Thomas Fenney

Date of report: 03/08/2026 Ref: 2026-0446 Deceased name: Thomas Fenney Coroner name: Jyoti Gill Coroner Area: Kent and Medway This report is being sent to: Darent Valley hospital | NHS England REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

I am Jyoti Gill, Assistant Coroner for Kent and Medway.

3 August 2026

1. Chief Exceutive of Darent Valley Hospital
2. NHS England

You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 September 2026. I, the coroner, may extend the period if an appropriate application is  made.

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 a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding publication of your response. These representations should be  made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive  information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary

There are concerns that Mr Fenney’s previous gastric bypass surgery was not clearly or  consistently documented, meaning this important history was not considered when feeding was initiated; that the NG Care Bundle provides no guidance for patients with prior gastric  surgery, creating uncertainty about whether Nasogastric (NG) or Nasojejunal (NJ) feeding is  safest; and that although malpositioned NG tubes are removed immediately when identified on X-rays performed in the radiology department, this safeguard does not exist for portable chest  X-rays, as seen in Mr Fenney’s case where the tube was not removed despite being reported  as unsafe. Together, these issues highlight wider risks that other trusts may also lack clear  documentation systems, specific feeding guidance for post-gastric surgery patients, and robust procedures to ensure prompt removal of unsafe NG tubes identified on portable imaging.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

On 25 June 2025 I commenced an investigation into the death of Thomas FENNEY, aged 77  Years. The investigation concluded at the end of the inquest on 28 May 2026 . The conclusion of the  inquest was that Mr Fenney died as a result of post stroke complications causing aspiration  pneumonia on the background of a recent discharge from hospital following surgery which  required the withholding of anticoagulation medication. Thomas Fenney underwent right sided inguinal hernia repair at Medway hospital on 23 May  2025 and was discharged on 30 May 2025. Mr Fenney was admitted to Darent Valley Hospital on 31 May 2025 following a fall at home with slurred speech and left sided leg and arm  weakness. Mr Fenney had several comorbidities. He suffered a large right hemispheric Total  Anterior Circulation Ischaemic stroke (TACI) and developed post stroke complications of  aspiration pneumonia. Whilst in hospital Mr Fenney developed acute worsening of chronic  heart failure, pneumonia, scrotal cellulitis and Type 1 respiratory failure. Mr Fenney was also  unable to eat or drink, and a Nasogastric tube was inserted for feeding and administering  medications. An X ray on 16 June 2025 revealed that the Nasogastric tube was unsafe for  feeding but the radiology report contained a spelling error and a doctor assumed it was safe  and so Nasogastric feeding commenced. The report from the radiologist also advised urgent  removal of the tube. Unfortunately, Mr Fenney’s condition deteriorated on the evening of 16  June 2025, and a decision was made to keep him comfortable. Sadly, Mr Fenney passed  away on the 19 June 2025 at Darent Valley Hospital. 1a Aspiration Pneumonia 1b Stroke 1c 1d II    Chronic Kidney Disease, Hypertension, Diabetes Mellitus, Gastric Bypass , Nasogastric  Feed

Mr Fenney was admitted to Darent Valley Hospital on 31 May 2025 with slurred speech and  left-sided weakness, against a background of multiple comorbidities including hypertension,  type 2 diabetes, CKD, atrial fibrillation, previous MI and SMV thrombosis. Initial CT imaging was significantly degraded by motion artefact but suggested chronic ischaemic changes,  occlusion of the right common and internal carotid arteries, and possible acute-on-chronic  infarction, with MRI recommended. He was not eligible for thrombolysis due to apixaban use,  was started on aspirin, and an NG tube was inserted due to unsafe swallow. By 1 June, repeat CT confirmed an extensive right MCA territory stroke. He developed a wet cough and was  treated for aspiration pneumonia, with antibiotics escalated over subsequent days; he also  developed scrotal cellulitis. His respiratory status worsened with periodic apnoeic episodes,  pulmonary oedema on CXR, and reduced ejection fraction on echocardiogram. On 13 June he deteriorated into type 1 respiratory failure, prompting a MET call; CTPA showed no pulmonary embolism but significant cardiac enlargement, bronchial thickening and severe anasarca.  Despite further antibiotic changes and respiratory support including Optiflow and later CPAP,  his condition continued to decline. A CXR on 16 June showed the NG tube was malpositioned  and unsafe for feeding. He developed worsening bilateral consolidation and persistent  respiratory failure, leading to escalation to tazocin. With ongoing deterioration, a palliative approach was agreed, and Mr Fenney sadly died on 19 June 2025.

During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should  receive it. I also may send a copy of the report to any other person who I believe may find it useful or of  interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]

1. Mr Fenney’s Family
2. Chief Executive of Darent Valley Hospital
3. NHS England

I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026) Any representations will be  sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional  information relating to the publication of reports and responses. 12 Signature: [REDACTED]