Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0504, written 10 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2025 |
|---|---|
| Reference | 2025-0504 |
| Deceased | Adrienne Studholme |
| Coroner | Christopher Long |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Lancashire Hospitals 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Executive Medical Director, East Lancashire Hospitals NHS Trust 1 CORONER I am Mr Christopher Long , senior coroner, for the coroner area of Lancashire and Blackburn with Darwen 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 26 March 2024 I commenced an investigation into the death of Adrienne Caroline Studholme, age 62. The investigation concluded at the end of the inquest on 8th and 9th October 2025.The conclusion of the inquest was Adrienne Caroline STUDHOLME died on 23 September 2023 at Royal Blackburn Hospital, Blackburn in Lancashire. Adrienne underwent an elective left nephrectomy on 10 September 2023 complicated by abdominal wall haematoma requiring a further operation on 11 September 2023 before being discharged. She was readmitted on 20 September 2023 at around 3.05 hours with epigastric pain and seizures. Diagnostic checks completed later that afternoon identified spontaneous splenic haemorrhage and rupture (a known complication of nephrectomy) which were operated upon at 18.30 hours, after which she had a myocardial infarction. Despite treatment over the next three days, she did not recover. Her death was contributed to by a delay in diagnosing and treating the splenic rupture. The medical cause of death was found to be: 1a Haemopericardium due to a ruptured acute myocardial infarction 1b Occlusive coronary artery thrombus 1c Coronary artery atheroma, splenic rupture and operation for renal cyst 4 CIRCUMSTANCES OF THE DEATH Adrienne Caroline STUDHOLME died on 23 September 2023 at Royal Blackburn Hospital, Blackburn in Lancashire. Adrienne underwent an elective left nephrectomy on 10 September 2023 complicated by abdominal wall haematoma requiring a further operation on 11 September 2023 before being discharged. She was readmitted on 20 September 2023 at around 3.05 hours with epigastric pain and seizures. Diagnostic checks completed later that afternoon identified spontaneous splenic haemorrhage and rupture (a known complication of nephrectomy) which were operated upon at 18.30 hours, after which she had a myocardial infarction. Despite treatment over the next three days, she did not recover. Her death was contributed to by a delay in diagnosing and treating the splenic rupture 1 5 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 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. – (1) The fluid balance chart was found to be inaccurate. The evidence suggested that the accuracy of the chart relied on staff collecting and refilling empty water jugs and took no account of steps families may take to provide fluid (2) Evidence was heard that seizure activity would not be taken into account in assessing a patient in the Emergency Department unless it was witnessed by a member of staff (3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department. 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 8 December 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family of Adrienne Studholme 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. She 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 [DATE] 10 October 2025 HM Senior Coroner Lancashire and Blackburn with Darwen 2
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.
Trust HQ Royal Blackburn Hospital Haslingden Road Blackburn BB2 3HH Nov 2025 PRIVATE & CONFIDENTIAL Mr C Long, HM Coroner – via email Dear Mr Long, Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – A Studholme We acknowledge receipt of the Regulation 28 Prevention of Future Deaths report which was issued at the conclusion of the inquest touching the sad death of Adrienne Studholme on the 8th and 9th October 2025. A senior, core group was coordinated to consider the Trust response to these concerns. MATTERS OF CONCERN (1) The fluid balance chart was found to be inaccurate. The evidence suggested that the accuracy of the chart relied on staff collecting and refilling empty water jugs and took no account of steps families may take to provide fluid (2) Evidence was heard that seizure activity would not be taken into account in assessing a patient in the Emergency Department unless it was witnessed by a member of staff (3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department. Fluid balance The Trust acknowledges that fluid monitoring is a recognised national challenge across the NHS. We are committed to addressing this issue locally and have implemented, and continue to develop, measures aimed at improving the accuracy and consistency of fluid balance monitoring within our services. The Trust has an existing policy in place (copy attached) which outlines the expectation regarding which patients should be monitored on a fluid balance chart. This also describes audit and assurance processes for monitoring compliance. If gaps in compliance are identified, the policy sets out how actions to remedy this are implemented and monitored. We are currently undertaking a test of change focusing on a more targeted approach, moving from universal charting for every patient, to a risk-based system that prioritises the patients based on clinical need. In specific response to your concern, this new approach includes the engagement of patients and families in accurately recording fluid intake. This is supported by a trial leaflet and recording sheet which enables patients and families to write down what they drink (on their own or via family/friends), whilst they are on or off the clinical departments so these can be matched or added to the fluid balance chart within the patients’ records. Emergency department With respect to point 2, this concern appears to have arisen from a miscommunication of the evidence provided and reflects neither current nor historic practice within the Emergency Department. Having contacted the consultant who was giving evidence, the point they were trying to convey was that a history of seizures would not warrant immediate escalation to a doctor (either from triage or subsequently). An actively seizing patient would represent a potential medical emergency, or - were it to occur in the department - a potential deterioration in a patient’s condition and that this therefore would be immediately escalated when reported from any source. The third area of concern is that there is currently no process for patient’s who present to the Emergency Department following recent surgery to be seen by the original treating department. This is not amenable to a simple procedure – a referral in the context of a problem unrelated to the surgery, where the surgical team may not have expertise related to that condition, would be both futile and add complexity. In this case the initial presentation did not indicate any link with the previous procedure during triage. It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented. Future assurance monitoring The test of change regarding fluid balance and the professional standards implementation will continue to be monitored through internal assurance processes, with any escalations to the Quality Committee until all actions have been embedded as business as usual with monitoring processes in place. Please do not hesitate to contact me with any questions or concern regarding the content of this response; we are keen to work with the Coroner to demonstrate our ongoing commitment to delivering the safest care possible for our patients. Yours sincerely, Executive Medical Director East Lancashire Hospitals NHS Trust Appendix 1 – Systemic Review of Fluid Balance Monitoring Appendix 2 – Clinical Observation Policy e002260.full.pdfCP37 Clinical Observation Policy [Policies Trust Wide].pdf
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