Lady Lola Crouch

H.M Area Coroner 
Ms Sonia Hayes 
SEAX House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

Our Ref: 

16 April 2025 

Dear Ms Hayes 

Regulation 28 Report to Prevent Future Deaths – Lady Lola Kay Crouch 

I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated  21 
February 2025, relating to the Inquest of Lady Lola Kay Crouch. 

We have considered your concerns and set out our formal response to each matter using 
your numbering as follows. 

Matters of Concern 

(1) Lady Lola was not informed of the findings of potential malignancy from a CT 
scan in December 2022. This was not followed up and was then not given as 
part of the history when Lady Lola attended hospital in February 2023. 

We acknowledge that patients should always receive full, timely and accurate information 
about their imaging results, and it is our responsibility to share this information with them 
to deliver excellent care.  

Our  policy  ‘Communication  of  time  critical  or  unexpected  significant  findings  during 
diagnostic  reporting’  MSEPO-21240’  makes  clear  that  the  referring  clinician  is 
responsible  for  the  review  of  any  radiology  they  request.  Where  radiological  imaging 
reports  detect  an  unexpected,  significant  or  time  sensitive  finding,  our  policy  provides 
that  a  radiology  alert  is  sent  to  the  responsible  consultant  with  the  full  report  so  that 
prompt action can be taken, including communication with the patient.  

Our  policy  details  the  expectations  around  communication  of  radiology  results  in  the 
broadest sense, including verbal discussions with staff, recording key information in the 
patient record, and if appropriate, raising alerts to share with other professionals including 
primary  care.  Our  policy  is  subject  to  annual  audit  to  monitor  compliance  and 
effectiveness. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This process provides assurance that diagnostic imaging is reviewed by the right person 
in a timely manner to inform clinical decision making and facilitate patient communication 
of possible diagnosis. 

As  part of  our  digital improvement  innovation  project,  we  have  signed  up  to the  ‘NHS 
App’  radiology  reporting  service  whereby  patients  now  receive  a  copy  of  their  own 
imaging  reports to their personal NHS App. The  reports include  a summary of  clinical 
findings that can be read by patients to improve communication and understanding of 
their own health record. 

I am advised by my surgical colleagues that presentations to the Emergency Department 
(ED) with signs and symptoms of bowel obstruction, particularly small bowel obstruction, 
have a  variety  of  differential diagnoses.  As  in  Lady  Lola’s  case,  with  a  background of 
multiple  previous  complex  open  operations,  adhesions  are  the  leading  cause  of  small 
bowel obstruction.  

Lady  Lola  had  a  short  presenting  history  and  a  CT  scan  suggestive  of  small  bowel 
obstruction  with  differential  diagnoses,  but  suggestive  of  adhesive  obstruction  as  the 
most likely cause. Taking all these features into account and coupled with the fact that 
her symptoms completely resolved within two days of conservative management alone, 
this would be suggestive of adhesive small bowel obstruction.  

Further, full  resolution  of  Lady  Lola’s  symptoms  for  two  months  subsequent  to  an  ED 
presentation would also be a highly unexpected outcome in a case of malignant small 
bowel obstruction. When discussing results with any complex, unwell surgical patient in 
the emergency setting, scan results could be poorly communicated or misunderstood.  

It  has  been  recognised  that  further  investigation  and  information  for  the  patient  would 
have been appropriate in this case and this learning has been shared across the general 
surgical team through morbidity and mortality meeting discussion. 

(2) Staffing levels – A Medical Emergency call was not triggered overnight on the 
surgical  ward when elevated  NEWS  scores required  medical review  that  was 
escalated but delayed due to doctor staffing levels. 

Our ‘NEWS2’ escalation policy was in place at the time of Lady Lola’s attendances. The 
outcome of Lady Lola’s case was communicated at both our July 2024 and August 2024 
general surgical audit meetings to share learning. During the meetings we highlighted 
the importance of compliance with the NEWS2 escalation policy again and reminded the 
surgical  staff  about  the  role  of  the  trigger  response  team,  and  our  local  departmental 
escalation  process.  The  trigger  response  and  hospital  out  of  hours  team  are 
automatically  notified  by  the  electronic  observation  system,  NEWS  escalations  and 
attend the unwell patient.  

 
 
 
 
 
 
 
 
 
 
 
 
 Since  Lady  Lola’s  case  we  have  established  the  hospital  out  of  hours  service  in  the 
surgical  department  to  provide  a  more  robust  response  to  the  surgical  wards.  This 
process has been in place for other specialties previously and we know it works very well.  

Along with the hospital wide trigger response team and hospital out of hours service, this 
provides the surgical team, with senior nursing support who can provide the more junior 
surgical  resident  with  clinical  support,  vascular  access,  resuscitative  support,  and 
escalation prompting. We have further reiterated the NEWS and local clinical escalation 
process to the new residents as part of our standard induction process.  

In terms of staffing, we have a policy that clearly identifies the actions required to address 
unfilled  junior  doctor  rota  gaps.    This  involves  enacting  the  acting  down  policy: 
‘Unforeseen duties – Consultant, MSEPO21041’.  Where we have unfilled junior doctor 
gaps in the rota that cannot be filled, the Consultant and Registrar for general surgery 
and urology will act down to ensure that sufficient support is provided.  

We  have  implemented  the  necessary  changes  to  ensure  that  patients  are  properly 
informed  of  their  imaging  results,  and  embedded  new  processes  within  our  surgical 
teams to make sure surgical colleagues are well supported overnight for urgent cases 
and when required the Consultants act down as per policy.  

I am assured that we have appropriately addressed your concerns in this case, however 
if I can assist further with these matters, please do not hesitate to contact me. 

Yours sincerely 

Chief Executive 
Mid and South Essex NHS Foundation Trust