Ann Caldicott

HM Coroner Sarah Clarke  
North East Kent Coroners 
Oakwood House  
Oakwood Road  
Maidstone  
Kent 
ME16 8AE 

Dear Ma’am,  

Chief Executives Office 
Trust Offices 
Kent & Canterbury Hospital 
Ethelbert Road 
Canterbury 
Kent 
CT1 3NG 

04 August 2025   

Regulation 28 – Prevention of Future Deaths (PFD) Response regarding the inquest into the 
death of Mrs Ann Caldicott  

On behalf of East Kent University Hospitals NHS Foundation Trust (the “Trust”), we would like to 
reiterate our apology to the family of Mrs Caldicott. We want to assure the coroner and the family 
that steps have been and will continue to be taken to ensure that this situation does not arise again.  

The matters that gave rise to the PFD and the Trust’s response to each point is outlined below:  

1.  Mrs Caldicott’s malnutrition and declining frailty were not investigated despite continued 

requests by Mrs Caldicott and her family to primary and secondary care settings.  

Prior to the issuing of the PFD, and as part of our expected processes, a Nutrition Trust Wide 
Improvement Plan (“TWIP”) had been developed for 2025/26. This followed an internal review of 
quality  indicators  across  the  previous  year  which  had  demonstrated  inconsistent  standards  of 
nutritional  care  being  provided,  including  contributing  factors  of  gaps  in  staff  knowledge  (for 
example  around  naso-gastric  feeding),  and  nutrition  and  hydration  not  consistently  being 
discussed as part of the Multi-Disciplinary Team (MDT) board rounds, which can hinder timely 
recognition and management of these patients’ nutritional needs. 

Key priorities in the TWIP include: 

• 

 Identifying essential nutrition training requirements and delivering this training to all staff 
groups. 

•  Enhanced  daily  ward  processes  to  identify  at-risk  patients  early  and  ensure  an 

appropriate nutritional care plan is developed and implemented. 
Improved communication across teams and with families.  

• 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In light of the coroner’s findings, the TWIP has been re-reviewed and the MDT element further 
strengthened, to ensure clear clinical leadership, to drive lasting improvements. 

Progress  and  outcomes,  including  updates from care groups  on their  actions,  will  be  regularly 
measured  and  reported  to  the  Nutrition  Steering  Group  on  a  bi-monthly  basis,  and  to  the 
Fundamentals  of  Care  Committee  (FOC)  quarterly.  Any  concerns,  delays,  or  barriers  will  be 
escalated through these reporting frameworks to ensure senior support and leadership. 

We are committed to embedding these changes to ensure that nutritional care is recognised and 
prioritised as a fundamental aspect of patient safety and quality across the Trust, with the goal of 
improving patient outcomes and preventing future harm. 

The  Trust  is  also  committed  to  ensuring  family  concerns  are  listened  to  and  a  guideline  for 
clinicians for the implementation of Martha’s Rule was approved in July 2025 and is now actively 
being used by families and clinicians. A copy of the Trust’s guideline can be provided on request.  

Action: Complete and ongoing  

2.  Mrs Caldicott marked anaemia and poor nutritional state meant that she was not suitable 

for potentially lifesaving treatment when it became necessary.  

Mrs Caldicott was identified to have been losing weight and anaemic during a hospital attendance 
in  January  2023.  Investigations  were  undertaken  and  she  was  referred  to  the  outpatient 
gastroenterology  team.  She  was  also  under  the  care  of  the  diabetic  and  endocrine  team.  It  is 
likely  that  Mrs  Caldicott’s  anaemia  was  as  a  result  of  her  other  chronic  health  conditions.  No 
specific  gastro-intestinal  cause  of  anaemia  or  weight  loss  were  identified.  Also,  no  underlying 
cancer diagnosis was identified on CT, gastroscopy and sigmoidoscopy.  

However, there was potentially a missed opportunity to consider Mrs Caldicott’s declining health 
more  holistically.  Weight  loss and  anaemia  are  likely  to  have  been  consequences  of  Mrs 
Calidcott’s chronic health conditions. Her general condition had declined significantly over the few 
months  leading  up  to  her  death.  Whilst  nutritional  state  and  anaemia  were  factors  in  decision 
making  about  treatment  options  for  the  perforated  bladder,  there  were  other  serious  co-
morbidities and current acute kidney injury which also impacted. 

A multi professional review of the 12 months care and treatment preceding her admission late 
2023 will take place. This is described further later in this letter. 

Action: Complete  

3.  No  internal  investigations  were  conducted  by  Mrs  Caldicott’s  GP  or  by  the  East  Kent 
Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of 
the circumstances of Mrs Caldicott’s Death.  

The Trust has found several points at which an investigation could have been triggered into the 
care Mrs Caldicott received. Unfortunately, there were missed opportunities meaning that some 
of  the  issues  only  came  to  light  during  the  Inquest  itself  and  beyond.  We  apologise  to  Mrs 
Caldicott’s family in this regard.  

 
 
 
 
 
 
 
 
 
 
 
 We have highlighted this case to the Lead Medical Examiner as the first point at which it was felt 
a Structured Judgement Review could have taken place. If this had happened then it would have 
triggered many other actions and the Trust could have learned from this case earlier than it has 
now. Individual feedback has been provided and additional support will be provided to the Medical 
Examiner team to allow them to better identify cases for further investigation.  

Regrettably, the clinician who gave evidence at the Inquest did not raise a Datix and therefore, 
once  again,  the  opportunity  to  investigate  and  learn  was  lost.  We  apologise  that  this  wasn’t 
completed  in  a  timely  manner  but  the  clinicians  have  been  received  feedback  and  they  have 
reflected on the importance of raising incidents for learning and improvement. The Trust realises 
this  is  not  reassuring  but  we  believe  this  to  be  an  isolated  incident.  However,  as  part  of  our 
commitment to improving governance and patient safety, the Trust will continue to review learning 
from incidents, complaints, claims and inquests.  

Action: Ongoing  

4.  The Court was informed that there had been an SJR (of which I had not previously been 
notified) following Mrs Caldicott’s death. The Dr providing evidence was to raise a Datix 
in  relation  to  Mrs  Caldicott’s  previous  attendances  and  failed  discharges.  At  the 
resumed inquest the Court were informed these investigations had not taken place and 
were not to take place. 

See above.  

Action: Ongoing  

5. 

No  consideration  was  given  prior  to  Mrs  Caldicott’s  final  admission  and  some  18 
months after the onset of symptoms of vomiting and chronic weightless, of support 
for Mrs Caldicott’s nutritional status.  

Mrs Caldicott was identified to have been losing weight and anaemic during a hospital admission 
in  late  2022.  Investigations  are  undertaken  and  she  was  referred  to  the  outpatient 
gastroenterology  team.  She  was  also  under  the  care  of  the  diabetic  and  endocrine  team.  It  is 
likely  that  Mrs  Caldicott’s  anaemia  was  as  a  result  of  her  other  chronic  health  conditions.  No 
specific gastro intestinal cause of anaemia or weight loss were identified. No underlying cancer 
diagnosis was identified on CT, gastroscopy and sigmoidoscopy. 

We believe that the Manor Clinic can also respond in this regard as her primary care provider.  

6. 

If Mrs Caldicott had been in a better nutritional state on her final admission to the Kent 
and  Canterbury,  then  she  would  have  been  well  enough  to  undergo  lifesaving 
treatment following the bladder perforation. 

The Trust feels this is an opinion better suited for an expert to determine and not one that requires 
action per se. However, the William Harvey Clinical lead for Nutrition Dr Helen Mackie, consultant 
gastroenterologist has stated, that it is difficult to say with any certainty what the probability would 
have been.  

 
 
 
 
 
 
 
 
 On review of Mrs Caldicott’s hospital records from January 23 to the time of her death she was 
seen by several specialities. She had a number of chronic health conditions which may have been 
contributory to her cachexia and weight loss. Hyperthyroidism, Diabetes Mellitus, hypertension, 
generalised atherosclerotic disease, brain small vessel disease, and latterly, acute kidney injury.  

Investigations did not identify a cancer diagnosis nor any other clear cause of her weight loss. 
She  was  also  anaemic  and  this  was  a  chronic  anaemic  most  likely  due  to  underlying  chronic 
health conditions. 

Even  if  her  nutritional  state  had  been  optimised  earlier,  it  is  impossible  to  speculate  if  that 
optimisation  would  have  improved  her  general  health  to  the  level  of  further  live-saving 
treatment.  It is likely that her other health conditions were the drivers of her poor nutritional state 
rather that a consequence of it. 

We  will  be  undertaking  a  full  multi-professional  case  note  review  of  Mrs  Caldicott’s  care  and 
treatment in the months preceding her admission which will ascertain if her continuing decline in 
health could have been identified earlier in a more holistic manor. We anticipate that this will take 
2 months and we will inform the family of the outcome of this review.  

Action: ongoing. 

We hope that we have assured you that whilst the Trust has not completed all of the actions that 
you have identified, we are learning and improving and sincerely hope that a case such as Mrs 
Caldicott’s does not happen again.  

Yours sincerely 

Chief Executive

31 Manor Road
  Folkestone
  Kent, CT20 2SE

    www.manorclinic.co.uk

Response to Regulation 28 Report – Inquest into the Death of Mrs. Ann
Caldicott:

Thank you for your letter and the Regulation 28 Report following the inquest into the
death of Mrs Ann Caldicott. We acknowledge the serious concerns raised regarding
her care, particularly the missed opportunities to address her frailty and nutritional
needs.

Following the inquest in January 2025, Mrs. Caldicott’s case was discussed in detail at
our clinical meeting on 3rd February 2025 and again at our multidisciplinary meeting
on 22nd July 2025. We have since conducted a thorough internal review and
identified several key learning points and areas for improvement.

Lessons Learned

1. Early Identification of Frailty and Malnutrition

There was a delay in recognising Mrs. Caldicott’s declining nutritional status
and frailty. Earlier intervention may have led to better outcomes and
improved suitability for potential treatment options.
Inadequate Multidisciplinary Involvement
Opportunities to involve the frailty team, dietitians, pharmacists, and mental
health or safeguarding teams were not taken in a timely manner.

2.

3. Chronic Condition Oversight

Mrs. Caldicott had chronic kidney disease, and we recognise the need for
more proactive management and earlier referral to nephrology in accordance
with NICE guidelines.

Actions Taken Since Mrs. Caldicott’s Death

We have implemented several changes across our practice to prevent similar issues
in the future:

1. Frailty and Malnutrition Identification

(cid:127) Regular weight and height monitoring is now in place for all patients aged

 65 and over.
(cid:127) Any unintentional weight loss is immediately flagged and followed up.
(cid:127) The Primary Care Network’s Frailty First Contact Practitioner (FCP) Dietitian
is now actively involved in early assessments.
(cid:127) Referral criteria for the FCP Dietitian have been clarified, laminated, and
placed in all clinical rooms. These were also reviewed during clinical meetings.
(cid:127) Unintentional weight loss is proactively investigated, with dietary
supplementation considered as appropriate.

2. Strengthening the Role of the Frailty and Dietetic Teams

(cid:127) Clinicians are encouraged to refer frail patients early to the dietitian and
frailty teams for proactive support.
(cid:127) Discussions now routinely consider whether additional input is needed from
our practice pharmacist (e.g., for nutritional supplements) or from mental
health or safeguarding services.

3. Chronic Kidney Disease (CKD) Management

4.

(cid:127) CKD monitoring protocols have been re-emphasised to all clinicians and are
now regularly discussed in clinical meetings.
(cid:127) Referrals to renal specialists are made in line with NICE guidance.
Improved Monitoring in Care Homes
(cid:127) Our home-visiting nurse now ensures that height and weight measurements
are recorded for all new care home residents.
(cid:127) Any observed weight loss is followed up with appropriate investigations and
dietary interventions as needed.
5. Significant Event and Death Review

(cid:127) Unexpected deaths are routinely included in our clinical meeting
discussions.
(cid:127) However, as Mrs. Caldicott passed away in hospital following a prolonged
inpatient stay, her case was not initially flagged for review. We were unaware
of the full circumstances surrounding her death until the Coroner contacted
us.
(cid:127) We can find no record that we were formally notified by the hospital of her
death or the cause. It was only upon receiving the Coroner’s request for
information that the practice became aware of the details. We have shared
this feedback with the Trust to support improvements in their practice.

6. Support for Vulnerable and At-Risk Groups

(cid:127) Our rough sleeping policy has been updated to include assessment of
nutritional status.
(cid:127) We ensure that patients experiencing rough sleeping are under the care of
the Rainbow Centre, where they can receive appropriate nutritional support.
(cid:127) Frailty and nutritional checks are now encouraged even in non-traditional
settings or populations.

 (cid:127) Our self-neglect policy has also been updated to include frailty and
nutritional status as key considerations.
7. Listening to Family and Public Concerns

(cid:127) We take seriously any concerns raised by family members or members of
the public regarding our patients.
(cid:127) With appropriate regard for confidentiality, we always seek to contact the
patient and respond to concerns raised in a sensitive and timely manner.

Ongoing Commitment

These changes have already been implemented and will be reviewed again in three
months to ensure their continued effectiveness and integration into our routine
clinical practice. We remain committed to a culture of learning and continuous
improvement, and we acknowledge our responsibility to act on the findings from this
case.

We extend our sincere condolences once again to Mrs. Caldicott’s family and thank
the Coroner for highlighting areas where we can enhance patient safety and quality
of care.

 (Salaried GP)

 (Senior Partner)