024. Jason was found unresponsive at 05:00 and died at 06:30 on that day.

The four missed opportunities were as follows

1) The renal registrar did not verbally instruct the nursing team to administer antibiotics at 18:15 hours.
2) The renal unit nurses either disregarded or did not read the registrar review and the management plan and EPMA prescription requiring immediate administration of antibiotics.
3) At 22:15 there was a handover from renal unit to acute medical unit (AMU). The renal unit nurses did not record on the handover notes the requirement to administer antibiotics.
4) On handover the AMU nurses either disregarded or did not check the management plan and EPMA prescription requiring the administration of antibiotics.

The error was discovered on registrar review in the AMU at 00:10 hours the next day but there was then a further inexplicable delay. Antibiotics were administered at 01:20 hours, Jason became unresponsive at 05:00 and died shortly thereafter.

The court found that these were basic errors and that the delay in the administration of antibiotics likely hastened Jason’s death and more than minimally contributed to Jason’s cause of death.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0336
Date of report: 2 July 2025
Coroner: Guy Davies
Coroner area: Cornwall & the Isles of Scilly

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Aug 2025 (estimated).

Sent to

Royal Cornwall Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.