Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0348, written 9 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2025 |
|---|---|
| Reference | 2025-0348 |
| Deceased | Shaun Marriott |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Surrey and Sussex Healthcare NHS 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Surrey and Sussex Healthcare NHS Trust 1 CORONER I am Joanne ANDREWS, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 Mr Marriott elected to undergo a haemorrhoidal artery ligation with mucopexy surgery following consultations with his surgeon. He underwent a pre-assessment for the surgery on 30 March 2024 which was conduced by telephone using the assessment on the Surrey and Sussex Healthcare NHS Trust Cerner system. During the assessment he was asked about his family medical history and his own history of haematological conditions. He was not asked about his family history of haematological conditions directly as this is not required by the system. The evidence to the Court was that the clinicians relied upon the patient's response to their family medical history question to ascertain this. The evidence was that Mr Marriott was aware of his significant family history of blood clotting disorders. The evidence from clinicians who assessed him was that this was not disclosed to them. The family believe that he did make this known but there is no evidence which indicates when, where or to whom this was made. The evidence was that he had not been directly asked about this and it was not stated on his notes or GP documentation. On 12 April 2025 he underwent the haemorrhoidal artery ligation with mucopexy surgery as a day patient. He was given compression stockings as per the Trust guidance as well as mechanical calf compression during the procedure which was above what the guidance required. On 15 April 2024 he sadly died at home. A post mortem found he died due to a Pulmonary embolism which on the evidence was a result of the surgery. 4 CIRCUMSTANCES OF THE DEATH 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. Regulation 28 – After Inquest Template Updated 23/05/2025 TG The MATTERS OF CONCERN are as follows: The evidence was that the system which is used for assessment of patients prior to day surgery does not (a) directly require a question to be asked about their haematological family history or (b) record negative answers to the questions related to the patient's own haematolgical history 6 ACTION SHOULD BE TAKEN 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 September 4, 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 Mr Marriott I have also sent it to Moatfield Surgery who may find it useful or of interest. I 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. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 09/07/2025 Joanne ANDREWS Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 23/05/2025 TG
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.
NHS Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH15RH Tel: 01737 768 511 www.surreyandsussex.nhs.uk Name: Title: Chief Medical Officer Direct Line 01737 231825 Email: edward.cetti@nhs.net Ms Joanne Andrews Area Coroner for West Sussex, Brighton and Hove Woodvale Crematorium Lewes Road, Brighton BN2 3QB Our ref: #34 Date 28 August 2025 Dear Ms Andrews Regulation 28 Report - response by Surrey & Sussex Healthcare NHS Trust Inquest touching the death of Mr Shaun Marriott This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to paragraph 7 to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 9 July 2025, made subsequent to the inquest into the death of Mr Marriott, which was concluded on 3 July 2025. The Trust was given until 4 September 2025 to respond to the coroner, pursuant to Regulation 29(4) Coroners (Investigations) Regulations 2013. We would like to start this response by offering our sincere condolences to Mr Marriott’s family and partner. As a Trust we are committed to learning from the issues raised during the Inquest. The Prevention of Future Deaths report identifies that Mr Marriott was not asked directly about his family history of haematological conditions, specifically venous thromboemboli Putting people first Delivering excellent, accessible healthcare An Associated University Hospital of Brighton and Sussex Medical School NHS Surrey and Sussex Healthcare NHS Trust (blood clots), as this was not required by the computer system when taking a clinical history. We describe the details of the actions that we have undertaken in this regard. The patient questionnaire did not have a place for the patient to enter this important family history. The pre-operative assessment form did not have prompts for the question to be reviewed or asked. The Trust has now added an extra question on the pre-operative assessment ‘power’ form on the Family History Page. The Trust has also included other potential family history that may need further investigation (for example, cardiac, musculoskeletal). The Trust has not yet added this question to the patient questionnaire, but this will be completed with a future update of the questionnaire service itself making the whole process easier for patients. This action will be completed by January 2026. The Trust modified the way the pre-operative assessment form worked because we realised during this investigation that sometimes, patient responses may not have been visible at the time the pre-operative assessment form was completed - this has now been completed. This was not specifically related to this issue at hand. If a response to this question is added then it will add a "problem" to the record of "Significant Family History" and add the detail of what the issues were. This problem and the comments will pull through to the anaesthetic assessment stage and also show in the venous thromboembolism (VTE) form. It will highlight this issue to the anaesthetist on the day of surgery. The Trust may anticipate that this sort of extra information may in fact lead to further investigation(s) and the clock stops for elective surgery - which would have been material in Mr Marriott’s case - if the GP record makes no reference to further investigations. We have also added the VTE form and an asterisk indicating that it has not been completed on the Anaesthetist Workflow page for the day of surgery. The anaesthetists have discussed this issue and it is also being discussed at the next clinical governance day. In addition to these urgent clinical and administrative changes, the Trust has also undertaken an After-Action Review to ascertain how this gap was not identified earlier, and to seek recommendations and actions to ensure any learning from the death of a patient is established promptly and action taken. We hope the above provides you with sufficient information and assurance but if you require more details, please do not hesitate to contact me. 2 NHS Surrey and Sussex Healthcare NHS Trust Yours sincerely, Chief Medical Officer 3
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