Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0537, written 23 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 | 23 Oct 2025 |
|---|---|
| Reference | 2025-0537 |
| Deceased | Mark Foster |
| Coroner | Kirsty Gomersal |
| Coroner area | Cumbria |
| 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.
MISS K J GOMERSAL HM SENIOR CORONER County of Cumbria Fairfield Station Rd Cockermouth, CA13 9PT REGULATION 28 REPORT TO PREVENT FUTURE DEATHS MARK RYAN FOSTER THIS REPORT IS BEING SENT TO: Castlegate & Derwent Surgery Isel Road Cockermouth CA13 9HT 1 CORONER I am Miss Kirsty Gomersal HM Senior Coroner for County of Cumbria 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: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents 3 INVESTIGATION and INQUEST Dr Mark Ryan FOSTER, who was known as Ryan, died on 17 February 2024 at his home address. Following post-mortem examination, the medical cause of Dr Foster’s death was found to be: 1(a) Pulmonary Embolism An investigation into Dr Foster’s death was commenced on 29 May 2024. An Inquest into Dr Foster’s death was opened on 15 August 2024 by HM Assistant Coroner Dr N A Shaw. Dr Foster’s Inquest was heard before me on 12 and 13 August 2025 and was concluded on 20 October 2025 when I delivered my findings and conclusions. The determination was: Dr Mark Ryan Foster was usually fit and well. He had been experiencing shortness of breath since December 2023. On 11 January 2024, he consulted with his GP. A chest x-ray was carried out and this was unremarkable. Dr Foster's symptoms of breathlessness persisted and he attended his GP on 12 February 2024. Dr Foster was examined and a ddimer was ordered. For reasons that cannot be determined, the ddimer was not carried out that day. Dr Foster re-attended the Practice on 14 February 2024 for the ddimer test. A re-examination, including ECG, was carried out by a nurse who ordered blood tests. This did not include a ddimer. The results of the blood test were received in the late afternoon of 15 February 2024. The most significant finding was a markedly elevated pro-BNP of 1981. A telephone consultation with a GP took place at 09:43 on 16 February 2024. Dr Foster was not referred to secondary care. On 17 February 2024, Dr Foster was witnessed to collapse at home at approximately 13:10. Despite resuscitation efforts, Dr Foster's death was confirmed at 14:12. The cause of Dr Foster's death was a pulmonary embolism. On the balance of probabilities, the pulmonary embolism onset was around 1 February 2024. Dr Foster required admission to hospital on 16 February 2024. On the balance of probabilities, Dr Foster would have survived if admitted to hospital and treated. The conclusion of the inquest was: Natural causes contributed to by neglect 4 CIRCUMSTANCES OF THE DEATH Dr Foster was 53 years old. He was usually fit and well. He had been experiencing breathlessness since December 2023. Following a telephone consultation with a GP on 11 January 2024, a chest xray was carried out which was unremarkable. The symptoms of breathlessness persisted. Dr Foster attended a face-to-face consultation at the Castlegate & Derwent Practice with a trainee GP on 12 February 2024. The Wells Score was utilised and a ddimer (and ECG) ordered to rule out a pulmonary embolism. For reasons that could not be ascertained, the ddimer was not carried out that same day; it was booked for the afternoon of 14 February 2024 with a Practice Nurse. The Practice Nurse recognised the urgency of a ddimer test. The Practice Nurse also recognised that because of the time of the appointment on 14 February, bloods would not be sent to the laboratory until the following day. The Practice Nurse sought advice from a GP, carried out an examination (including an ECG) and requested blood tests, but not a ddimer. There was a missed opportunity for Ryan to be seen by a GP on 14 February 2024. It was accepted that the Practice Nurse, although experienced, was acting outside her normal practice. However, it could not be determined that this missed opportunity met the legal threshold for causation. The blood test results were received on the late afternoon of 15 February 2024. The results were broadly unremarkable save the pro-BNP which was markedly raised at 1981. The expected level for a patient such as Ryan is 50. A level about 400-500 is elevated. A level above 1000 is very rare. A raised BNP is a sign of heart failure. A telephone consultation with a GP took place at 09:43 on 16 February 2024 to discuss the results. The GP was not aware that a pulmonary embolism could cause heart failure. Ryan was referred for an outpatient ECHO, the waiting time for which was around 4-6 weeks. On 17 February 2024, Ryan called for help. At about 13:10, he was witnessed to collapse in the hallway of his home address. Despite resuscitation by paramedics, Ryan was confirmed deceased at 14:12. Post-mortem showed an occlusive thromboembolus in the right pulmonary artery which extensively branched into the distal segmental pulmonary vessels. Expert opinion was that the onset of the pulmonary embolism was around 1 February 2024. I found that there were missed opportunities to see Ryan in person and to refer him to hospital on 16 February 2024. I heard evidence from two expert witnesses which included: • The chest xray and blood tests had excluded most causes of breathlessness. • The pro-BNP of 1981 was significantly elevated and consequently worrying. • A telephone consultation was neither safe nor appropriate; Ryan should have been seen in person. • Referral to secondary care was definitely required such that it was mandatory. • • Had Ryan been admitted to hospital, on the balance of probabilities, he would The referral for an outpatient ECHO was not appropriate. have survived. I found that: • Had Ryan been admitted to hospital on 16 February 2024, on the balance of probabilities, he would have survived. • Not admitting Ryan to hospital on 16 February, more than minimally, negligibly or trivially contributed to his death on the balance of probabilities. • Ryan was in a dependent position because of his illness. • By not admitting Ryan to hospital, there was a failure to provide or procure basic medical care. This failure fell far below what could reasonably be expected and was therefore a “gross” failing. This gross failure more than minimally, negligibly or trivially contributed to Ryan’s death on the balance of probabilities. Therefore, Ryan’s death was contributed to by neglect. • • • I heard evidence of the difficulties that the practice faced at the time and the difficulties faced by the GP who spoke to Ryan on 16 February 2024. During the inquest, I heard evidence of the steps that had been taken by the Practice since Ryan’s death. Those steps included training on pulmonary embolism, reduction in the number of trainees, increased face-to-face consultations and clarification of the processes for requesting blood tests However, I also heard evidence that the Practice is not well governed and is in a “state of turmoil” such that leadership and safety is undermined. The Practice has not been able to address certain matters. Further, the Practice’s investigation into Ryan’s death has not been fully completed. Whilst the Practice has made improvements to the significant event process, it does not yet have a cogent smethod of investigating incidents. 5 CORONER’S CONCERNS 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: 1. Castlegate & Derwent Practice does not have unified leadership and governance. 2. Castlegate & Derwent Practice does not yet have a robust method of investigating incidents. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the Castlegate & Derwent Practice has 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 19 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: and Ryan’s family (via his Solicitors Clyde & Co) Care Quality Commission I have also sent a copy to National Institute for Health and Care Excellence (“NICE”) NHS North East and North Cumbria Integrated Care Board. 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 Dated this 23 day of October 2025 Miss Kirsty J Gomersal LLB HM Senior Coroner County of Cumbria
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.
Response to Regulation 28 Report to Prevent Future Deaths 23/10/25 Matters of Concern: 1. Castlegate & Derwent Practice does not have unified leadership and governance. 2. Castlegate & Derwent Practice does not yet have a robust method of investigating incidents. Response: 1. Leadership and Governance Castlegate & Derwent Surgery has gone and continues to go through a very difficult and challenging time. Our former business manager was ejected from the practice in February 2023 due to fraud, misconduct and dereliction of duty. As a result of his misconduct and dereliction of duty the practice suffered crippling financial losses, which significantly threatened the ongoing viability of the practice. For 18 months we were unable to recruit a practice manager to replace the ejected manager and were without a practice manager until November 2024 when our now practice manager was appointed to the role. In the interim period, initially one partner worked in a management role, with this responsibility subsequently being shared with two other partners from November 2023. One partner ceased his management role in September 2024. Partners have continued to support the practice manager with management since their appointment. As a result of the dismissal of our former business manager, a CQC inspection was triggered in April 2023 which found the practice to require improvement in several domains and overall. A further CQC inspection took place in May 2024 which found the practice to be inadequate in the Well-led domain and to require improvement overall. A further full CQC inspection took place in January 2025 which saw an improvement in the Well-led domain from inadequate to requires improvement, but the practice was found still to require improvement overall. Following the CQC inspection in May 2024, on 9th August 2024 we were issued with a warning notice from the CQC for failure to comply with Regulation 17 (1) Safe care and treatment, of The Health and Social Care Act 2008 Regulations. This was namely in relation to failure to establish policies, systems, governance and processes which operate effectively to assess, monitor and improve the quality and safety of care provided in the carrying on of the regulated activities. The CQC also found a backlog of significant events, and that we were unable to demonstrate learning from significant events. They found that the management of significant events and complaints at the practice did not keep staff or service users safe. Under the management of our former business manager there was a lack of governance and assurance structures which presented a risk to patient care. It was also identified learning from significant events and complaints was not maximised. We have subsequently worked very hard to address these failings. The new practice manager has worked closely with partners since appointment to ensure that robust governance and assurance systems are in place. This has included introducing a Governance Scheme of Delegation, reviewing the practice’s Organisational Structure, updating and improving the practice’s Risk Register, introducing a rolling programme of meetings, and taking ownership for the management of complaints. We have also worked closely with the CQC and the ICB in order to address these matters. Over the last 12 months, the practice manager has supported partners to ensure effective governance, assurance and auditing processes to assess, monitor and drive improvement in of the quality and safety of the service. The practice manager has supported partners in establishing and embedding systems and processes to monitor and mitigate risks in relation to health, safely and well being of patients. This now includes: • Structured monthly Partners Governance Meetings with a clear agenda with standing items including; significant events, complaints, audit & risk, etc • New Risk Register held on Practice Index and updated by all as new risks identified • Regular monthly risk management meeting • Regular monthly significant events meeting • Regular safeguarding meetings • Regular monthly complaints meeting These changes were in their infancy at the time of the CQC inspection in January 2025 but have now been fully embedded into the operational management of the practice over the last 12 months and all of the practice is now engaged with the new governance processes. The CQC Inspector has been meeting regularly with the practice manager since the Inspection Report was published to review ongoing progress, and evidence has been shared to support compliance. Whilst governance aspects are now working well, unfortunately there is an ongoing partnership dispute. One partner has accused the others of breaching the partnership agreement and of colluding with the former business manager. In January 2025 there were seven partners, there are currently five remaining. The dispute continues, and these allegations have resulted in the resignation of all other remaining partners. Two previous partners have already left, and those who have given notice have planned departure dates over the coming year. This is an extremely challenging situation and poses a significant risk to the practice. It appears unlikely that the dispute will be resolved, as the partner raising the allegations has not engaged in the external mediation process that was initiated in the summer and a subsequent mediation process that is currently in progress. Whilst this continues, it will be difficult for the practice to maintain unified leadership. However, unified governance processes remain in place as described above, all partners are engaging in the updated structures and processes, and there is a strong management team of four managers in place. We are working hard to mitigate the risk posed by the above situation in order to ensure the continued safe running of the practice. We are in the process of approaching other organisations with a view to merger or takeover of the practice. We are also actively recruiting GPs and other clinicians to support with the current and upcoming vacancies. 2. Method of investigating incidents The processes and procedures for managing significant events and investigating incidents are very different now as to how they were in early 2024. At the time of Dr Foster’s death, our significant events process was managed by one of the partners. It was found by the CQC that this process was inadequate and did not meet the expected standards. Staff involved in the significant event process were not trained, the practice was not registered with the correct national reporting systems and partners were not aware of their CQC reporting responsibilities. In September 2024 as result of the warning notice issued by CQC in August 2024 a new significant events process was implemented under the management of a very experienced salaried GP. We now have in place a robust system for the management of significant events to maximise learning from these. All practice staff have now been enrolled on significant event training. The GP who leads on significant events has trained management, administrative and IT infrastructure support. In particular, the appointed GP has been tasked to establish and share learning practice wide. The practice is now also using LFPSE (Learn from patient safety events) service to report events externally. This prompts consideration of onward reporting to other external agencies such as the CQC. The System for logging and managing significant events is detailed below: • All staff have been instructed to report significant events on the NHS ‘Record patient safety events’ website • All staff then report the significant event to the appointed GP • Staff log the event on the “learning from patient safety events” (LFPSE) portal from NHSE. • Significant events are anonymously documented on the Practice Index Platform by the appointed GP • Any actions required from the significant event are recorded on Practice Index and allocated to the relevant member of staff • All documentation, correspondence and related paperwork is scanned and stored on the surgery’s server in a protected folder • All hard copy documentation is filed and stored • Significant Events will be analysed on a monthly basis by the appointed GP with • • trends identified for further investigation Learning from significant events will be discussed at morning multi-disciplinary teams meetings, monthly significant event meetings and at Partner Governance Meetings Learning from significant events is now shared (where appropriate) in the weekly Staff Briefing Communication which is emailed to all surgery staff to foster improvement to patient care • An open, inclusive and learning culture will be adopted to ensure that there is a ‘no blame culture’ in relation to significant events and staff feel supported throughout the process. The CQC saw evidence at their last inspection in May 2025 that significant events were now being reported appropriately and that all staff were given the opportunity to attend significant events meetings, with the expectation of one person from each department attending as a minimum. Processes to share learning from significant events were still being embedded at that time but are now firmly in place. Please also find attached our new practice “Quick guide to Significant Events” flow chart. 17th December 2025
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