Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0463, written 11 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2025 |
|---|---|
| Reference | 2025-0463 |
| Deceased | Michael Moore |
| Coroner | Samantha Goward |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: NHS ENGLAND 1 CORONER I am Samantha GOWARD, Senior Coroner for the coroner area of Norfolk 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 30 September 2024 I commenced an investigation into the death of Michael Leonard MOORE aged 83. The investigation concluded at the end of the inquest on 04 September 2025. The medical cause of death was: Recurrent Metastatic High Grade Urothelial Carcinoma 1a) 1b) 1c) 1d) 2) Left Subacute Frontal Infarct, Ischaemic Heart Disease The conclusion of the inquest was: Died due to underlying natural causes, the diagnosis and treatment of which was delayed due to lengthy waiting lists. 4 CIRCUMSTANCES OF THE DEATH 1. In summary, Mr Moore was being managed under the hospital’s Urology team after a previous diagnosis of high risk non-muscle invasive bladder cancer for which he was having surveillance cystoscopies (bladder checks) since 2021. He had also had radiotherapy for prostate cancer in 2012. 2. At a check up in July 2023, an abnormal area was noted, and a biopsy was requested. While he was still awaiting the biopsy, some 9 months later, he was admitted as an emergency in April 2024. On examination he was found to have a mass causing compression. A defunctioning colostomy was performed to bypass the obstruction on 15 April 2024 and a biopsy taken which showed disease in keeping with spread from a high grade urothelial carcinoma (bladder cancer) which was said to be advanced and not curable. He was seen on 2 July 2024 by an Oncologist who felt that due to the advanced cancer and his frailty, active treatment was not in his best interests & Mr Moore was placed under the care of the palliative team and died at home on 17 September 2024. 3. The evidence heard was that there was a delay in the biopsy being performed after the check up in July 2023 due to lengthy waiting lists at the Trust. I was advised that Mr Moore should have had his biopsy within 28 days – so by late August 2023. Regulation 28 – After Inquest Document Template Updated 30/07/2021 4. 5. It was not done until April 2024, and then only as he was admitted as an emergency. This was therefore approximately an 8 month delay (and based on the fact he was still on the waiting list, would have been longer if not for the emergency admission). I heard evidence that he suffered a cerebral infarct in June 2024 while awaiting Oncology review. It was said in July 2024 when he was seen by an Oncologist that the only treatment option for him was palliative chemo, but he was not fit enough to undergo that treatment. If he had undergone a biopsy in August 2023, on the basis of the evidence heard I found that this would have identified the reoccurrence of the cancer at that time. On the balance of probabilities the cancer would have been at an earlier stage and there would have been more treatment options available. It was not possible to say on balance of probabilities, based on available evidence, that any treatment would have been curative given the nature of the cancer and his frailty, but it is a possibility and there was a missed opportunity to commence earlier treatment. 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: The evidence of the Hospital Trust was that work had been ongoing in recent years to reduce delays, but that while there had been some initial improvement, there had been a further decline which I was told is in part due to an increase in referrals due to high profile celebrities announcing their cancer diagnoses and rightly encouraging people to come forward with any symptoms of concern. Therefore, despite local measures to improve performance, this has been significantly affected by a rise in cancer referrals. I was advised that this surge has been widely reported across the NHS and I was advised that NHS England has acknowledged persistent capacity constraints across many providers. The concern therefore is that the NHS does not have the ability to deal with the significant number of cancer referrals received and this is causing significant delays in waiting times which impacts on those awaiting a diagnosis, undergoing surveillance and delays in diagnosing a recurrence and those awaiting treatment. 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 November 06, 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: Mr Moore’s family Norfolk and Norwich University Hospital Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 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: 11/09/2025 Samantha GOWARD Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH 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.
Ms Samantha Goward
HM Senior Coroner
Norfolk Coroner’s Service
County Hall
Martineau Lane
Norwich
NR1 2DH
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
5th November 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Michael Leonard Moore
who died on 17 September 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11
September 2025 concerning the death of Michael Leonard Moore on 17 September
2024. In advance of responding to the specific concerns raised in your Report, I would
like to express my deep condolences to Michael’s family and loved ones. NHS
England is keen to assure the family and yourself that the concerns raised about
Michael’s care have been listened to and reflected upon.
Your report raises concerns around the NHS being unable to deal with the significant
increase in cancer referrals received, causing significant delays in waiting times for
referral, which in turn impacts on those awaiting a diagnosis or undergoing
surveillance, and those awaiting treatment.
Regional improvements
NHS England’s East of England regional colleagues have been advised by NHS
Norfolk and Waveney Integrated Care Board (N&W ICB) that, to address the situation
going forward, the following actions have been agreed with the Urology department at
Norfolk and Norwich University Hospital:
1. A ‘capacity and demand’ review to identify gaps in service and move away from
ad hoc Waiting List Initiatives (WLIs), with a view to meeting demand through
recruitment to substantive posts. There is anticipated funding in place for the
extension of a current locum post via the Cancer Alliance.
2. A ‘review and validation’ of the Category P2 list which is part of the National
Clinical Prioritisation Programme, which is a technical and clinical review of
patients waiting for elective care treatment. Categories P2-P4 relate to the
period of time in which it would be clinically appropriate for a patient to wait for
their procedure. Confirmed P2 cases should not wait longer than 4-6 weeks for
treatment.
3. A ‘case by case’ review of patients awaiting both rigid cystoscopy and biopsy,
as these represent the highest risk if delayed. These will be expedited as
appropriate.
Alongside this, through the Clinical Harm Incident Group, Norfolk and Norwich
University Hospital will continue to monitor potential or actual harm caused to long
waiting patients that either have an emergency admission or die whilst on an elective
waiting list or breach 104 days on their cancer pathways, providing the opportunity to
identify emerging issues within specialties and address these. One of their local
Patient Safety priorities for 2025/26 is emergency admissions of patients on a waiting
list, and a thematic review is planned. More generally, the ongoing scrutiny of the
waiting list, review of long waiting patients and scrutiny through validation continues.
National position
According to your Report, the evidence of the Hospital Trust at the inquest hearing
included that the surge in cancer referrals has been widely reported across the NHS
and that NHS England has acknowledged persistent capacity constraints across many
providers. It is correct that the number of people referred for urgent cancer checks has
increased significantly over the past decade. This reached 3.2 million in 2024-25,
which was double the number of referrals in 2014-15. However, while there is ongoing
work to deliver on the national cancer waiting times standards, performance has
actually improved over the past two years. In March 2025, the NHS in England
achieved its target for the Faster Diagnosis Standard (FDS) – this standard was that
77% of people should receive a diagnosis or ruling out of cancer within 28 days of an
urgent referral. The NHS also met its interim 70% target, set in the 2024/25 Priorities
and Operational Planning Guidance, for the 62 day standard (the standard is that 85%
of people with cancer should start treatment within 62 days of an urgent referral). This
improvement gave NHS England the confidence to set more stretching national targets
in its 2025/26 Operational Planning Guidance. The new targets are 80% for the FDS
and 75% for the 62 day standard.
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
Michael, 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,
National Medical Director
NHS England
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