Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0307, written 18 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 | 18 Jun 2025 |
|---|---|
| Reference | 2025-0307 |
| Deceased | Charlotte Alderson |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Community health care and emergency services related deaths · Emergency services related deaths (2019 onwards) |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 1 CORONER , Secretary of State for Health and Social Care I am Darren STEWART OBE, HM Area Coroner for the coroner area of Suffolk 2 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. 3 INVESTIGATION and INQUEST On 03 January 2023 I commenced an investigation into the death of Charlotte Louise ALDERSON aged 34. The investigation concluded at the end of the inquest on 02 May 2025 which I heard with a Jury. The conclusion of the Inquest Jury was that: Narrative Conclusion - Mrs Alderson reported feeling unwell from 17th December 2022. She attended the GP Surgery on 19th December 2022. Observations were taken which were considered to be within normal range. Centor score of 2 was generated which indicated no anti-biotics were required at this time. An outer ear infection was diagnosed and a prescription was given for a topical anti-biotic spray. Redness of the throat was observed and a throat swab was taken to be sent for analysis. It was recorded she was taking over- the-counter pain relief. It was advised she should return to the surgery if her symptoms worsened. Mrs Alderson reported feeling better on 20th December 2022 but then felt worse that evening. She then suffered bouts of sickness and diarrhoea throughout the night. On 21st December 2022 at 7am, Mrs Alderson reported this to her husband and went to bed. At 11am on the same day, her husband checked on her and upon observing a blue tinge to her lips, called 111. The 111 call handler triaged the symptoms using a computer- based system. Upon reporting a blue tinge to Mrs Alderson's lips in module 0, a category 2 ambulance response was triggered. The 111 call handler manually called 999 as the system did not automatically dispatch an ambulance. Mrs Alderson's condition worsened, and her husband made an additional call to 999. He was advised the ambulance was en route. The ambulance arrived at 11:57am and a Senior Emergency Medical Technician (EMT) made a clinical assessment of Mrs Alderson, including multiple observations. The Senior EMT did not observe blue-tinged lips. Observations were generally within normal range, other than a slightly elevated temperature and heart rate. At the scene, the Senior EMT called Mrs Alderson's GP surgery and discussed symptoms and observations with the duty doctor. This was standard practice at the time. With no requirement identified for immediate hospitalisation, the ambulance left at 13:15. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Mrs Alderson's conditioned worsened further and her husband left to purchase pain relief. Upon his return, he found Mrs Alderson in a state of collapse. She was unconscious but breathing. He called 999 immediately (14:09). During this call, Mrs Alderson stopped breathing. Bystander CPR commenced and an ambulance was dispatched at 14:15. En route to the scene, further backup was requested due to the report that Mrs Alderson had stopped breathing. The ambulance arrived at 14:26 and the ambulance crew took control of resuscitation attempts. Leading Operations Manager Team arrived at 14:37, followed by the critical care team (HEMS) a minute later, who employed multiple methods of resuscitation. Resuscitation attempts were ceased at 15:29 and Record of Life Extinct was completed at 15:54. The post-mortem examination carried out on 30th December 2022 found that the cause of death was as a result of multi-organ failure due to septic shock, arising from the rapid progression of a bacterial infection into the bloodstream. This infection was identified as beta haemolytic streptococcus infection, the presence of which was confirmed by the results of the swab previously taken for testing on 19th of December 2022. The toxicology report was unremarkable. It is therefore concluded that Charlotte Louise Alderson died of natural causes. The jury would like to express their sincere personal condolences to the family. The medical cause of death was confirmed as: 1a Multi Organ Failure 1b Septic Shock 1c Beta Haemolytic Streptococcus Infection 4 CIRCUMSTANCES OF THE DEATH See Above Narrative 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) I have concerns in three areas which are as follows: There are two scoring systems used by clinicians to assess infection in a. patients presenting to them, namely; CENTOR and FEVERPAIN. Either may be used by clinicians. Both systems use similar parameters to diagnose and indicate treatment. However, in their application to a given set of circumstances they can produce different outcomes, specifically in relation to the prescription of antibiotics. It is possible in Mrs ALDERSON’s case that the use of the FEVERPAIN scoring system (as opposed to CENTOR) may have made a difference by indicating a prescription for antibiotics, which if taken on the day she was assessed by her Regulation 28 – After Inquest Document Template Updated 30/07/2021 GP, may have resulted in a different outcome. There is a need to review these scoring systems, drawing upon the most effective elements of each, with a view to providing guidance on a single scoring system that can consistently be applied by clinicians. Evidence received during the Inquest indicated that a number of existing b. measures within the National Health Service are capable of modification to provide testing tools for the early identification of sepsis/risk of sepsis and which would better inform decisions to prescribe antibiotics. These include CRP, finger prick and lateral flow tests. The risks associated with sepsis and the speed with which a rapid deterioration can occur in patients without clear warning signs of sepsis being present, are well known. There is therefore a need for the expeditious development of measures which assist clinicians in the early identification and treatment of sepsis. During the course of the evidence presented at this Inquest, the Court c. heard that the Interoperability toolkit (ITK) used to handover information between 111 and 999 services will on occasions fail, requiring the manual backup of a telephone call. This was identified as a national issue which, although not frequent, when it occurs carries a significant risk of critical information not being passed due to human error. I am concerned that in such circumstances the manual backup is not adequate and there is a risk that significant information is not passed thereby increasing a risk to life. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 13th, 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Family of Charlotte ALDERSON , The Market Cross Surgery, Mildenhall , The Market Cross Surgery, Mildenhall East of England Ambulance Service NHS Trust NHS 111 (Practice Plus Group) I have also sent it to: The Royal College of General Practitioners who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 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 Dated: 18/06/2025 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Darren STEWART OBE HM Area Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
From Baroness Gillian Merron
Parliamentary Under-Secretary of State for
Patient Safety, Women’s Health and Mental Health
39 Victoria Street
London SW1H 0EU
12 August 2025
Our ref: PFD – 25-06-18 - ALDERSON
HM Coroner Darren Stewart OBE
HM Area Coroner for Suffolk
The Coroner’s Court and Offices,
Beacon House,
Whitehouse Road,
Ipswich,
IP1 5PB
By email: coroners.service@suffolk.gov.uk
Dear Mr Darren Stewart OBE,
Thank you for the Regulation 28 report of 18/06/2025 sent to the Secretary of State for Health and
Social Care, about the death of Charlotte Louise Alderson. I am replying as the Minister with
responsibility for Patient Safety, Women’s Health and Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Alderson’s death,
and I offer my sincere condolences to their family and loved ones. The circumstances your report
describes are very concerning and I am grateful to you for bringing these matters to my attention.
Your report detailed three concerns regarding: the need to review the FeverPAIN and Centor scoring
systems with a view to providing guidance on a single scoring system that can consistently be applied
by clinicians; the need for the development of measures such as C-reactive protein (CRP), finger
prick and lateral flow tests to assist clinicians in identifying sepsis early and inform decisions to
prescribe antibiotics; and the risks associated with the failure of the Interoperability toolkit (ITK) used
to handover information between 111 and 999 services.
In preparing this response, my officials have made enquiries with NHS England, the UK Health
Security Agency (UKHSA) and the National Institute for Health and Care Excellence (NICE) to ensure
we adequately address your concerns. Sepsis is a devastating condition, which takes the lives of too
many people too soon, including Mrs Alderson. The government is clear that patients should expect
and receive the highest standard of service and care from the NHS.
I would first like to address your concern regarding the use of the FeverPAIN and Centor scoring
systems. As your report outlines, the importance of reliable screening tools to determine the need
for antibiotics is tragically evident in this case. NICE is responsible for guidance on clinical processes,
including guidance on the use of scoring system diagnostics. The NICE guideline, NG84, on
antimicrobial prescribing for acute sore throat recommends that clinicians use FeverPAIN or Centor
criteria to identify people who are likely to benefit from an antibiotic. NICE acknowledges that there
is currently uncertainty about which scoring system is more effective, and that using either scoring
tool in clinical practice is preferential to using neither. The concerns highlighted in your report around
the use of FeverPAIN and Centor scoring systems, and other diagnostic testing tools, will be taken
forward and considered by the NICE surveillance team.
The Department, through the National Institute for Health and Care Research (NIHR), continues to
invest in research to support scoring systems. For example, an NIHR MedTech and In Vitro
Diagnostics Co-operative has recently funded research into the diagnostic accuracy of FeverPAIN
and Centor criteria for bacterial throat infection. NICE regularly reviews the evidence generated
through research such as this with the aim to improve patient outcomes. Additionally, UKHSA is
actively working with academic partners to support a review of Group A Streptococcus diagnostic
strategies in England, as part of the wider aim to reduce avoidable harm and improve patient
outcomes.
Your second concern relates to diagnostic tools for the early identification of sepsis. Currently, there
is no single diagnostic test for sepsis and the signs and symptoms can vary hugely. This, along with
the speed with which patients can deteriorate from sepsis, makes sepsis challenging to identify and
diagnose. Therefore, promptly identifying and treating sick and deteriorating patients, regardless of
cause, is crucial. We must do all we can to learn from tragic incidents such as Mrs Alderson’s death
to help prevent future preventable deaths.
To support the identification of sepsis among healthcare professionals, the National Early Warning
Score (NEWS2) is used as a clinical screening tool for the recognition of acutely unwell and
deteriorating adults. NEWS2, when used alongside clinical history and examination, supports
clinicians to determine the need for immediate care, such as potentially life-saving treatment with
antibiotics for patents with suspected sepsis.
Although NEWS2 is used in 99% of Acute Trusts and 100% of Ambulance Trusts in England, some
patients with sepsis, including Mrs Alderson, are still not being treated with antibiotics quickly enough.
To support understanding of sepsis amongst healthcare professionals, NICE published updated
national guidance in March 2024 on sepsis recognition, diagnosis and early management (NG51),
which complements NHS England’s sepsis
includes
recommendations on finding and controlling the source of infection and encourages clinicians to
consider sepsis early when faced with non-specific symptoms. An update to the NICE sepsis
guidance is currently out for consultation, to ensure it reflects latest evidence. The consultation
specifically calls for further research on how rapid microbiological testing can guide the management
of suspected sepsis. This call is encouraging and could support the development of measures that
will assist clinicians in the early identification of sepsis, leading to quicker and more targeted treatment
and better patient outcomes.
training programmes. The guidance
Additionally, NHS England’s Urgent and Emergency Care Plan 2025/26 supports the use of NEWS2
and commits to working with Royal Colleges and Societies on updating and sharing sepsis guidance
and learning from best practice.
NICE does not currently recommend the use of testing tools such as CRP, finger prick, or lateral flow
tests for the early identification of sepsis. However, I am reassured that NICE operates a proactive
surveillance programme for new evidence. Once new evidence emerges, NICE then considers
whether existing guidance should be reviewed and, if appropriate, it is updated.
Treatment of sepsis relies on keeping antibiotics working. Developing diagnostics that enable early
detection of infections to drive optimal antimicrobial usage is a priority for this government, as set out
in the 2024-29 UK antimicrobial resistance national action plan. The government is committed to
driving evidence generation to improve our understanding of sepsis diagnosis and immediate
management. DHSC continues to fund research through the NIHR and has provided over £21 million
in programme funding for sepsis diagnostics and screening since 2020, over £14 million of which
was focused on research into sepsis-related diagnostics. This includes research to develop a small
point-of-care test using sepsis-specific ‘C-Reactive Protein and Very Low-density Lipoprotein
complex’ (CRP-VLDL) in the blood, and to develop a finger-prick test for sepsis that aims to produce
results in 10 minutes. Further research to consider the broader clinical impact of diagnostics and
interventions within management pathways will be key.
Finally, you raised concerns regarding system failures of the Interoperability toolkit (ITK) when
transferring incident information from 111 to 999 and the associated risks to patient safety. The ITK
is an interoperability standard, which sets out how information is securely exchanged from 111 and
999 and was introduced to speed up this transfer. The established procedure for transferring
Category 2 calls from 111 to 999 is to electronically transfer the case to the ambulance service’s
Computer Aided Dispatch system. If the electronic transfer fails or is not available, the 111-call handler
verbally relays the case via 999 to facilitate the safe handover of the call. The manual transfer of
information from 111 to 999 mitigates the risk associated with system failure. I have been reassured
that if electronic transfers fail with any regularity, investigations are undertaken to identify the cause
and, where appropriate, mitigating actions are taken.
I hope this response is helpful. Thank you again for bringing these concerns to my attention.
All good wishes,
BARONESS MERRON
PARLIAMENTARY UNDER-SECRETARY OF STATE FOR
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH
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