David Bateman: Prevention of Future Deaths Report

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Interim Chief Executive 
NHS University Hospitals Trust Plymouth

I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly.

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. [HYPERLINKS] 

On 30 July 2024 I commenced an investigation into the death of 76-year-old David Arthur Sharp BATEMAN, known as Dave to family and friends. The investigation  concluded at the end of the inquest on 15 May 2025.  

The medical cause of death was found as follows

1a Frailty Syndrome 
1b Progressive Deconditioning following Recurrent Admissions for Pelvic Collections 
1c Laparoscopic Pan Proctocolectomy and Ileostomy (3/9/2023)

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

David Arthur Sharp BATEMAN died on 22 July 2024 at Pengover House Care Home Liskeard Cornwall from recognised complications following an elective operation, namely a Laparoscopic Pan Proctocolectomy and Ileostomy performed at University Hospital Plymouth on 3 September 2023. 

The conclusion of the inquest was as follows

David Arthur Sharp BATEMAN died as a result of recognised complications of an elective operation. 

Dave opted for an elective surgical procedure due to high-risk cancerous colon polyps which had developed following a lengthy period of ulcerative colitis. 

The surgery was performed on 3 September 2023 at Derriford University Hospital Plymouth (UHP) and was uneventful.  However, following that initial procedure,  Dave suffered significant post operative complications which required multiple  admissions to Derriford and interventions/treatments for a pelvic collection and  urethral injury.  

Dave had a final operation to try and deal with these complications on 24 December 2023.  

It was found that before the operation on 3 September 2023 that Dave was fit, active and relatively healthy.  However, by 24 December 2023 Dave had physically deconditioned and developed significant cognitive impairment.  

It was found that Dave’s deconditioning led to the development of dementia such that he was no longer able to care for himself and had entered a period of  irreversible decline after the final operation on 24 December 2023, that led to his  death from frailty syndrome on 22 July 2024. 

The court found evidence of poor nursing care on Derriford UHP Wolf Ward, particularly during the immediate post-operative period, from 3 September to 24 December. The poor nursing care contributed to Dave’s deconditioning in the  following: 

– Ineffective support for taking nutrition, leading to significant weight loss. The medical records indicated that Dave’s weight dropped from 86 kilos on 7.9.23, down to 64.8 kilos on 2 Dec 2023, amounting to approximately 25% weight loss 
– Insufficient monitoring of weight 
– Inadequate physiotherapy 
– Repeatedly found to be lying in a soiled bed
– Frequently in an unwashed condition 
– Frequently with a split stoma bag 
 
The court found on the basis of evidence from the hospital’s treating consultant  that this poor care and treatment from September to December 2023 amounted to a missed opportunity to rehabilitate Dave following the operation. The treating  consultant stated that such poor care raised a mortality risk for other patients. 

There were three witnesses from UHP giving evidence before the court, a  consultant and two nursing witnesses. They were unable to assist the court upon whether these issues of poor care have been addressed. 

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 finding of poor nursing care and treatment that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients. 
2. There was no evidence before the court that these concerns have been  addressed and remedied. 

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 17 July 2025. 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 family.

I am also under a duty to send the Chief Coroner a copy of your response.

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.