Graham Oxley

I am Carl J Fitch, His Majesty’s Assistant Coroner for the coroner area of South Yorkshire West.

On 23 June 2025 I commenced an investigation into the death of Graham Ian OXLEY. The investigation concluded at the end of the inquest on 19th March  2026. The conclusion of the inquest was – Graham Ian Oxley died on 22nd February 2025 at the Northern General Hospital, Sheffield after suffering serious side effects from pembrolizumab  immunotherapy given following kidney cancer surgery. 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 cause of death was established as: 1a. Myositis, myocarditis and myasthenia gravis 1b. Complication of pembrolizumab immunotherapy II. Renal cancer

Mr Graham Ian Oxley was diagnosed with renal cell carcinoma and underwent radical nephrectomy in October 2024. His Post-operative recovery included  wound infection and persistent numbness around the surgical site. Follow-up  imaging showed no metastatic disease and he was offered adjuvant  pembrolizumab immunotherapy to reduce the risk of cancer recurrence.  Pembrolizumab was administered on 9 January 2025, and 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 28 January 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. Following discussion with his wife and clinicians,  life-sustaining treatment was withdrawn.

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 investigation has identified that immunotherapy is being used more  frequently and 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. The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Urgent oncology advice – The Trust describes access to urgent oncology  advice through a queue-based triage system and accepts that delays may  occur. The response does not demonstrate how time-critical immunotherapy  toxicity is reliably prioritised or escalated when delays arise. (2) Immunotherapy alert card pathway – Patients are issued with an  immunotherapy alert card intended to signal urgent risk. 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.

In my opinion action should be taken to prevent future deaths and I believe  you SHEFFIELD TEACHING HOSPITAL NHS FOUNDATION TRUST have the power to take such action.