Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0239, written 21 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 May 2025 |
|---|---|
| Reference | 2025-0239 |
| Deceased | Malcolm Morris |
| Coroner | John Thompson |
| Coroner area | Northumberland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South Tyneside and Sunderland NHS Foundation Trust · Northumbria Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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JAMES THOMPSON Assistant Coroner for Northumberland County Hall, Morpeth, Northumberland NE61 2EF Tel 01670 622600 i REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, NHS England 1 | CORONER | am James Thompson, Assistant Coroner for the coroner area of Northumberland. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On 17th July 2024 | commenced an investigation into the death of Malcolm Morris, 63 years. The investigation concluded at the end of the inquest on 16th August 2025. T i j was that Malcolm Morris died on 5th January 2024 at Northumberland. A narrative conclusion was recorded. The medical cause of death was - 1a Pulmonary Embolism 1b ic 1d Il Lymphoedema complicating right Inguinal Lymph Node Dissection for Squamous Cell Carcinoma plus Obesity 4_| CIRCUMSTANCES OF THE DEATH Mr Morris was diagnosed with penile cancer in May 2023 and underwent necessary surgery to remove it, he suffered with repeated infections which required further treatment & surgery to address this. In July 2023 he had a right inguinal node dissection to arrest the spread of the cancer. He was seen to be infection free by November 2023. He was seen post operatively to develop lymphoedema which is a recognised complication of the surgery. He was referred for treatment of the lymphedema. This amongst other treatments required the wearing of compression garments. At an assessment of his lymphoedema on 3rd January 2024 his right thigh was seen to be swollen. On examination the compression garment was not located in a way that applied pressure to his right thigh. He displayed no symptoms suggestive of a deep vein thrombosis including pain. It is not possible on the evidence to say if a deep vein thrombosis was present at that time. On 5th January 2024 after complaining of pain in his right thigh he collapsed and died. His death was due to a pulmonary embolism which is a naturally occurring disease running its full course and resuiting in his death. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Mr Morris required various periods of hospital admission in Sunderland for elective and also urgent surgery. This was in part to address his cancer and also to treat recurrent wound infections arising from his surgery. Sunderland Royal Hospital is a regional centre for the cancer Mr Morris suffered with. He resided in Northumberland which is outside the usual catchment area for the hospital trust. Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland. They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service. As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take. Evidence | heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible. This meant detailed information on Mr Morris’s discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents. In Mr Morris’s case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital. My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services. Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community. The evidence | have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services. Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16" July 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the following Interested Persons - The family of Mr Malcolm Morris South Tyneside and Sunderland NHS Foundation Trust Northumbria Healthcare NHS Foundation Trust St.Oswald’s Hospice Limited | am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. ! may also send a copy of your response to any other person who | believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 | 21% May 2025 Signed: James E Thompson : HM Assistant Coroner for Northumberland
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr James Thompson
HM Assistant Coroner for Northumberland
Coroner’s Office
Northumberland County Council
County Hall
Morpeth
Northumberland
NE61 2EF
Co-National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
21 July 2025
Dear Mr Thompson,
Re: Regulation 28 Report to Prevent Future Deaths – Malcolm Morris who died
on 5 January 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 May
2025 concerning the death of Malcolm Morris on 5 January 2024. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Malcolm’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Malcolm’s care have been
listened to and reflected upon.
Your report raises concerns around disjointed communication between hospital and
community healthcare systems across different geographical areas and the impact
this has on the efficiency of referrals to district nursing services.
My response has been informed by engagement with NHS England’s North East and
Yorkshire regional colleagues, NHS Pathways and National Patient Safety colleagues.
NHS England recognises that limited information sharing between care settings can
contribute to delays in discharge, incomplete handovers and less effective continuity
of care, particularly when patients receive support across organisational or
geographical boundaries.
Over the past three years, NHS England has developed and led ‘The Frontline
Digitisation’ (FLD) Programme, which has supported trusts in adopting electronic
patient record (EPR) systems, and which nationally supports increased consistency in
digital maturity and improves information sharing between and within organisations.
The FLD Programme not only enables organisations to purchase EPRs but also
advises on safe and effective deployment. However, whilst FLD enhances local digital
capabilities, interoperability (i.e. how different digital systems communicate with one
another) is typically configured and managed at a local level, rather than being led
nationally by NHS England. This will be based on local arrangements between
provider organisations and regional centres, will be cognisant of the wider catchment
area and will depend on the range of technology suppliers. As such, interoperability
will vary depending on local infrastructure and information governance arrangements.
For safety reasons, the deployment of digital clinical systems, of which the EPR is one,
requires health provider organisations to employ Clinical Safety Officers who
undertake a
their deployment.
Implementation plans should clearly state how certain circumstances, such as those
described in this case, should be managed.
full and detailed risk assessment regarding
All healthcare provider organisations continue to have the need to be able to respond
to all types of information flows (digital and paper) into and out of their organisation as
they frequently work with, for example, smaller health and social care organisations,
e.g. hospices who are yet be digitised. In other words, every digitised organisation
needs to be able to receive and send care information in both digitised and non-
digitised formats. Managing this is integral to the safe design of patient pathways and
how a hospital discharges its care responsibilities, regardless of whether these care
pathways are local, regional or national services.
For information, the Sunderland Royal Hospital, part of South Tyneside and
Sunderland NHS Foundation Trust (STSFT), already has an EPR that meets the FLD
Programme’s core standards and has received funding as part of the FLD Programme
to support optimisation of their EPR.
Northumbria Healthcare NHS Foundation Trust’s (NHFT’s) EPR had not met the FLD
Programme’s core standards and has therefore received funding as part of the
Programme to extend functionality.
Both trusts are part of The Great North Care Record (GNCR), which shares healthcare
data which should be available at the point of care. The type of information typically
available on the GNCR includes - Clinical correspondence, Alerts, Appointments,
Cellular pathology and Allergies.
To further support more consistent interoperability across the NHS, NHS England has
developed the ‘Booking and Referral Standard’ (BaRS), which is a national framework
designed to help digitise and standardise referrals and bookings across care settings,
including urgent and emergency care (UEC), general practice, hospital, and
community services.
BaRS is still in the very early stages of implementation, but it offers a significant
opportunity to improve information flow, reduce missed handovers, and support
timelier and coordinated discharges. Realising the full benefits of BaRS will require
broad adoption across the health and care system, including provider engagement
and supplier integration. This means that progress may be complex, slow, and shaped
by wider policy, operational capacity, and investment considerations.
In the meantime, it remains essential that hospitals and local health systems have
clear, clinically safe fallback processes for when digital interoperability is not yet in
place, including robust discharge summaries and communication protocols to support
safe, joined-up care.
Colleagues from our North East and Yorkshire regional team have been in touch with
STSFT, who recognise that whilst your Report was issued to NHS England, there is
still learning for the Trust in terms of improving discharge and referral processes for
outside of area patients. In response, their Incident Review Group recently
commissioned a clinician review to look into the circumstances of Malcolm’s hospital
discharge and identify any necessary improvements. Once the learning has been
established the report will be shared with North East and North Cumbria Integrated
Care Board (ICB), with findings and/or any emerging actions to then be shared with
NHS England.
NHFT acknowledges the challenges that the different digital infrastructures in place
have on the quality of discharge arrangements, particularly when outside of their area.
The Trust has commenced an audit of their Situation, Background, Assessment,
Recommendation (SBAR) communication arrangements and has put in place a new
hub model to better support clinical triage.
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
Malcolm, 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)
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