Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0468, written 15 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 | 15 Sep 2025 |
|---|---|
| Reference | 2025-0468 |
| Deceased | Linda Sharp |
| Coroner | Paul Marks |
| Coroner area | East Riding and Hull |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A 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. President of the Royal College of General Practitioners, 1 CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. 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 17th January 2025, I commenced an investigation into the death of Linda Janet Sharp, aged 70 years. The investigation concluded at the end of the inquest on 18th August 2025. The narrative conclusion of the inquest was:- Linda Janet Sharp first had symptoms of thromboembolic disease at the time of consultation on the 17th October 2023. She had further presentations to healthcare professionals from that date until the 20th November 2023, all which would have been consistent with thromboembolic disease. Had she been referred to hospital after any of these consultations, a diagnosis of pulmonary embolism would have been considered and she would have received empirical therapeutic anticoagulation therapy with a low molecular-weight- heparin preparation pending definitive tests to confirm or refute the diagnosis. Had such a management plan been instituted, she would not have died on the 21st November 2023 4 CIRCUMSTANCES OF THE DEATH Linda Janet Sharp had significant comorbidities in the form of hypertension, type 2 diabetes mellitus, hypothyroidism, stable angina, left bundle branch block, anaphylactic reaction secondary to penicillin, osteoporosis, gastritis and duodenitis. She also had generalised anxiety and was an ex-cigarette smoker. She attended her General Practitioner on the 17th October 2023 complaining of swelling in her right leg. The WELL's score, which is a risk stratification tool for thromboembolic disease was applied without further testing, that might have included a D Dimer test or Doppler ultrasound study of the calf vessels, and she was reassured and given safety netting advice. On the 2nd November 2023, she was attended by paramedics because of shortness of breath and taken to Scarborough General Hospital for further assessment. Tests for thromboembolic disease were not performed and empirical anticoagulation was not prescribed. She was discharged later that day. On the 6th November 2023, she attended the Emergency Department at Leicester Royal Infirmary due to an allergic reaction, possibly arising from amlodipine therapy. On the 15th November 2023, she was seen by an advanced nurse practitioner at her GP surgery where it was assumed 1 her moderately low oxygen saturation was due to chronic pulmonary obstructive disease, but no confirmatory tests were carried out. On the 16th November 2023, she was attended by the ambulance service and was noted to have initial low oxygen saturation levels which rose to normal limits after a second set of observations had been carried out. She was not conveyed to hospital on that occasion. A further attendance by paramedics occurred on the 19th November 2023. I had accepted evidence from the attending paramedic that if he had known about the previous attendance on the 16th November 2023, he would have conveyed Linda to hospital. Mrs Sharp was seen again in her GP surgery on the 20th November 2023 complaining of breathlessness and haemoptysis. Various investigations were commissioned, but pulmonary embolism which can be associated with haemoptysis was not considered in any differential diagnoses that was formulated. Linda Sharp had a cardiac arrest at her home address around 23:30 hours on the 20th November 2023, but despite the provision of advanced life support by paramedics, who attended, she could not be resuscitated and died at 00:31 hours on the 21st November 2023. I have accepted expert evidence that a deep vein thrombosis could have been diagnosed from the 17th October 2023 onwards and that her various presentations in general practice and to the ambulance service were likely to have been underpinned by episodes of thromboembolism. I have also accepted the WELL's score algorithm employed alone, does not exclude a thromboembolism and needs to be supplemented by other tests. If at any point between the 17th October 2023 and the 20th November 2023, when Linda Sharp was associated with healthcare professionals, she had been taken to hospital, on balance, thromboembolic disease would have been considered and steps taken to confirm or refute such a diagnosis. The suspicion of the diagnosis would have resulted in the administration of a therapeutic dose of a low molecular-weight- heparin preparation, which on balance, would have prevented further thrombus formation within six hours of administration, and with this, on the balance of probabilities, the massive pulmonary embolism that occurred before midnight on the 20th November 2023 and her subsequent death on the 21st November 2023 would have been avoided. Treatment would have proceeded before confirmatory tests been performed according to standard protocol. 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. – Expert evidence was heard which stated that it is fundamentally flawed to conflate a low Wells score with there being no possibility of a deep vein thrombosis (DVT) and/or a pulmonary embolus (PE). A Wells score on its own does not exclude a a DVT or PE. 5 6 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action, possibly by making your membership and other clinicians aware of this. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th November 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Yorkshire Ambulance Service; Scarborough General Hospital; . 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 15th September 2025 3
2 responses 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.
MINISTRY OF DEFENCE
FLOOR 5 ZONE B MAIN BUILDING
WHITEHALL LONDON SW1A 2HB
MINISTER FOR THE HOUSE OF LORDS
4.4.5
15 January 2026
Dear Dr Sharpstone,
Thank you for your report of 26 September 2025 to the Ministry of Defence (MOD),
following your Inquest into the death of Ms Catherine Moore. First and foremost, I
wish to express my sincere condolences to Ms Moore’s family, friends and all those
affected by this tragic incident.
The circumstances surrounding Ms Moore’s death are deeply troubling, and I have
reflected on the findings of your Inquest with great care. I appreciate your
acknowledgment of the improvements the MOD has made to vehicle maintenance
processes, particularly in relation to steering components, since this tragic event. I
have sought additional assurances to confirm that all reasonably foreseeable risks
are being monitored and mitigated.
I am confident that the Electronic Safety Notice issued will address the risk of
steering system misalignment being missed again. Furthermore, work to update
vehicle maintenance guidance for MOD Land Rovers is progressing, and this will
provide a robust, long-term solution to wheel alignment checks. I remain committed
to monitoring these efforts closely and will continue to seek assurances regarding
the safety and reliability of our vehicles.
Your report raises important concerns regarding the Joint Asset Management
Equipment Solutions (JAMES) platform, as well as the repair and maintenance of the
MOD Land Rover involved. In considering my response, I have sought advice from
Subject Matter Experts in engineering, maintenance, Defence safety and the JAMES
platform to ensure we have carefully and thoroughly considered your concerns.
JAMES is a complex system, and this complexity stems from the sheer volume and
variety of equipment it is designed to manage. It is unfortunate that the platform was
not presented or explained sufficiently at the inquest, but I am reassured that the
system is fit for purpose for the current, trained user community. That said, I take the
concerns you have raised very seriously, and I have addressed each in the
addendum overleaf.
Dr Daniel Sharpstone
HM Assistant Coroner for Suffolk
I hope this response provides reassurance of my commitment to ensuring the
highest standards of safety across Defence. Thank you for bringing these important
matters to my attention.
Yours sincerely,
THE LORD COAKER
Addendum to Response: Summary of JAMES
JAMES is a digital compliance and information tool that supports Defence
maintenance policy by enabling safe, standardised, and well-documented
engineering and maintenance activities. It covers the full gamut of Defence
equipment and is a vital tool to ensure Defence has oversight of the location and
readiness of its equipment, and helps us to embed safety across all Defence
activities.
It ensures that only qualified personnel perform maintenance, with users trained
through a formal Learning Management System and following Standard Operating
Procedures, ensuring activities are safe, auditable, and compliant with Defence
safety standards.
1. Terminology and User-Interface Issues.
You highlight in your report that; the terminology and descriptors on JAMES
forms were very difficult to understand; the user interface is unclear; and the
tabling and format are unclear.
JAMES employs standardised engineering and maintenance terminology aligned
with Army Equipment Support Publications. All users are required to complete
training via the Learning Management System to understand the terminology and
effectively navigate the system. Though it has been in use for some time (and is
indeed due to be replaced in 2027), it is considered functional and fit for purpose by
the user community, and the training equips personnel with the skills to operate it
successfully. The digital nature of the system does not lend itself to clear
presentation of the interface in hardcopy form, and I understand this was an issue
during the inquest.
2. Data Access and Extraction.
You highlight in your report that; it was unclear how data could be extracted for
governance purposes; there is lack of clarity on how to locate data and
information on the maintenance and repairs; there was no evidence of ability
or/to process or extract data from JAMES to facilitate systems and process
audits; and there is no formal searchable database.
JAMES is optimised for digital use, with structured dashboards and reports that
support inspections, audits, and fleet management. Data extraction is routine for
authorised users, and higher-level accounts enable data access across formations.
PowerBI dashboards further enhance managerial oversight.
JAMES records all faults, repairs, and inspections, allowing users to access full
maintenance histories. Users are trained to update, extract and utilise the data
effectively. Additionally, JAMES captures fault histories and trends, highlighting
recurring issues to inform Electronic Safety Notices and policy updates. Army
Command Standing Orders mandate annual audits of all Army Land Equipment
holdings, and JAMES supports these as well as other audits, technical evaluations
and lesson identified processes.
3. Record Keeping and Traceability of Tasks.
You highlight in your report that; there are no details of the referrer if checks are
needed with regards to the reasons for the referral; no check in the system
allowing feedback to the referrer; limited reasons given for an entry into
JAMES; limited details of work done other than task closed or fully fit; and
little formal space on system for suggestions with regards to further work or
maintenance on the matter attended to and repaired.
JAMES primarily tracks task completion, timing, and outcomes. It logs the
departmental originator of faults (e.g. Motor Transport) and allows follow-up.
Feedback mechanisms are under review and though log-in data and user identifiers
are recorded, JAMES is not designed for ongoing dialogue between referrers and
repairers. Users are trained to provide concise, yet accurate entries and brief entries
are common for routine faults.
Regarding your specific observation of the term "Task Closed", this indicates that a
repair is complete, and the vehicle is task worthy and ready for road use. While
detailed work notes are encouraged, they are not mandatory. The term and its
meaning are widely understood and tied to inspection protocols.
Mechanics are also empowered to log new faults encountered during repairs, and
JAMES supports recording multiple faults per vehicle. Additional work is logged
separately, with further work recommendations managed by maintenance personnel
and their Chain of Command.
4. Process Clarity and Scheduling.
You highlight in your report that; the rationale and/or schedule in JAMES for
some processes, for e.g. ad hoc inspections was unclear and there was
repetition of identical time and dates attached to different tasks.
The term “ad hoc” in JAMES refers to inspections outside scheduled Maintenance
Engineering Inspections or servicing, such as post-incident checks or handovers.
Incidents of matching timestamps for multiple fault repairs are often a result of batch
processing onto JAMES by the user, who would enter data onto the system in one
go after completing multiple or simultaneous repairs.
5. Repair and Maintenance of MOD Land Rover.
You highlight in your report that; there is no process with regards to; inspection,
checking, audit, feedback and testing of MOD vehicle maintenance and repairs
or for real time feedback.
Inspections are conducted in line with policies and publications and recorded in
JAMES. As referenced at point 2, the system supports internal and external audits,
and all Army Land Equipment holdings are audited annually.
With specific reference to the repair and maintenance of the MOD Land Rover,
particularly the steering box, an Electronic Safety Notice (ESN) has been issued to
mitigate against steering system misalignment checks being missed. Concurrently,
work is underway to update the inspection criteria for MOD Land Rovers, ensuring a
comprehensive and long-term solution.
Any ineffective repairs are re-reported as faults through communication between the
Mechanical Transport cell and workshops for reinspection and resolution.
Honorary Secretary of Council Professor Paul Marks Senior Coroner for Coroner Area of City of Kingston Upon Hull and County of East Riding of Yorkshire 11 November 2025 Dear HM Coroner Regulation 28 Report to Prevent Future Deaths - touching on the death of Linda Janet Sharp Thank you for asking us to comment on the matters of concern following the sad death of Linda Janet Sharp who died on the 21 November 2023. Our sincere condolences go to her family and friends. ‘The matters of concern relate to expert evidence was heard which stated that it is fundamentally flawed to conflate a low Wells score with there being no possibility of a deep vein thrombosis (DVT) and/or a pulmonary embolus (PE). A Wells score on its own does not exclude a DVT or PE’ The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training promoting research and advocating and representing the College and its 54,000 members. General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. There are 5 areas of capability aligned to the General Medical Council’s Generic Professional capabilities, and these are supported by Topic guides under which is included six clinical topic guides. The clinical topic guide relating to cardiovascular health includes a specific core area on thromboembolism under circulatory disorders. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing is covered in NICE guidance NG 158 first published in March 2020 and updated in August 2023. There is a visual representation of the NICE guidance ng158 and this outlines the correct use of the 2 level DVT Wells score outlining the concomitant use of D dimer and Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III Ultrasound scanning. GPs and Hospital specialists would follow this guidance on managing their patients. We recognise that in this case the guidelines were not followed and the misinterpretation of the Wells score early in the aetiology of the condition, alongside other missed opportunities could have contributed to the circumstances leading to Linda Janet Sharp’s death. The College has therefore commissioned some internal work through our elearning team to highlight the specific issue of interpretation of the Wells score. We shall aim to publish this to be available to members in the first quarter of 2026 and the college will be responsible for the production and content of the e learning module. We shall promote this through our members network and our regular Chair’s blog which reaches out to all 54,000 of our members. Yours sincerely RCGP Honorary Secretary
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