Lorraine Parker

Parliamentary Under-Secretary of State  
for Public Health and Prevention  

39 Victoria Street  
London  
SW1H 0EU  

18 June 2025  

Our ref: 

HM Coroner Heidi J Connor  
Coroner’s Office  
Reading Town Hall  
Blagrave Street  
Reading   
RG1 1QH  

By email: 

Dear Ms Connor,   

Thank you for the Regulation 28 report of 23rd April 2025 sent to the Department of Health 
and  Social  Care  about  the  death  of  Lorraine  Parker.  I  am  replying  as  the  Minister  with 
responsibility for cancer policy.        

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Parker’s 
death, and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

The report raises concerns over the lack of formal guidance requiring consultant surgeons 
to  consider  CT  scanning  for  post-operative  patients  with  persistently  high  or  rising  CRP 
levels,  and  an  over-reliance  on  clinical  judgement  without  sufficient  consideration  of 
objective markers such as CRP. It also notes the absence of clear documentation around 
decisions to use, or not use, imaging in these scenarios, and raised a broader concern that 
apparent clinical improvement at the bedside may mask serious post-surgical complications 
that could only be identified through appropriate imaging.  

In  preparing  this  response,  my  officials  have  made  enquiries  with  colleagues  across  the 
health system, including the National Institute for Health and Care Excellence (NICE), the 
Care Quality Commission (CQC) and multiple teams across the Department of Health and 
Social Care to ensure we adequately address your concerns.  

In this case, there was not one single error but multiple errors that contributed to the death 
of Ms Parker.   

Lord Darzi’s independent report on the state of the NHS highlighted the challenges facing 
our health service, which is why we have launched: 

•  a 10-Year Health Plan to reform the NHS and make it fit for the future  

  
  
  
  
  
  
  
  
  
  
   
   
   
   
 
 •  a refreshed workforce plan to ensure the NHS has the right people in the right 

places with the right skills to deliver the care patients need   

•  a National Cancer Plan for England to reduce the number of lives lost to cancer 

and improve patient experiences and outcomes.  

With  regard  to  concerns  about  guidance  for  clinicians,  the  NICE  guideline  on  colorectal 
cancer (NG151) aims to improve quality of life and survival for adults with colorectal cancer 
by providing evidence-based recommendations on the management of both local disease 
and metastatic (secondary) cancer. It covers which interventions should be used for different 
types and stages of the disease, helping to guide decisions on surgery, chemotherapy, and 
other treatments.  

The NICE guideline does not provide detailed protocols for postoperative tests or scans, and 
clinicians  would  be  expected  to  use  their  judgement  and  follow  local  protocols  or  other 
relevant professional guidance. However, whilst the Department has no immediate plans to 
instruct  NICE  to  produce  standalone  guidance  on  post-surgery  imaging  based  on  CRP 
thresholds,  details  of  this  case  have  been  shared  with  colleagues  in  NICE’s  prioritisation 
team to consider if further action should be taken.  

With regard to concerns about clinical judgement, NHS Trusts are responsible for ensuring 
staff  are  sufficiently  competent  to  deliver  care. Accordingly,  the  Trust  in  question  should 
consider their protocols in the wake of this case. The CQC has passed details of the case 
to the relevant inspection team for Royal Berkshire Hospital for further consideration.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.    

Yours sincerely,

Ms Heidi J Connor  
HM Senior Coroner  
Berkshire Coroner’s Office 
Reading Town Hall  
Blagrave Street  
Reading 
RG1 1QH  

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

13 June 2025   

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Lorraine Sandra Parker 
who died on 30 March 2024  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 April 
2025 concerning the death of Lorraine Sandra Parker on 30 March 2024. Whilst NHS 
England  is  not  specifically  named  as  a  respondent  in  your  Report,  the  Report  was 
 the National Director of Patient Safety 
addressed to my colleague 
for NHS England, (and a Deputy Chief Medical Officer at the Department of Health 
and Social Care (DHSC)). 

I  am  therefore  responding  to  you  in  my  capacity  as  Co-National  Medical  Director 
(Secondary Care) for NHS England, with responsibility for all Regulation 28 Reports 
addressed to the organisation, and would like to assure you that Dr Fowler has been 
sighted  on  your  Report  and  has  provided  input  into  this  response.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Lorraine’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the Coroner that the concerns raised about Lorraine’s care have 
been listened to and reflected upon.   

Your Report raises the concern that there is a lack of guidance for surgeons regarding 
CT scanning for patients who have undergone major abdominal surgery and where 
they have a raised C-reactive protein (CRP), which is either continuing to rise or is not 
decreasing.  You  raise  that  clinical  judgement  alone  is  not  always  sufficient  in  this 
scenario.  

While  NHS  England  notes  your  concerns,  clinical  guidelines  are  primarily  the 
responsibility of the National Institute for Health and Care Excellence (NICE) and the 
appropriate  Royal  Colleges.  NHS  Trusts  are  expected  to  have  due  regard  to  any 
clinical guidelines and to implement the appropriate local processes and/or guidance. 
I note that you have also addressed your Report to the Association of Coloproctology 
of  Great  Britain  (ACPGBI)  and  the  Royal  College  of  Surgeons,  who  are  the  more 
appropriate organisations to respond to your concerns.  

NHS England has however discussed your Report with the ACPGBI, and it is agreed 
that  there  is  not  a  requirement  for  further  guidance  to  be  written.  CRP  levels  are 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 commonly  used  as  a  marker  to  indicate  or  exclude  evidence  of  leaks,  including 
anastomotic leaks following abdominal surgery.  

The following articles and guidance are relevant and may assist the Coroner further: 

•  ACPGBI  Guidance  on  Prevention,  Diagnosis  and  Management  of  Colorectal 

Anastomotic Leakage – March 2016. 

•  National  Library  of  Medicine  article:  ‘Serum  C-reactive  protein  is  a  useful 
marker  to  exclude  anastomotic  leakage  after  colorectal  surgery’  dated  3 
February 2020. 
‘Early warning model to detect anastomotic leakage following colon surgery: a 
clinical observational study’ dated 8 October 2024. 

• 

NHS England notes the local delays in reporting experienced by Lorraine, who was 
sent  home  on  31  January  2024  without  a  post-operative  scan  despite  an  elevated 
CRP, together with the misreporting of the CT scan in February 2024. Clinical Quality 
colleagues in the South East region have been made aware of your Report and asked 
to engage with the relevant Integrated Care Board / Trust on the details of Lorraine’s 
case and to seek assurance that learnings have been taken.  

I  would  also  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 
Lorraine, 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,  

Co-National Medical Director 
(Secondary Care)

(a Royal College
rit of Surgeons
ae KN of England

tet. sea ae ADVANCING SURGICAL CARE
BY EMAIL

Heidi J Connor
Senior Coroner for Berkshire

3 June 2025

Dear Madam Coroner,

Thank you for providing RCS England with details in your recent issuance of a Regulation 28:
Report to Prevent Future Deaths. The Chief Executive has passed this notice to me as the Vice-
President responsible for patient safety.

We are extremely sorry to hear of the death of Lorraine Parker and express our sincere
condolences to her family.

We take note of the cautionary points made within the report, specifically, the need to take note
of increasing CRP following sigmoid colectomy and bowel anastomosis for adenocarcinoma,
and the failure, in this case, to act on this to obtain appropriate imaging in a timely manner.

Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care,
is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical
Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of
Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they
are best placed to consider the need for guidance. We will contact them to support their
assessment and any dissemination of guidance or other communications.

We will ensure that a precautionary anonymised educational surgical vignette relating to this
death is included in the Confidential Reporting System for Surgery (CORESS) surgical safety
feedback reports published in the journals of the Royal College of Surgeons of England and
circulated to our members. We will also encourage the Royal College of Surgeons of Edinburgh
to do the same.

Thank you for drawing our attention to this unfortunate case.

Yours Sincerely,

VicePresident 7

Registered Charity no: 212808

5 June 2025 

Heidi J Connor 

Senior Coroner for Berkshire 

Reading Museum and Town Hall 

Blagrave Street 

Reading  

RG1 1QH 

Dear Ms Connor, 

Thank you for your correspondence dated 23 April 2025 in the form of Regulation 28: Report to Prevent 
Future  Deaths.  I  am  writing  on  behalf  of  the  ACPGBI  Executive  Committee,  which  I  currently  Chair  as 
President. 

The report has been scrutinised by me and discussed by the Executive Committee on 2 June 2025. 

In  relation  to  the  matters  of  concern  raised,  I  attach  Issues  in  Professional  Practice  Guidance  on  the 
Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with 
ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering 
subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please 
see  in  particular  pages  16-17,  where  cut  off  values  for  CRP  triggering  a  subsequent  CT  scan  are  also 
considered.  In  addition,  there  have  been  several  subsequent  publications  (available  on  Pubmed) 
confirming this practice. 

On this basis, given current guidance exists, it is the view of the ACPGBI Executive that further additional 
guidance from ACPGBI is not required at this time. It is not clear to the Executive whether this existing 
guidance was considered during the investigative process outlined. 

Yours sincerely, 

President, ACPGBI 

www.acpgbi.org.uk 
The Association of Coloproctology of Great Britain and Ireland 
Royal College of Surgeons of England / 35-43 Lincoln’s Inn Fields / London WC2A 3PE / Telephone: +44 (0)20 7973 0307 / +44 (0)20 7973 0373 

Registered Charity 1118063 A company limited by guarantee registered in England and Wales Company reg. no. 5962281 

Email: admin@acpgbi.org.uk 

The Association of Coloproctologyof Great Britain and Ireland