Coroner questions Sheffield NHS trust’s actions over death of cancer patient
South Yorkshire West assistant coroner Carl Fitch issued a prevention of future deaths report
A coroner has urged changes to the care of cancer patients following the death of a man in hospital in Sheffield following serious side-effects from immunotherapy treatment.
South Yorkshire West assistant coroner Carl Fitch issued a prevention of future deaths report with recommendations to Sheffield Teaching Hospitals NHS Foundation Trust.
The report follows an inquest held into the death of Graham Ian Oxley, which concluded on March 19, 2026.
Mr Oxley died February 22, 2025 at the Northern General Hospital after suffering serious side-effects from pembrolizumab immunotherapy given following kidney cancer surgery.
The coroner reported: “The treatment caused inflammation affecting his heart, muscles and nerves, which led to worsening problems with his breathing and heart.
“He was treated in hospital but his condition continued to decline and life support treatment was stopped.”
The immunotherapy treatment was administered on January 9, 2025. The report said: “Within days, Mr Oxley developed symptoms including diarrhoea, fatigue, breathlessness, weakness and later neuromuscular impairment.
“He made repeated attempts to obtain advice via oncology emergency contact numbers, without success. He attended emergency care but was left without diagnosis.
“On January 28, 2025 he was admitted to Weston Park Hospital, appearing jaundiced with neuromuscular weakness. He rapidly deteriorated requiring intensive care. He was diagnosed with immunotherapy-related toxicity.
“He received escalating aggressive immunosuppressive treatment including steroids, IVIG and abatacept. Despite treatment, his condition progressed to multi-organ failure.”
Mr Fitch concluded that immunotherapy is being used more frequently and said “there are concerns about the reliable operation of systems intended to support early recognition, escalation and access to specialist care for patients experiencing serious immunotherapy toxicity”.
He said the NHS trust describes access to urgent oncology advice through a queue-based triage system and accepted that delays may occur. “The response does not demonstrate how time-critical immunotherapy toxicity is reliably prioritised or escalated when delays arise,”he added.
The report also said that patients are issued with an immunotherapy alert card. It added: “The trust’s response does not show that possession or presentation of an alert card triggers a distinct fast-track or priority pathway, instead linking it to the same triage arrangements.
“These matters create a risk of future deaths where patients experiencing immunotherapy toxicity may encounter delay in accessing specialist advice and where urgent risk signals do not result in priority assessment.”
The NHS trust has until May 20, 2026, to respond.