Pamela Brand

Mr Darren Stewart OBE 
HM Area Coroner for Suffolk 
Ipswich Coroner’s Court 
Beacon House  
Whitehouse Road 
Ipswich  
Suffolk  
IP1 5PB 

Legal Services 
West Suffolk NHS Foundation Trust 
Hardwick Lane 
Bury St Edmunds 
Suffolk  
IP33 2QZ 

20 October 2025 

Dear HM Coroner 

Re:  Response relating to Regulation 28 Report into the death of Pamela Christine 
Brand  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18 June 2025, 
but received 5 August 2025 concerning the death of Mrs Pamela Brand on 2 April 2024.  

In advance of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Mrs Brand’s family and loved ones. West Suffolk Foundation Trust 
(WSFT) are keen to assure the family and  HM Coroner that the concerns raised about Mrs 
Brand’s care have been listened to and reflected upon. 

Your Report specifically raises concerns that the hospital medical records lacked key detail 
regarding  Mrs  Brand’s  observations  and  rationale  for  clinical  decision  making.  Specifically, 
that, although it had no bearing in Mrs Brand’s case, for future patients, poor record-keeping 
may adversely impact on care and treatment.  

Communication 
We recognise that good record keeping is inextricably linked with communication. It is at the 
heart of everything we do, and we are working hard to improve both aspects of our care and 
specific projects are highlighted below.  

A review undertaken before the global pandemic by NHS Improvement recognised that every 
36 hours, a million contacts are made between patients and healthcare staff in the NHS and 
each of these is likely to generate further communication between staff.  We recognise that 
failings in that communication are a common finding across the NHS. Good communication is 
about  passing  on  clear  and  accurate  information.    However,  it  is  also  about  expressing 
uncertainty; reading or ‘sensing’ situations; assessing others; understanding decisions; and, 
probing issues and concerns with the right priority.   

We  acknowledge  that  verbal  communication  which  is  then  reflected  in  a  patients’  medical 
records  is  more  complex  than  just  words.  The  examples  of  when  this  goes  wrong  often 

          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 illustrate a combination of both human and system failures which we are working to address 
as discussed below.  Unsafe communication can be as much down to the wrong tone of voice, 
dismissive body language, or a lack of information, or the presentation of items in a confusing 
order.  

On  a  daily  basis,  our  staff  have  to  use  a  combination  of  human  initiative,  compassion  and 
commitment to communicate effectively in the context of time pressures; practical constraints; 
and, conflicting demands in a busy and fast moving care environment.  As a Trust, we are firm 
in our commitment to drive change and improve communication, led by the Chief Nurse and 
Medical Director. 

Record Keeping 
Record keeping has evolved over time and continues to do so. The single biggest change in 
recent times was when WSFT moved to a fully digitalised medical record in 2016. Since that 
time, we have continued to evolve the systems with clinical colleagues and other healthcare 
partners.  However, record keeping is also a clinical skill that all our staff continue to refine 
and develop through their careers personally. There is no right or wrong clinical record. That 
is reflected in the absence of advice nationally on what makes a good record. What guidance 
exists is often general, non-specific and high level.  

This is something NHS England recognised in March 2025, when it produced guidance for 
GPs on defining high quality patient records1 when it said: - 

“The  meaning  of  what  previously  may  have  been  described  as  a  high-quality  record  has 
changed  dramatically  over  the  years. It  is  also  important  to  remember  that  patient  record 
systems contain a variety of clinical and non-clinical data from demographics, administrative, 
correspondence, clinical interactions, etc. It must also go further to capture context and in a 
modern-day general practice IT system, providing a conduit by which health professionals can 
communicate, interact, and record decisions. The quality of the record must be defined in the 
context for which it is used….” 

Although aimed at GPs it is equally true for acute NHS Trusts like WSFT. NHSE’s guidance 
goes on to say that:- 

“A high-quality record, therefore, needs to: 

•  be complete, accurate, relevant, accessible, and timely (CARAT) 
•  enable the effective and reliable presentation of patient information from the patient’s 
records  relating  not  just  to  the  clinical  data  but  other  forms  of  data  such  as 
demographics, appointments, administrative, documentation, etc. …” 

The  GMC’s  guidance  on  effective record  keeping  mirrors  this,  when it  says  a doctor  “must 
make sure that formal records of your work (including patients' records) are clear, accurate, 
contemporaneous and legible"2  

The GMC  guidance,  with our  emphasis  added  goes  on to  explain that  one “should take  a 
proportionate approach to the level of detail but patients’ records should usually include: 

a.  relevant clinical findings 

1 NHS England » High quality patient records version 1.1 dated 28.3.2025 
2 Good Medical practice, para 69… 2024 

          
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 b.  drugs, investigations or treatments proposed, provided or prescribed  
c. 
d.  concerns  or  preferences  expressed  by  the  patient  that  might  be  relevant  to  their 

the information shared with patients  

ongoing care, and whether these were addressed 

e.  information  about  any 

reasonable  adjustments  and  communication  support 

preferences 

f.  decisions  made,  actions  agreed  (including  decisions  to  take  no  action)  and 

when/whether decisions should be reviewed 

g.  who is creating the record and when” 

The MDU have defined effective record keeping and updated its guidance in August 20253. 
Its guidance is that records should be: complete, contemporaneous, clear and legible, entered 
for the correct patient, avoid ambiguous abbreviations, avoid jokey comments, not tampered 
with, and checked.  It also emphasises that there is a need for records to be proportionate.  

Striking  the  balance  between  detail  and  proportionality  is  the  key  for  the  future  and  is 
something our Digital and Data team are working on. A current proposal is looking at trying to 
address  the  burden  of  documentation  with  an  aim  to  review  and  justify  the  current  level  of 
documentation that nurses are expected to complete in a single shift. 

Lastly, the NMC guidance on record keeping is set out in appendix 1 below. 

Summary of Learning 
At  WSFT  we have reflected  on  the  national  guidance  above  and  incorporated that  into  the 
specific teaching we have provided staff at all levels. Drawing all this all together, please find 
listed  below  details  of  the  action/projects/teaching  undertaken  with  a  focus  on  improving 
record keeping for future patients at WSFT. We sincerely hope this work goes some way to 
addressing this important national and local issue you have highlighted:  

1.  The Digital and Data team are currently drafting a proposal aimed at trying to address 
the burden of documentation, focusing on achieving the right balance of proportionality. 
The  aim  is  to  review  and  justify  the  current  level  of  documentation  that  nurses  are 
expected to complete in a single shift and streamline this. It cannot just be the case 
that we create more documentation, without addressing the human factors that prevent 
that. This is likely to be a larger piece of work and longer-term project running into next 
year. 

2.  The  Trust  Solicitor  delivers  a  mixture  of  bespoke  lectures  on  documentation  to 
departments throughout the year, in addition to having a regular teaching slot delivering  
training to aspiring leaders as part of the Band 6 study programme x3 times per year. 
This lecture focuses on sharing learning from real life cases and experiences to put 
“flesh on the bones of the general guidance above” about documentation. It includes 
feedback  from  previous  Coroner’s  cases  such  as  this  one  and  explains  a  different 
perspective of how records are reviewed and used.  A variation of this lecture has also 
been delivered nationally in November 2023 at the National Rheumatology conference. 

3 Effective record-keeping - The MDU 5 August 2025. Writing Clear, accurate and effective records supports 
clinical decision making and patient care 

          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  In the last 18 months there have been specific documentation projects aimed at driving 

up improvements in areas of: 

a.  Fluid  balance  measurement  –  we  are  attempting  to  resolve  this  through  further 

education by the DPG and quality improvement projects.  

b.  Thromboprophylaxis - workflows are informed by the responsible committee and 

changes to system design are requested as required. 

c.  Discharge summaries – the associate medical director has refined the process for 

completing discharge summaries to improve timeliness and accuracy. 

4.  The deteriorating patient team have created a safety alert learning bulletin, a copy is 
at appendix 2, and caried out a safety walkabout with the aim of driving up standards 
in documentation and other areas. Point 5 of the bulletin emphasises the need for clear 
documentation.   

5.  In future there are plans for the junior doctors to conduct a VTE treatment audit with a 
focus  on  our  documentation  and  what  further  steps  are  needed  to  drive  this  work 
forward into the future.  

In addition to all of the above, in order to minimise harm and prevent documentation becoming 
a  barrier  to  effective  communication  in  future,  WSFT  will  continue  to  work  with  all  system 
partners,  both  to monitor  and  review  performance as  we  look  for  new  ways to  address  the 
difficulties of maintaining and achieving accurate record keeping.  

Thank  you  for  bringing  this  important  patient  safety  issue  to  our  attention.  We  hope  this 
information assists to address your concerns and please do not hesitate to contact us should 
you need any further information. 

Yours sincerely 

Chief Executive 

Encs  
App1 -  NMC code for record keeping 
App2 – Learning bulletin 

          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 Appendix 1 - NMC code for record keeping. 

          
 
 
 
 
 
 
 
 
 
 
 Appendix 2 – Safety First Alert