Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0274, written 4 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jun 2025 |
|---|---|
| Reference | 2025-0274 |
| Deceased | David Heffer |
| Coroner | Sonia Hayes |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Suffolk and North Essex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of East Suffolk and North Essex NHS Foundation Trust CORONER I am Sonia Hayes, Area Coroner, for the coroner area of Essex CORONER’S LEGAL POWERS I 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. INVESTIGATION and INQUEST On 3 May 2024 I commenced an investigation into the death of DAVID HEFFER, AGE 84. The investigation concluded at the end of the inquest on 23 April 2025. The conclusion of the inquest was I(a) Septicaemia (b) Acute peritonitis (c) Duodenal and Omental Perforation Post Endoscopic Retrograde Cholangio Pancreatography (d) II Ischaemic Heart Disease, Obstructive Jaundice Mr Heffer died from a rare but recognised complication of a necessary medical procedure and the stent added to the risk of this complication. CIRCUMSTANCES OF THE DEATH David Heffer died on 13 April 2024 of Septicaemia due to Acute Peritonitis secondary to Duodenal and Omental Perforation Post Endoscopic Retrograde Cholangio Pancreatography (ERCP) on 8 April 2024 for Obstructive Jaundice in a background of Ischaemic Heart Disease. Mr Heffer was discharged the 1 2 3 4 1 same day as the ERCP and readmitted on 9 April 2024 in severe pain and diagnosed with biliary sepsis and perforation. Mr Heffer received treatment for sepsis but was not suitable for surgical intervention due to his underlying bladder cancer and probable cholangiocarcinoma. 5 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. (2) The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation. 6 7 8 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 30 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Family I have also sent it to Care Quality Commission who may find it useful or of interest. 2 The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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 4 JUNE 2025 HM Area Coroner for Essex Sonia Hayes 3
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.
Ms Sonia Hayes Area Coroner for Essex Essex Coroners Service Seax House Essex County Council Victoria Road South Chelmsford CM1 1LX Dear Ms Hayes Colchester District General Hospital Turner Road Colchester CO4 5JL 30 July 2025 Our Reference: REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF MR DAVID HEFFER WHICH CONLUDED ON 23 APRIL 2025 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 4 June 2025 (“the Report”). The Report highlighted concerns relating to Colchester Hospital, those concerns were expressed as follows: 1. The treating doctor was not informed when Mr Heffer was readmitted with a complication of the Endoscopic Retrograde Cholangiopancreatography (ERCP), and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. 2. The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation. The information presented below is intended to describe the actions which have been taken/are being taken by East Suffolk and North Essex NHS Foundation Trust (“the Trust”) to mitigate the risk of future deaths and address the concerns you have raised. The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. The Trust acknowledges that the treating endoscopist was not informed of Mr Heffer’s readmission with a complication. The treating endoscopist was only made aware of the readmission following contact from the coroner’s service. The Trust acknowledges this represents a missed opportunity for early clinical input from the treating endoscopist, for reflective learning regarding the case and equipment used (specifically, the stent size) and to have open discussions with Mr Heffer and his family. The Trust acknowledges the need for better communication between clinicians. Reminders will be provided to all general surgical teams, who remain the primary team managing ERCP-related complications, as agreed unanimously at the regional ERCP Clinical Delivery Group—that where feasible, the procedural endoscopist should be informed of any complication arising from an ERCP they performed. The expectation is that a phone call should be made to inform the procedural endoscopist of the readmission. Informing procedural endoscopists of any complication arising from an ERCP they performed will be included in departmental handover guidance and reinforced through clinical education sessions. The Trust is committed to learning from deaths. The Division has agreed to conduct a Bi-monthly Endoscopy Governance meeting at the Colchester site to align with the Governance meetings that currently take place at Ipswich Hospital and promote a consistent approach to Governance at a local level. The Bi-monthly Endoscopy Governance meeting will include a standing agenda item to review all Colchester Hospital ERCP-related complications and deaths. Minutes will be taken at these meetings and shared with all endoscopy colleagues to ensure that those who are not able to attend are informed of the discussions that have taken place and any actions required. The Division are arranging the date for the first meeting to take place at Colchester Hospital which is planned for 1st September 2025. The Division has also implemented a cross-site ERCP Governance review meeting which takes place every three months. This meeting is attended by all ERCP clinicians at both Colchester and Ipswich Hospital and provides a forum for case studies to be reviewed, from both sites, to look at outcomes and to share any learning. In addition to the Governance meetings outlined above, the Trust will be conducting a yearly site specific ERCP audit. This audit will be presented locally and regionally to ensure patterns are identified and lessons disseminated. The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation. The Trust acknowledges the concerns regarding the quality and completeness of Mr Heffer’s medical records, including legibility and availability of key clinical information. The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 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. EPIC will allow for real time, centralised access to clinical documentation, investigations and procedure details across sites. Records within EPIC will be input electronically, they will be time stamped and legible. This will help to improve continuity and clarity of information contained within medical records. An electronic medical records system will improve auditability and traceability of patient pathways. This will allow for prompt case review and early identification of learning. Specifically in relation to the endoscopy unit there will be structured templates and mandatory fields which include stent type and sizing. This will reduce any omissions. The Trust hopes that the above information demonstrates the learning and training that has been implemented and adequately responds to your concerns I would like to personally extend our sincerest condolences to David’s family for their loss. If I can be of further assistance, please do not hesitate to contact me. Yours sincerely, Chief Executive Officer East Suffolk & North Essex NHS Foundation Trust
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