Chloe Hunt

Ms Sonia Hayes
Area Coroner for Essex
Essex County Council
Seax House
Victoria Road South
Chelmsford
Essex
CM1 1QH

Dear Ms Hayes

Colchester General Hospital
Turner Road
Colchester
CO4 5JL

12 August 2024

Our Reference: 

REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF CHLOE
HUNT WHICH CONLUDED ON 19 JUNE 2024

I write in connection with the above mentioned Inquest and the Regulation 28 Report to Prevent
Deaths issued by yourself on 19 June 2024.

I would like to take this opportunity to extend my condolences to Chloe’s family for their loss.

The Regulation 28 Report to Prevent Deaths issued by yourself on 19 June 2024 highlighted concerns
relating to Colchester Hospital, those concerns were expressed as follows:

a. Chloe explained on 11 March 2022 in Accident & Emergency to the doctor her background of
complex trauma and how difficult she found it to be in hospital. This was not factored into a
plan for treatment.

b.

Imaging established Chloe had swallowed 3 full-sized pens, 2 free in her stomach and 1 was
impacted in her duodenum. There was a lack of consideration of the complexities of removal
to  guide  whether  the  removal  should  be  endoscopic  or  surgical.  Endoscopy  could  not  be
converted into a procedure under anaesthetic in the interventional radiology suite.

c. The requirement for reintubation after each pen removal and the difficulty for a patient to
tolerate multiple procedures without anaesthetic was not considered for Chloe on referral for
removal, or whether this might need to be converted to a procedure under anaesthetic.

d. There  was  a  lack  of  urgency  in  treating  Chloe  and  lack  of  recognition  of  her  deteriorating

clinical condition.

e. Chloe was tachycardic throughout her admission with low blood pressure and there was no
investigation of the underlying cause in a young otherwise physically healthy woman. NEWS
Scores should not replace consideration of the whole clinical picture for a patient.

f.

In  the  hours  before  Chloe’s  death,  she  required  oxygen  for  the  first-time  that  was
administered  for  approximately  75  minutes  and  Chloe’s  heart  rate  reduced  to  normal  for

 several hours for the first time in her admission. This reduction was not sustained, and her
heart  rated  elevated  later.  These  changes  were  not  recognised  as  signs  Chloe  was  a
deteriorating patient.

g. Chloe’s low oxygen saturation level and the prescription of Oxygen was not documented on

14 March.

h. From  the  timing  of  the  recognition  of  Chloe’s  in-hospital  cardiac  arrest  there  was
approximately  10  minutes  before  the  first  heart  rhythm  was  recorded  during  the
resuscitation.

The information presented below is intended to describe the actions which have been taken/are
being taken East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths
and address the concerns you have raised.

Chloe’s presentation and treatment plan for the removal of foreign objections – points a) – c)
raised above.

Chloe presented to the Emergency Department on Friday afternoon 11 March 2022 and was admitted
to hospital. Upon assessment on 12 March 2022 it was deemed that a conservative management plan
should be taken. Having reflected on this decision making it is accepted that there was no benefit to
this management plan and a different course of action could have been considered over the weekend.

Having reviewed the decision process taken on Monday 14 March 2022, it is noted that the available
imaging  did  not  confirm  that  a  pen  was  impacted,  and  the  clinicians  caring  for  Chloe  could  only
establish that the pen was impacted by undertaking an endoscopy. Up to this point, it was the working
diagnosis that the pens could all be removed safely under endoscopy.

When considering how best to proceed in Chloe’s case, a number of factors were taken into account
including  reviewing  the  records  of  previous  endoscopies,  the  ability  to  tolerate  those  procedures,
Chloe’s  risk  profile  and  the  risks  of  surgery,  the  clinical  information  available  at  the  time  and  the
informed consent provided by Chloe at the time to proceed to endoscopy.

It is the Trust’s view that having assessed all the above factors, it was clinically indicated to proceed
to endoscopy and it was reasonable to do so. However, having established at endoscopy that a pen
was impacted and required surgical removal, it is recognised that communication between the clinical
teams  should  have  taken  place  to  decide  next  steps.  This  would  probably  have  been  to  end  the
endoscopy procedure and re-list Chloe on the emergency operating list for a procedure (either further
endoscopy or an operation) under general anaesthetic on 14 March 2023, rather than waiting for a
place on the emergency list the next day. This however would have also required a priority assessment
against the cases already in the list.

Every day the Trust has an emergency theatre list for procedures usually carried out under general
anaesthetic, which is used by all specialities within the Trust. This list runs 24 hours a day if required.
All  emergency  operations  are  placed  on  the  list  and  the  clinicians  responsible  for  conducting  the
emergency theatre list (surgeons and anaesthetists) meet daily to prioritise the patients on the list
and then carry out the procedures in order of priority. Although not a daily occurrence, emergency
procedures might also include endoscopy under general anaesthetic from time to time.

 Chloe’s case has been presented at the governance meeting and morbidity and mortality review to
take the learning out of Chloe’s case and circulate the areas in which decision making can be improved.

Recognition of Chloe as a deteriorating patient – points d) & f) raised above

Chloe’s admission has been reviewed for signs of deterioration.

It is noted that on the evening prior to her cardiac arrest, Chloe was still taking her tablets herself with
sips of water. Chloe got up to go to the toilet at 3:45am and interacted with the nurses about her
cannula/drip stand. While Chloe was asking for pain relief, there is no clear evidence that Chloe had
suffered  a  perforation,  nor  was  the  description  of  Chloe’s  presentation  and  interactions  on  the
evening  a  sign  of  a  patient  who  was  about  to  have  an  event  relating  to  an  upper  gastrointestinal
obstruction and grossly abnormal electrolytes.

The only abnormality detected in the admission was Chloe’s mild tachycardia. This point is addressed
below.

Having reviewed Chloe’s case it appears as there was no clear indication that Chloe was about to suffer
a  sudden  acute  event  relating  to  an  upper  gastrointestinal  obstruction  and  grossly  abnormal
electrolytes.

However,  it  is  noted  that  there  may  have  been  an  opportunity  to  explore  clinical  reasons  for  the
requirement of pain relief, including conduct a further set of observations at that point and exploring
reasons for persistent tachycardia (detailed below).

Chloe’s case has been discussed with staff members, through the daily ward huddle and the Two at
the Top meeting (outlined below) as well as at the joint governance meeting to promote learning from
Chloe’s case and highlight additional actions that can be taken to help establish potential underlying
causes for abnormalities in an otherwise seemingly stable patient.

Investigation of tachycardia – point e) raised above

Chloe’s  notes  have  been  reviewed  and  it  is  noted  that  almost  all  of  Chloe’s  electrocardiograms
undertaken  since 2020 show  a  sinus  tachycardia  and  this  is replicated  throughout most  of  Chloe’s
admissions, where her observations show a sinus tachycardia.

The  cause  of  persistent  tachycardia  can  be  difficult  to  determine  in  patients  who  are  receiving
medications which in themselves, can be the cause of tachycardia.

The Trust has however reviewed the case and acknowledge that a further electrocardiogram could
have been undertaken during the admission to provide further clinical insight into Chloe’s condition.

This learning point has been circulated to staff members, through the daily ward huddle, reiterating
the need to consider persistent tachycardia signs and to undertake further investigations to establish
the underlying cause.

Oxygen prescription – point g) raised above

The Trust would like to take this opportunity to provide assurance that whilst the saturation level and
oxygen administered on 14 March 2023 were not recorded in the notes, the low saturation level was
clinically recognised and appropriate steps were taken to address this, by administering oxygen.

 The Trust has however acknowledged that the low saturations were not recorded in the notes. This
learning point has been circulated to staff members, through the daily ward huddle, reiterating the
need for oxygen saturations to be recorded prior to the administration of oxygen.

The Trust has also  circulated  a further  copy of the Emergency Oxygen Use  in Adult  Patients  policy
which gives staff clear guidance on prescribing, administering and monitoring oxygen.

To  ensure  patient’s  notes  are  being  completed  in  the  correct  manner,  the  Matron  for  the  ward
conducts a spot check on drugs charts once a week to make sure the drugs charts on the ward are
being completed correctly. Where a dose is omitted, an electronic incident report is raised and then
reviewed for the Two at the Top meeting. This is highlighted to the staff though the weekly review of
the drugs charts.

The Two at the Top meeting is a monthly governance meeting which takes place to review various
areas of patient care and safety at a senior clinician level. It covers areas such as patient management,
NEWS & sepsis, medicines management, incident and complaint themes and clinical audits. Any issues
with omitted doses are addressed through the governance process from service meeting to divisional
board, as well as at ward level, to enable further Trust learning to be implemented in areas of need.

In addition to the steps above, the ward notes are subject to a clinical audit, which are peer reviewed
(excluding Acute Kidney Injury and Sepsis which are done at ward level) from an external team, who
visit the ward monthly and carry out a review of a randomly selected 10 patient notes, reviewing these
against the quality standards. This enables the ward to obtain an external view on note keeping and
promote learning established from outside the ward.

The  Trust  has  recently  signed  a  contract  with  EPIC  to  transition  its  patient  records  system  to  an
electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.

This will have the benefit of being more user friendly and provide greater compliance with completing
documents, as the system is able to be programmed to ensure areas of information are documented
before being able to proceed through the system. It is also possible to set alerts that are triggered by
timeframes to ensure staff are notified of any immediate actions that need to be carried out.

Resuscitation – point h) raised above

The Trust would like to take this opportunity to provide assurance that as soon as Chloe was found to
be  in  cardiac  arrest,  basic  life  support  was  administered  immediately,  comprising  of  chest
compressions.

On  this  occasion,  whilst  chest  compressions  were  being  administered  to  Chloe,  the  resuscitation
trolley on the ward was sourced and attempts were made to connect the defibrillator leads but these
attempts were not successful. A further resuscitation trolley was obtained from a nearby ward.

The defibrillator leads were then connected and a rhythm was obtained. It therefore appears the initial
unsuccessful monitoring attempts were a result of operator error.

Through the Stanway ward huddle, all band 5/6/7 staff on the ward have been asked to book onto
Immediate Life Support training through the Trust’s training portal to ensure that there would be a
member of staff on each shift that has had the Immediate Life Support training, which includes the
use of defibrillators.

Discussions have  also  been held  with the Resuscitation  Committee at a recent meeting to make  a
recommendation that all band 6 & 7 nurses on adult in-patient wards should have Immediate Life
Support training as role essential training. Some band 5 nurses in specialist / required areas will also

 need to be included. This  proposal will be  undertaken as  part of  the Resuscitation  Training  Needs
Analysis that is underway and will need executive approval.

In addition, the Matron carries out a monthly quality audit. This is an online form that is completed by
the  Matron.  The  Matron’s  quality  audit  includes  making  sure  the  resuscitation  trolley  has  been
checked daily and fully checked weekly, and signed as being checked. This quality audit will allow the
Trust to identify any issues with resuscitation trolleys and address these.

I hope the above information demonstrates the learning and training that has been implemented to
cover the concerns of the Coroner.

I once again would like to extend my sincerest condolences to the family of Chloe for their loss.

If I can be of further assistance, please do not hesitate to contact me.

Yours sincerely

pp

Chief Executive Officer
East Suffolk & North Essex NHS Foundation Trust

Ms Sonia Hayes 
Area Coroner 
Essex and Thurrock Coroner’s Service 
Essex County Council  
Seax House 
Victoria Road South 
Chelmsford  
CM1 1QH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

9 September 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Chloe Hunt who died on 
15 March 2022.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
June  2024  concerning  the  death  of  Chloe  Hunt  on  15  March  2022.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Chloe’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that the concerns  raised  about  Chloe’s  care  have  been 
listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  Chloe’s  family  or  friends.  I  realise  that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them. 

Your Report raises concerns with the care provided to Chloe whilst she was a patient 
at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS 
Foundation Trust respond to your concerns, which do not fall under NHS England’s 
remit.   

I would, however, like to provide assurance that my senior regional colleagues in the 
East of England are aware of your Report and have been engaging with the Trust on 
the concerns raised.  

NHS  England  has  been  sighted  on  the  Trust’s  response  to  the  Coroner  dated  12 
August  2024,  and  we  note  that  learnings  have  been  taken  from  Chloe’s  care  and 
presented at their Governance meetings, Morbidity and Mortality Review meetings and 
daily  ward  huddles.  We  also  note  that  they  are  taking  actions  to  ensure  there  will 
always be a member of staff on shift with Immediate Life Support training. I refer the 
Coroner to the Trust’s full response for further information.  

I would like to provide further assurances on the national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 other clinical and quality colleagues from across the regions. This ensures that key 
learnings  and  insights  around  events,  such  as  the  sad  death  of  Chloe,  are  shared 
across  the  NHS  at  both  a  national  and  regional  level  and  helps  us  to  pay  close 
attention to any emerging trends that may require further review and action.    
Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director