Connor Nelson: Prevention of future death report

The Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust

I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

On 9.12.24, I commenced an investigation into the death of Connor Nelson
The investigation concluded at the end of the inquest on the 18^th November 2025

The conclusion of the inquest was a narrative as follows:
Connor  died  from  hypoxic  ischaemic  encephalopathy,  an  un-survivable  brain  injury caused by a prolonged period of lack of oxygen, during a cardiac arrest. The arrest occurred on the Emergency Assessment Unit at Kings Mill Hospital (KMH) on 10.11.24. There was a significant delay in providing a necessary defibrillator shock during the arrest, which made a more than minimal, negligible or trivial contribution to his death.

The cardiac arrest was likely caused by a ventricular arrythmia, secondary to congenital prolonged QT syndrome, which was undiagnosed in life, despite multiple opportunities to do so.

Lack of anti-sickness medication and a lack of Potassium replacement in the hours prior to the cardiac arrest, both also likely made a contribution to the development of the arrythmia that led to the cardiac arrest, and to his death, as did his underlying health conditions.

Connors death was contributed to by neglect

Connor died from hypoxic ischaemic encephalopathy on 30.11.24, at Kings Mill Hospital, following  a  prolonged  cardiopulmonary  arrest  on  10.11.24.  He  had  undiagnosed congenital prolonged QTc syndrome, which led to an arrythmia and to his arrest.

The resuscitation provided at the time of his arrest was sub-optimal, with a delay of nine minutes in administering a necessary shock.
There were multiple opportunities to make the diagnosis of congenital Prolonged QT syndrome, prior to his final admission. There were repeated abnormal ECG findings of prolonged QTc from November 2022 onwards, but no necessary repeat ECGs when Connor was well, and no necessary cardiac follow up to arrange the cardiac investigations required to make the diagnosis.

Connor had significant issues with alcohol dependence and anxiety and depression, and it would have been challenging for him to manage the condition. However had it been diagnosed as it should have been, he and his family would have been aware of it, and perhaps family and professional support would have enabled him to change his lifestyle. Whilst this is a possibility, I cannot say a diagnosis in life would have probably prevented his death.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
1.   The lack of evidence of any improvement in the ability of Emergency Assessment
Unit staff to respond effectively to a cardiac arrest
2.   The lack of understanding by medical staff, of the importance of identifying prolonged QTc syndrome in patients attending KMH, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the KMH Cardiology team.

I am not reassured that necessary actions to address these serious issues identified are in place.

In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by the 27th January 2026. I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1.   The family
2.   The Nottinghamshire Healthcare NHS Trust

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.

You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.