Lorraine Parker

Sent via Email 

Chief Executive’s Office 

Royal Berkshire Hospital 

Level 4, Main Entrance 

London Road 

Reading 

Berkshire, RG1 5AN 

Tel: 0118 322 7230 

16th July 2025 

Dear Mrs. Connor 

Thank you for your Regulation 28 report dated 23rd April 2025 concerning the death of Lorraine Parker 

who died on 30th April 2024. This Regulation 28 also referred to the deaths of 

 who 

died on 28th December 2023 and 

 who died on 4th March 2024. I would like to take 

this opportunity to express my deepest condolences to the families of Lorraine, 

 and 

. The Royal Berkshire Foundation Trust (RBFT) is committed to learning from deaths 

and improving patient safety. 

Please find below the trust’s response in relation to the prevention of future deaths report addressing 

each point in turn. 

1. 

 On  the  evidence  I  have  seen  from  the  three  inquests  referred  to,  the  Royal  Berkshire

Hospital’s death investigation process is not working well. 

The Trust Board is assured that learning from deaths is underpinned by a robust, structured process 

which  includes compliance  with  a  comprehensive  formal  policy  outlining  our  approach  to  learning 

from deaths, including standardised reporting, investigation, and review processes, and engagement 

with bereaved families. Fostering a culture where staff feel comfortable raising concerns and sharing 

learning  points  has  been  very  important  to  embed  alongside  implementing  changes  based  on  the 

learning from deaths process to improve patient safety and quality of care.  

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1 
 The attached appendix (Appendix 1) outlines how the different processes work within the Trust 

It has been recognised through this inquest process that there are some specialties where there has 

been  a  need  to  support  strengthened  learning  and  we  can  report  that  this  additional  support  has 

already  been  deployed.  With  regard  to  meaningful  engagement  in  processes,  and  how  informed 

discussions and identified learning are captured in clinical governance minutes, senior members of 

the Trust’s Quality Governance Team have been attending surgery clinical governance meetings to 

support  the  learning  and  have  seen  evidence  of  adoption  of  Trust  processes.  These  meetings, 

attended by senior surgical consultants, resident (trainee) doctors and other members of the multi-

disciplinary  team  ensuring  learning  is  cascaded  throughout  the  team.  Key  learning  has  also  been 

shared with other Specialty Clinical Governance Leads, the Mortality Surveillance Group and other key 

Trust committees.    

2. 

I have seen evidence of delayed morbidity and mortality meetings with no clear system for 

ensuring that these discussions happen timeously.  

3.  There  is  little  (if  any)  record  of  areas  of  concern  identified  at  meetings  –  whether  at 

morbidity and mortality meetings or clinical governance meetings.  

Morbidity and mortality meetings are undertaken in each specialty where a death happens as part of 

specialty clinical governance processes. A systematic way for teams to capture learning is in place and 

set  out  below.  The  Trust  also  attaches  Appendix  2,  a  set  of  forms  to  support  the  review  process, 

designed to highlight any issues that may have arisen in care, together with a means of recording any 

recommendations and actions.  This process is well established for specialties including intensive care 

and renal medicine and has been introduced into M&M meetings for general surgery from May 2025 

with  the  learning  captured  within  the  clinical  governance  minutes.  Specialty  clinical  governance 

minutes are disseminated to specialty team members by email as well as to the governance team and 

stored on a Trust shared drive where all specialty clinical governance minutes are held.  

The  specialty  Clinical  Governance  leads  undertake  a  development  half  day  three  times  a  year  to 

support them in their role and Learning from Deaths and patient safety are regular agenda items. The 

concerns raised in this PFD, the learning, and actions being undertaken were disseminated at the most 

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 recent workshop on  June  18th,  which  included  presentations  and  shared examples  of  how to  have 

effective clinical governance meetings, and of good practice. 

General Surgery has a clinical governance meeting 12 times a year. The current process for Morbidity 

and Mortality (M&M) is that the case is discussed in the month following the date of discharge from 

hospital or date of death e.g. if a death occurs in February, the objective is to discuss the death and 

any learning in the March meeting. All deaths, irrespective of cause, and/or whether there has been 

a significant complication, are discussed. If the operating surgeon is on leave or the case needs further 

information to inform discussion, the case is brought back to the next meeting; this can result in a 

delay in discussing a particular case.   During these morbidity and mortality meetings the surgeons 

have a frank and detailed discussion to explore what happened and identify opportunities for learning. 

The General Surgeons recognise their process for capturing the above M&M and care issues within 

their clinical governance minutes, has been very poor. Until April 2025, the governance minutes have 

been recorded by one of the administrative staff (i.e. not medically trained) without direction as to 

how  or  what  to  record  into  the  minutes.  Without  explicit  identification  of  learning  points  this  has 

erroneously resulted in the record stating “no learning identified” even in situations where concerns 

were raised, learning points outlined and actions identified.  In addition, the M&Ms have happened in 

such a timely way following a death that the opportunities to include the outcomes of a Structured 

Judgement Review (SJR) and/or Patient Safety Incident Review Framework (PSIRF) processes into the 

M&M discussion have been missed.  It is recognised that there was no systemised process to bring 

back learning from SJRs, patient safety processes and inquests. We would wish HM Coroner to know 

that  in  the  case  of  Mr  ME,  specifically  highlighted  by  HM  Coroner,  that  there was  re-discussion  in 

Clinical  Governance  following  the  SJR  process.  Clear  learning  points  were  identified  and  shared 

amongst the General Surgery department. We accept however that this was not adequately evidenced 

in our Clinical Governance meeting minutes. 

The specialty is now using the M&M slides (Appendix 2) to capture learning and highlight areas of 

concerns. Examples are given in Appendix 3 of this. Any challenging areas requiring further discussion 

will  be  brought to  the  next  consultant meeting to  allow time  for  full  exploration,  and  the  learning 

brought back to the following governance for dissemination. The documenting and contemporaneous 

note-taking of these discussions will be by the consultant body. The M&M process within the speciality 

is currently being restructured to ensure learning points from Structured Judgement Reviews (SJRs) 

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 and Patient Safety Incident Review Framework (PSIRF) processes are included in the presentations at 

the  M&M  meeting.  Individual  surgeons  will  be  responsible  for  checking  if  any  SJRs/Patient  Safety 

Reviews are pending and updating the slides for presentation to the department at the formal M&M 

meeting. This will include learning points and any other points deemed salient and notable for sharing 

with the wider group.  

The  Trust  acknowledges  HM  Coroner’s  concerns  that  some  of  these  reflections  and  notes  of 

discussions  are  not  provided  timeously  to  the  coroner.  The  Trust  confirms  the  notes  of  these 

discussions will be stored on shared clinical governance drive and the Trust will provide access to the 

Legal Services Team to these notes so that in future they are available when disclosing medical records 

to the court.   To assist with this, we are developing a checklist of items which may be required for 

inquests, along with how to locate them on the Trust’s systems.  

The Trust recognises there is a need for greater clarity of learning and actions undertaken for a case 

especially where there have been multiple types of review. Our intention is to provide a summary 

overview of the case with the notes disclosure (Appendix 4). This will include a brief factual timeline 

of the patient’s clinical journey, key diagnoses and treatment and circumstances of deterioration and 

death. The next section will include the Trust reviews undertaken, each with a concise summary of 

learning points, and outline of actions taken by the Trust including communications with the family. 

The  Trust will  identify  any  concerns  around  avoidability  and  preventability. The  Trust  will  be  clear 

whether all reviews are now complete and if any are ongoing. The latter recognises that additional 

reviews are on occasion indicated if new learning or information becomes available.  

4.  There is delayed escalation of concerns.  

General Surgery has appointed a departmental mortality lead and a patient safety lead, in addition to 

the current Clinical Governance lead. As well as their role within the department, these clinical roles 

will allow specific surgical attendance at Trust Mortality Surveillance and Patient Safety Committees. 

The consultants will all keep a contemporaneous record of data relating to bariatric and colorectal 

resections and from this data will have quarterly presentations of key performance indicators relating 

to  each  subspecialty.  This  will  allow  earlier  oversight  of  significant  complications  for  a  particular 

operation  or  a  particular  surgeon.  As  with  all  concerns,  the  Trust  has  an  open  culture  policy,  that 

should another member of staff have any concerns regarding performance or conduct, they can raise 

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 it, confidentially with their Clinical Lead, Clinical Director or Care Group Director; or indeed through 

the Trust Freedom to Speak Up processes.  

5.  Structured judgement reviews I have reviewed are at best, poor, and at worst, defensive.  

There is a systemised process in place for Structured Judgement Reviews to be undertaken within the 

Trust. Each specialty is notified when an SJR is to be undertaken with and is responsible for allocation 

of  the  SJR  and  its  subsequent  completion.  This  is  undertaken  by  a  consultant  who  has  not  been 

involved in the patient’s care. 

The mortality team were aware that the SJR 1s for ME and MR both done by upper GI surgeons and 

not  the  colorectal  surgeons,  were  not  sufficiently  thorough  or  enough  of  a  considered  review  by 

general surgery. The comple(cid:415)on did not meet the standard expected in rela(cid:415)on to this process.  

However,  for  MR,  given  the  wider  trust  inves(cid:415)ga(cid:415)on  and  the  detailed  statements  that  were  being 

compiled  for  the  inquest  we  did  not  undertake  to  repeat  the  SJR  as  this  more  detailed  review 

superseded the SJR process. This was something given careful thought to in how we could maximise 

our learning about this gentleman’s care, not least for his family. For ME an SJR 2 was undertaken, and 

significant learning was iden(cid:415)fied. Inten(cid:415)onally this was done by the Director for Planned Care who is 

a  gastroenterologist  and  experienced  endoscopist  and  not  by  the  surgical  team,  given  the  central 

relevance of the discrepancy between CT and endoscopic localization of the tumour and the issues 

related to tattooing. For LP, following immediate Medical Examiner scru(cid:415)ny, an SJR was not requested 

as the cause of death was not known and a referral was made to the Coroner. Following the Coronial 

post-mortem, with the finding of Medical Cause of Death 1a as pulmonary embolism, the case was 

progressed, as per Trust due process, to the VTE Commi(cid:425)ee for further review with learning iden(cid:415)fied 

and  documented.  This  was  highlighted  during  the  inquest.  This  learning  was  taken  back  though 

General Surgery clinical governance as part of good prac(cid:415)ce.  

Engagement with Learning from Deaths, including the SJR process is, in the main, very good across the 

Trust  and  is  an  important  learning  process  and  debrief  for  our  healthcare  teams,  as  well  as  the 

opportunity to engage with the deceased next of kin within that process. It is recognised that this can 

some(cid:415)mes vary between teams and individuals and we work increasingly closely with those who may 

require addi(cid:415)onal support to adopt this valuable way of working and learning.  

53

5 
 
 
 
 
 General  surgery  have  made  changes  to  how  structured  judgement  reviews  are  performed.  

Historically,  cases  were  allocated  to  an  individual  GI  surgeon,  who  may  not  have  had  the  same 

subspecialist interest (e.g. colorectal surgery, upper GI surgery, and bariatric surgery) as the particular 

case being examined.  It has been agreed that moving forward the SJR will be performed by a person 

with the same subspecialist interest, with and then reviewed by a second surgeon, preferably from 

outside that subspecialty.  Both surgeons will sign off on this and have their name attached to the 

report. This subspecialty engagement and sense checking of reviews should provide a robust approach 

with more thoughtful outcomes. We have also introduced a parallel anaesthe(cid:415)st led SJR to strengthen 

the  review  and  iden(cid:415)fy  learning,  in  recogni(cid:415)on  of  the  different  perspec(cid:415)ves  that  surgeons  and 

anaesthe(cid:415)sts can bring to the same case.  

Our mortality surveillance commi(cid:425)ee where individual cases are reviewed is extremely well a(cid:425)ended 

with robust discussion about the quality of care provided.  

6.  Delayed or no scrutiny of cases being reported to the coroner because the cause of death is 

unnatural,  given  that  medical  examiners  are  not  funded  to  scrutinise  those  cases. 

Opportunities for early learning are therefore being lost.  

The  Medical  Examiner  Service,  a  national  system  in  England  and  Wales, focuses  on  providing 

independent scrutiny of deaths that are not investigated by a coroner. 

Despite this, and of particular note, in all 3 cases that this PFD is in relation to, there was timely and 

proportionate scrutiny by a Medical Examiner. This supported timely referral to the Coroner, with two 

cases identified by the Medical Examiner as needing further review by the Trust in the form of a SJR. 

The third case was notified to the Coroner due to an unknown cause of death. A Coroner post-mortem 

was subsequently undertaken with the finding of MCCD 1a as pulmonary embolus. The appropriate 

Trust process was followed for this case with review by the VTE Committee with opportunities for 

learning identified through Medical Examiner scrutiny. 

The Trust Medical Examiner service works to national standards and undergoes quality assurance in 

relation  to  its  ongoing  performance  through  data  collection,  benchmarking  and  National  ME  and 

Regional  ME  visits  (2024  and  2025  respectively).  Quality  control  of  SJR  requests  by  the  Medical 

Examiner is undertaken on an annual basis and reported to the Trust Quality Governance Commi(cid:425)ee. 

54

6 
 
 
 
 
 Trust  Medical  examiners  offer  support  with  complex  cases,  and  ensure  that  deaths  meeting  the 

criteria for Coroner notification are promptly and accurately referred. Their scrutiny helps identify any 

concerns  that  may  require  further 

investigation.  Learning  from  deaths 

is  reported 

into 

Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (ICS) and Frimley ICS. 

7.  Systems of collating and providing medical records and clinical governance records to the 

coroner (and presumably to others involved in death investigation) are unreliable.  

The  Legal  Services  Department acknowledge  the  Coroner’s comments  with  regards  to  records  and 

other disclosure, and apologise for recent cases where this has fallen below the expected standard. It 

would  be  beneficial  to  learn  from  the  Coroner  what  format  is  required  in  disclosure  i.e.  whether 

chronologically ordered records or records ordered by document type would be preferable. The head 

of legal services has reached out to the Coroner/Coroner’s Officers regarding this and is awaiting a 

response 

The Legal Services Department are in the process of reviewing how we collate and provide medical 

records and clinical governance records to the Coroner. A number of new steps will be implemented 

which are as follows: 

a. 

Inquest disclosure checklist 

The  department  are  in  the  process  of  implementing  a  disclosure  checklist  which 

includes an outline of what has been requested by the Coroner’s Officer and what has 

been disclosed. The checklist will be required on every request by the Coroner, and 

will act as a “Front Page” of the inquest file so that it what has been disclosed to the 

Coroner  is  clear  to  the  file  handler.  The  checklist  will  require  team  members  to 

complete sections outlining what has been requested, what is available, and what has 

been  disclosed  including  the  dates  of  these.  Patient  Safety  incidents,  Structured 

Judgement  Reviews, 

and  Clinical  Governance/Mortality 

and  Morbidity 

documentation will also be obtained as a part of this checklist. There will also be 28 

day checks and 14 day checks, which will take place at the respective points before an 

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7 
 
 
 
 
 
 inquest. This will ensure that the file is checked prior to the inquest, to give assurances 

that  the  Coroner  has  been  provided  with  all  the  required  disclosure  prior  to  the 

inquest. 

b.  Formatting of records disclosed 

The  department are  also  in the  process of  updating the  format of medical  records 

bundles when disclosing to the Coroner and other external parties. Medical records 

bundles  are  downloaded  from  the  Electronic  Patient  Records  (EPR)  system  in 

chronological order insofar as is possible. Some scanned documents are uploaded to 

the  EPR  in  bulk  and  therefore  not  at  the  time  of  writing.  These  appear  in  the 

chronological order as the date they were uploaded onto EPR rather than the date on 

the 

individual  documents.  Records  from  other  systems  such  as  MediSight 

(Opthalmology),  ARIA  (Chemotherapy),  and  ICCA  (Intensive  Care)  will  also  be 

downloaded  and  requested.  These  records  will  feature  under  their  own  sections 

within the medical records bundle. Any paper records predating the EPR system will 

also feature under their own section. The bundle will be organised with an index page, 

clear sections denoting which system records are included, and pagination to include 

page numbers and cover pages for each section. 

8. 

I am concerned about whether the trust has done enough to deal with the concerns about 

this particular surgeon, not just in the Berkshire area, but more widely. 

Matters pertaining to the individual surgeon are of a sensitive and confidential nature and generally 

subject to data protection principles, however, we will summarise the actions taken by the Trust with 

respect  to  the  identified  concerns  about  this  surgeon’s  practice.  Further  information  can  be made 

available to Ms. Connor in confidence. 

When the concern regarding a potential increased complication rate came to light an in-depth local 

audit of practice was undertaken by the Trust. This did indeed identify that the surgeon had a higher 

complication rate than his peers. Following this, a mutual decision was taken to limit the surgeon’s 

scope of practice whilst a further investigation was conducted. This investigation was conducted in 

line with the Trust’s “Maintaining High Professional Standards (MHPS)” policy and encompassed four 

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 Terms of Reference including the excess complication rate. The process undertaken to first conduct a 

“fact finding” exercise followed by a full MHPS investigation follows the national MHPS framework; as 

does maintaining the restriction to practice to the minimum possible to ensure safe practice.  

The MHPS investigation was undertaken by a trained, external, independent investigator and found 

evidence to uphold all four Terms of Reference and proceeded to a formal hearing. At this hearing an 

appropriate sanction was handed down which remains on the surgeon’s record and an Action Plan for 

remediation was also instigated. 

Should the surgeon choose to return to full scope of practice, a further assessment by the Practitioner 

Performance Advice Service (PPAS), a branch of NHS Resolution specifically established to assist Trusts 

in managing and resolving practitioner concerns, and a period of retraining will be required.  

Throughout this process both the General Medical Council (GMC) and PPAS have been consulted with 

and  kept  informed.  The  surgeon  was  first  referred  to  the  GMC  in  2019  by the  wife  of  a  deceased 

patient following an earlier case. After a provisional enquiry they undertook a full investigation, which 

was protracted due to the covid pandemic. This concluded with a Fitness to Practice hearing with the 

MPTS in early 2024. Their decision was to offer a sanction to the surgeon, which was accepted by him. 

It should be noted that this sanction was related to medical indemnity and not to the surgeon’s clinical 

practice. 

Following the clinical negligence case against the surgeon and the private healthcare provider where 

he  worked,  which  was  bought  by  the  wife  of  the  deceased  and  heard  in  June  2024;  the  Trust’s 

Responsible Officer (RO) contacted the GMC and enquired whether this would alter their previous 

ruling on the case. They re-opened the case via a Rule 12 which enables them to re-examine a case if 

new information has come to light. The Trust was recently notified that the GMC had upheld their 

original ruling and there was no further action required. 

In parallel to this, since the original case, the Trust has been discussing the surgeon extensively with 

its GMC Employee Liaison Advisor (ELA). The ELA service provides a forum for informal discussion and 

advice between the GMC and the Trust RO and/or Chief Medical Officer. Our ELA is fully informed of 

the situation and the restricted scope of practice of the surgeon concerned. A copy of the final MHPS 

Investigation report was submitted to the ELA and she was assured by the actions that the Trust had 

taken as an organisation.  

Similarly, PPAS provide the Trust with a Liaison Officer; and she has also been available for advice and 

guidance  in  managing  the  practitioner  throughout.  Finally,  as  is  standard  practice,  as  soon  as  a 

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 restriction to practice was agreed with the surgeon, the Trust RO made contact with the RO at the 

local  private  hospital  that  the  surgeon  was  also  practising  at.  As  far  as  the  Trust  is  aware,  similar 

restrictions to the surgeon’s scope of practice were implemented there too and the RO is being kept 

informed of the Trust’s investigation and processes. To the Trust’s knowledge the surgeon does not 

undertake medical practice at any other providers.  

The Trust continues to keep matters under review and continues to manage this surgeon within the 

parameters of the relevant processes and procedures.  

In  light  of  the  Trust’s  duty  to  protect  employee  data,  regarding  information  contained  within  this 

response, where it needs to be shared with third parties, the Trust respectfully requests for this to be 

in compliance with the relevant data protection principles.  

In summary the steps taken by the Trust in order to escalate concerns in the Berkshire area were to 

assist the GMC, undertake an internal review, remove the surgeon from various high risk procedures, 

work with the GMC Employment Liaison Advisor and also liaise with the two private hospital networks 

in the area to highlight steps taken so they could make an informed decision as to what steps they 

needed to take in regard to the surgeon’s practicing privileges. The Trust considers it has taken all 

necessary,  proportionate  and  reasonable  steps  to  escalate  and  manage  concerns  in  regard  to  this 

surgeon. 

The Trust also considers it took swift action once a pattern of issues had arisen. The relevant dates 

are: 

ME initial Operation 21.11.23, with date of death 28.12.23 

LP initial operation 23.01.24; with date of death 13.03.24 

MR initial operation 13.02.24; with date of death 04.03.24. 

As can be seen, there is a period of just over 2 months between the deaths. Following the death of LP, 

discussions were had with the surgeon and the Trust requested he take a period of absence to reflect 

on  his  practice.  It  was  upon  his  return  a  formal  investigation  was  undertaken  and  restrictions  on 

practice provided. The Trust considers for this level of investigation to be commenced, a pattern needs 

to  be  established.  In  this  surgeon’s  case,  there  was  no  pattern  established  until  the  death  of  LP, 

following which the Trust took action to limit patient facing care. 

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 I trust this has provided the required assurance in relation to the changes that are being implemented 

within the speciality and within the internal legal processes in order to improve patient safety. Please 

do not hesitate to contact me should you need any further information 

Yours sincerely 

Chief Executive Officer 

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