Source · Prevention of Future Deaths
Eunice Brookes
Ref: 2026-0427
Date: 28 Jul 2026
Coroner: Elizabeth Didcock
Area: Nottingham City & Nottinghamshire
56-day deadline: 22 Dec 2026 est. (estimated from the Judiciary.uk publication date)
Responses identified: 0 of 1
0 responses identified · 1 indexed addressee
Response deadline: 22 December 2026 (estimated from the Judiciary.uk publication date).
Coroner's concerns
Coroner’s Concerns (source excerpt)
as set out in Box 6 above.
View full coroner's concerns
as set out in Box 6 above.
Report sections
Investigation and inquest
On 15.9.25, I commenced an investigation into the death of Eunice Mair Brookes. The investigation concluded at the end of the inquest on the 24.7.26.
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
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
Circumstances of the death
Eunice died on 8.9.25 at Bassetlaw District General Hospital. She had been admitted on 3.9.25 with a suspected gastrointestinal obstruction. This was not recognised as it should have been, and no surgical review was obtained and no nasogastric tube placed urgently as should have occurred. She had a known Hiatus Hernia, and was presenting with a significant change in her usual symptoms. She had significant vomiting of dark brown liquid (the colour and extent likely secondary to mucosal irritation and stomach outlet blockage). She had severe upper abdominal pain with distension. The working diagnosis of constipation did not explain these symptoms and signs.
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
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
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe you have the power to take such action.
Inquest conclusion
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
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
Similar PFD reports Shared signals
Responses identified
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Dec 2026 (estimated from the Judiciary.uk publication date).
Sent to
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Source links
Data: judiciary.uk.