Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0600, written 26 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2025 |
|---|---|
| Reference | 2025-0600 |
| Deceased | Evie Muir |
| Coroner | Stephen Simblet |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid and South Essex NHS Foundation 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. Mid and South Essex NHS Foundation Trust, Broomfield Hospital, Court Road, Broomfield, Essex. 1 CORONER I am STEPHEN SIMBLET KC assistant coroner, for the coroner area of Essex. 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 21/03/2025, I commenced an investigation into the death of Evie Gladys Muir, who died aged 17. The investigation concluded at the end of the inquest on 26/11/2025. The conclusion of the inquest was death by natural causes. The medical cause of her death was coronary artery vasculitis. 4 CIRCUMSTANCES OF THE DEATH The deceased died aged 17 of a heart attack suffered less than 2 weeks after her admission to hospital where she had a week- long stay for treatment for cardiac problems. She suffered with a rheumatological condition axial spondylarthritis for which she was receiving adalimumab medication. She was known to be HLA B27 positive. The deceased was discharged from hospital on 6th February having been provided with various medications. On 19th February, she collapsed with a cardiac arrest from which she could not successfully recover. 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) That hospital reviews into unusual cardiac deaths such as this one are not more widely shared with other clinicians involved with a patient’s care, and other disciplines, such as, in this case, rheumatology specialists. This means that the full clinical picture of how a patient died may not be sufficiently widely understood. (2) patients with cardiac problems known to be HLA B27 positive or otherwise known to present rheumatological conditions being 1 adequately assessed for the risks which those rheumatological problems might present, include vasculitis. . 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 25th January 2026. 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 : (i) (ii) (iii) and , parents of the deceased; to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. , Child Death Review Team Lead. I have also sent it to the Department of Health who may find it useful or of interest. 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 26th November 2025 Stephen Simblet KC Assistant Coroner 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.
H.M Assistant Coroner Mr Stephen Simblet KC SEAX House Victoria Road South Chelmsford Essex CM1 1QH 23 January 2026 Dear Mr Simblet KC Regulation 28 Report to Prevent Future Deaths – Miss Evie Gladys Muir I write further to your Regulation 28 Report to Prevent Future Deaths dated 26 November 2025, relating to the Inquest of Miss Evie Muir. We have considered your concerns and now set out our formal response to each matter using your numbering as follows. Matters of Concern 1. That hospital reviews into unusual cardiac deaths such as this one are not more widely shared with other clinicians involved with a patient’s care, and other disciplines, such as, in this case, rheumatology specialists. This means that the full clinical picture of how a patient died may not be sufficiently widely understood. Many medical specialist societies and national bodies have produced guidance on how to conduct morbidity and mortality (M&M) meetings, and these can be a valuable source of learning for the clinical teams and the wider organisation. At Mid and South Essex NHS Foundation Trust, the Cardiothoracic Centre (CTC) M&M meeting is conducted broadly in line with available guidance including an assessment of whether the death was potentially avoidable. Learning points are shared widely with the CTC team but are currently not included in the Trust-wide mortality review meetings which would allow dissemination to a much wider group of clinicians. We are currently undertaking a quality improvement programme to improve our processes for learning from deaths in line with our new operating model and clinical governance structure. The new process will allow sharing of learning between teams and across hospital sites. We do consider that it would have been beneficial for a joint review of Miss Muir’s care by both the Cardiology and Rheumatology teams. The Rheumatology team have confirmed that they will in future invite Cardiology colleagues to their departmental meetings to improve education of coronary vasculitis and myopericarditis. I understand that the Rheumatology team are working hard to improve awareness and management of cases such as Miss Muir’s. 2. Patients with cardiac problems known to be HLA B27 positive or otherwise known to present rheumatological conditions being adequately assessed for the risks which those rheumatological problems might present, include vasculitis. My clinical colleagues advise me that the coexistence of Ankylosing spondylitis with systemic vasculitis that specifically targets the coronary arteries is exceptionally rare and primarily documented in isolated case reports. We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue increase awareness among allied rheumatology health care professionals. to We plan to complete a full review of our Learning From Death’s process this year with the aim of ensuring that it is robust and effective. As part of this work, we will be looking at the effectiveness of M&M meetings and identifying opportunities to elevate their use, with a focus on opportunities for cross-speciality learning. If I can assist further with these matters, please do not hesitate to contact me. Yours sincerely Chief Executive Mid and South Essex NHS Foundation Trust
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