Colin Foley: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 01/04/2026
Ref: 2026-0188
Deceased name: Colin Foley
Coroner name: Paul Marks
Coroner Area: Hull and East Riding
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: NHS England
 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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| THIS REPORT IS BEING SENT TO: 1. Chief Executive N.H.S. England | |
| 1 | CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. |
| 2 | CORONER’S LEGAL POWERS 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. |
| 3 | INVESTIGATION and INQUEST On 10th October 2025, I commenced an investigation into the death of Colin Foley, aged 84 years. The investigation concluded at the end of the inquest on 11th March 2026, the narrative conclusion of the inquest was: Colin Foley was admitted to Hull Royal Infirmary on the 8th June 2025 with decompensated cardiac failure. He received treatment with intravenous frusemide according to standard practice. The intravenous cannula in his right forearm became painful, failed, and had to be removed. It subsequently became infected and this developed into cellulitis, sepsis, which caused multiorgan failure and Mr Foley’s death on the 28th June 2025. Whilst the infection could have been picked up earlier and antibiotics commenced, it cannot be said on the evidence heard, that earlier treatment would have  prevented his death. |
| 4 | CIRCUMSTANCES OF THE DEATH The findings of fact are attached. |
| 5 | CORONER’S CONCERNS 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. Evidence was heard at inquest that the insertion of intravenous access devices are frequently performed procedures in clinical practice which require meticulous attention to detail, not only in their insertion and maintenance, but also in the documentation surrounding them, as well as awareness of associated complications, some of which may be life threatening, that may occur. Whilst the Hull University Teaching Hospitals have instituted on-going training which will continue in perpetuity, I believe that the NHS at large should be aware of issues that relate to these commonly performed procedures. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action. This may include, for example, providing on-going training and audit relating to the use of these ubiquitous medical devices. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th May 2026. However, if you are able to comply with this, 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (Son); Hull University Teaching Hospitals NHS Trust; I am also sending a copy to the Department of Health and equivalent organisations in the other countries of the United Kingdom. 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. |
| 9 | [REDACTED] |