Joan Talbot: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
Date of report: 11/11/2025
Ref: 2025-0569
Deceased name: Joan Talbot
Coroner name: Liliane Field
Coroner Area: Inner South London
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: [REDACTED], Chief Executive Officer, King’s College Hospital NHS Trust, King’s College Hospital, Denmark Hill, London, SE5 9RS
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. [REDACTED], Chief Executive Officer, King’s College Hospital NHS Trust, King’s College Hospital, Denmark Hill, London, SE5 9RS | |
| 1 | CORONER I am Liliane Field, assistant coroner, for the coroner area of Inner London South |
| 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 6 September 2022, I commenced an investigation into the death of Joan Elizabeth Talbot, aged 74 years. The investigation concluded at the end of the inquest on 26 June 2025 The conclusion of the inquest was that Joan Talbot died on 24 August 2022 at King’s College Hospital, London. The medical cause of death was recorded as 1a Sepsis due to urinary tract infection and proctocolitis 1b Migrated ureteric stent 1c radiation induced scarring in the pelvis and ureters due to previous cervical carcinoma 2 Obesity I concluded with the following narrative Recognised long term complications of radiotherapy administered as necessary treatment for cancer |
| 4 | CIRCUMSTANCES OF THE DEATH Joan Talbot had a complex past medical history which included cervical cancer for which she had been treated with radiotherapy in 1987 which caused progressive and significant damage over the years initially affecting her bladder causing recurrent urinary tract infections. Her clinical condition began to deteriorate rapidly from March 2022, necessitating three hospital admissions with urinary tract infections, hydronephrosis caused by scarring from the radiotherapy and which required stenting and recurrent bouts of diarrhoea, at times bloody. She was admitted on a fourth and final time to KCH on 14 August 2022 with worsening bloody diarrhoea and a working diagnosis of acute colitis. Whilst waiting for a CT scan to investigate the diarrhoea she developed sepsis and was found to have a dislodged ureteric stent causing hydronephrosis and requiring a nephrostomy as urgent treatment for the sepsis. Her condition continued to deteriorate, and she died despite the nephrostomy and treatment for sepsis. At postmortem the acute colitis was found to be due to ischaemic colitis caused by radiation injury. It was also found that her bladder had been destroyed as a result of recurrent infections, also as a consequence of radiation injury. |
| 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 could 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. Mrs Talbot had been admitted on 3 occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team. There were gaps in continuity of care such that the significance of her history of diarrhoea was not fully appreciated resulting in delays in this presentation being investigated. Although the Trust has subsequently introduced a new record system that has the potential to assist with continuity of care, it has not asked itself how this system can be used most effectively to ensure continuity of care in this specific scenario, whether further refinements to the existing systems and processes may be required. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 6th 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons King’s College NHS Trust. I have also sent it to Mrs Talbot’s family who may find it useful or of interest. 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 | 11th November 2025 [REDACTED] Liliane Field Assistant Coroner |