BASILDON Hospital has been issued with a notice by the Essex Coroner, asking it to review procedures in the wake of the death of a man earlier this year.

The circumstances of the death of Thomas Burroughs, a a 35-year-old man with learning disabilities has been highlighted after a split catheter was left in him – despite the risk of infection.

Mr Burroughs, was nonverbal with a medical history of Cerebral Palsy, Scoliosis – a type of a spinal deformity – and pressure ulcers.

He was nil by mouth and fed with a percutaneous endoscopic gastrostomy (PEG) feeding tube.

Mr Burroughs had prolonged admission in hospital from September 6 to November 23 2023 and readmitted on November 29 2023 with recurrent aspiration pneumonia.

During his hospital admissions Mr Burroughs feeding regime was on hold for periods of time during his admission.

Mr Burroughs underwent procedures that included insertion of a Hickman Catheter and later a jejunal extension.

On January 13 2024 acute trust hospital ward staff noted a split in the lumen of the Hickman Catheter and this was clamped and dressed.

The incident was escalated for urgent medical review due to the significant risk of infection, however no online report was raised for the split Hickman Catheter

Mr Burroughs had a jejunal extension to his PEG on January 15 2024.

Advice was received that the Hickman Catheter should be removed as soon as possible if it was not being used.

He suffered a spike in temperature on January 19 2024 with no apparent symptoms of recurrent aspiration and the Hickman Line remained in situ.

The Hickman Catheter was surgically removed on January 30 2024.

Mr Burroughs died in hospital on February 2 2024.

A statement from Sonia Hayes, area coroner for Essex has issued a prevention of future deaths report to the Mid and South Essex NHS Trust ahead of the conclusion of an inquest.

She said: "During the course of the part-heard inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."

Diane Sarkar, Chief Nursing and Quality Officer for Mid and South Essex NHS Foundation Trust, said: "Our deepest condolences go to the family of Mr Burroughs at this difficult time.

"Whilst his case has been one that has been hugely complex and challenging, we recognise and understand the coroner's detailed review and concerns. These will help us make positive change and improve our care at the trust."