Lynn Silcock

Heath Westerman 
H.M. Assistant Coroner for Shropshire, 
Telford & Wrekin 
H.M. Coroner’s Service 
Guildhall 
Frankwell Quay  
Shrewsbury 
Shropshire  
SY3 8HQ 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

12 December 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Lynn Silcock who died on 
10th July 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23rd 
October 2025 concerning the death of Lynn Silcock on 10th July 2025. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Lynn's family and loved ones. NHS England is keen to assure 
the family and yourself that the concerns raised about Lynn’s care have been listened 
to and reflected upon.   

You raised concerns that Lynn was discharged by the gastroenterology team at The 
Royal Shrewsbury Hospital in September 2022, without referral to the cardiology team 
or a plan to be referred later, and that no investigation had taken place by Shrewsbury 
and Telford Hospital NHS Trust (‘SATH’) as to why this had occurred and what had 
gone wrong. 

The concerns raised in your Report will be dealt with by SATH, to whom your Report 
has also been addressed to, and there is no action for NHS England to take in regard 
to  this  matter  as  the  issues  fall  outside  of  NHS  England’s  role  and  remit  as  a 
commissioner of certain healthcare services. However, the following information may 
be useful to the Coroner as background. 

NHS  England  has  long  recognised  that  omissions  in  information-sharing  within  or 
between healthcare organisations can contribute to poor continuity of care and lead to 
poor  health  outcomes.  In  2021,  NHS  England  developed  and  rolled  out  a  national 
‘Frontline  Digitisation’  (FD)  Programme,  which  aimed  to  support  NHS  Trusts  in 
England  with  the  procurement  and  deployment  of  Electronic  Patient  Record  (EPR) 
systems. The aim of this was to support increased digital maturity of organisations and 
improve information sharing within and between organisations. Beyond facilitating the 
procurement of EPR systems, the FD Programme also provided guidance and support 
to ensure safe and effective deployments. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 As  part  of  this  initiative,  SATH  secured  a  multi-year  funding  to  implement  a 
replacement Patient Administration System (PAS) and Emergency Department (ED) 
solution. Subsequently, in April 2024, SATH deployed the ‘System C CareFlow EPR’. 
EPR  systems  typically  include  locally  configurable  functionality  to  ensure  that  NHS 
Trusts  can  adapt  them  to  meet  their  service  needs.  These  systems  can  include 
capabilities  for  creating  discharge  summaries,  patient  search  functions  and  the 
creation of referrals.  

However,  despite  EPR  systems  being  able  to  enhance  information  sharing  and 
referrals, these processes continue to rely on the user taking the correct action and 
there remains a risk of oversight, which may result in incomplete discharge summaries 
and/or referrals not being created or sent.  

To mitigate this risk, NHS Trusts should ensure that discharge and referral processes 
are  streamlined  and  aligned  with  clinical  workflows,  and  that  these  are  formalised 
within  local  Standard  Operating  Protocols  (SOPs).  These  workflows  should  be 
configured in a way that supports staff and should be rigorously tested, incorporated 
into  training  programmes  and  clearly  communicated  to  clinical  staff  for  them  to 
facilitate workflows in the most efficient and effective way possible. 

NHS England has requested to be included in SATH’s response to the concerns raised 
in your Report, and will review it to determine whether any further action is necessary.   

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Lynn, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 National Medical Director 
 NHS England

Royal Shrewsbury Hospital 

Mytton Oak Road 
Shrewsbury
Shropshire 
SY3 8XQ 

Mr Heath Westerman, Assistant Coroner 

HM Coroners Service 

Shirehall 

Abbey Foregate 

Shrewsbury 

Shropshire SY2 6ND 

Dear Mr Westerman, 

Thank you for your letter dated 23rd of October 2025 issued under Regulation 28: Report to 
prevent  future  deaths,  in  relation  to  the  risks  you  identified  examining  the  death  of  the  late 
Lynn Silcock. 

I  write  to  provide  details  of  the  steps  that  we  have  taken  and  plan  to  address  the  issues 
highlighted in your letter. These issues were outlined as: 

1. Discharged by the gastroenterology team without referral to the cardiology team as to

whether the discharge was appropriate.

2. Discharged without a cardiology clinic appointment or plan to be later rereferred.

3. There  was  no  document  exchange  or  communication  between  the  gastroenterology

team and the cardiology team meaning that Ms Silcock was then forgotten about.

4. No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why

between the treating teams and their respective administration teams.

I  have  taken  these  points  slightly  out  of  order  to  provide  appropriate  context  to  then  outline 
the actions we are taking to reduce the risk of a similar incident.  

 
 4.  No  investigation  by  Shrewsbury  and  Telford  NHS  Trust  as  to  what  went  wrong  and  why 
between the treating teams and their respective administration teams. 

The  case  of  Mrs  Silcock  has  been  raised  as  a  Patient  Safety  Investigation  (PSII)  under  the 
Patient Safety Incident Response framework and some of the initial work of that investigation 
has been used to inform the response outlined in this letter. 

The  PSII  was  raised  following  communication  between  the  coroner’s  office  and  the  Trust’s 
legal team following the issuing of Ms Silcock’s cause of death in July 2025. The legal team 
put in a Datix incident report which led to a review of the issues relating to Ms Silcock’s care. 
This led to the raising of the PSII via the Trust Executive chaired incident review group on the 
4th of November 2025. 

Before  the  point  in  July  when  Ms  Silcock  sadly  died  and  had  a  post-mortem  investigation 
there was no indication for the Trust that an incident had occurred as the Cardiology referral 
had not been received and so there was no tracking on the intended pathway. 

A  detailed  review  of  the  circumstances  around  the  lack  of  referral  to  Cardiology  has  been 
unable  to  determine  the  exact  mechanism  whereby  the  intended  referral  from  the  medical 
team to Cardiology failed to occur. On this basis, the PSII has been commissioned to further 
understand  the  current  risks  in  inpatient  to  outpatient  referrals  across  SaTH  clinical 
specialties. Further to this the PSII will also explore the likely optimum system to reduce risk 
of referrals being lost to help inform in the longer term the tools (likely to be digital) which can 
support a safe referral system which reduces risk to the lowest level reasonably practicable. 

1.  Discharged  by  the  gastroenterology  team  without  referral  to  the  cardiology  team  as  to 
whether the discharge was appropriate. 

2. Discharged without a cardiology clinic appointment or plan to be later rereferred. 

3. There was no document exchange or communication between the gastroenterology team 
and the cardiology team meaning that Ms Silcock was then forgotten about. 

Ms  Silcock  was  admitted  to  SaTH  in  2022  with  shortness  of  breath.  Initial  blood  test 
investigation  indicated  she  had  a  low  haemoglobin  (ie  she  was  anaemic).  A  cardiac  echo 
investigation was undertaken which reported severe aortic stenosis. 

The  investigation  results  outlined  above  led  to  discussions  with  gastroenterology  and 
cardiology  teams  regarding  ongoing  investigations  and  care.  This  resulted  in  the  decision 
based  on  the  specialist’s  advice  to  refer  Ms  Silcock  for  outpatient  upper  and  lower 
gastrointestinal (GI) endoscopy to investigate potential bleeding or malignancy in the GI tract. 
The medical team would also refer to the outpatient service of the cardiology team for further 
follow up and investigation of Ms Silcock’s aortic stenosis. 

 The possibility of bleeding or malignancy led to the endoscopy investigations being prioritised 
with  cardiology advising  these  should be  completed  first  then  cardiology  would  continue the 
process to investigate the aortic stenosis. On review it is clear there was no expectation that 
the  gastroenterology  team  would  be  responsible  for  following  up  the  referral  to  cardiology 
once Ms Silcock’s endoscopy investigations were completed. 

The decision to refer to the cardiology team as an outpatient is documented in the discharge 
letter and notes and should have occurred formally at the point of Ms Silcock’s discharge from 
the  medical  inpatient  team  in  2022.  The  process  failed  at  the  point  of  discharge  and  the 
referral to cardiology was lost in the system. It has not been possible despite in depth review 
to  explain  exactly  where  the  issue  arose  that  mean  this  referral  was  lost.  It  is  possible  to 
postulate  a  number  of  potential  scenarios,  but  we  do  not  know  the  precise  issue  that  led  to 
the missed opportunity to further investigate Ms Silcock’s stenosis. 

Based  on  the  initial  review  of  the  issues  around  Ms  Silcock’s  care  and  the  information 
gathered as part of the PSII we can say broadly: 

• There is variation across the inpatient specialties in the Trust in terms of the process of

referral to other specialties on an inpatient to outpatient basis.

• Not  all  specialties  have  a  defined  standard  operating  procedure  (SOP)  for  these
referrals which can lead to variation and potentially increase risk of referrals becoming
lost.

• There  is  currently  no  standardised  tool  available  to  teams  digitally  which  enables
referrals  to  be  made  and  tracked  or  audited  to  ensure  follow  up  appointments  are
made. The current process of referral is largely paper based, which can increase risk.

On the basis of these initial insights we have proposed two courses of action to address risk 
and reduce the likelihood of a similar incident occurring. One course of action is aimed at the 
short to medium term and the other looking for a longer term and sustainable solution to this 
challenge. 

Actions in the short to medium term: 

In  the  short  to  medium  term  the  Trust’s  Medical  Director  and  Deputy  Medical  Director  are 
tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a 
clear  standard  operating  procedure  (SOP)  for  inpatient  to  outpatient  referrals.  This  will  be 
documented  and  shared  across  the  team  with  clear  direction  on  process,  roles,  and 
responsibilities  in  ensuring  referrals  are  made  and  a  system  of  safety  netting  is  in  place  to 
ensure decisions to refer to other specialties are followed through and actioned. 

There will be a single referral email for each speciality for referral for outpatient follow-up, the 
referrals  within  the  team  will  then  be  managed  in  the  standard  way  all  referrals  are  with 
appropriate  triage.  This  process  will  be  developed  over  the  next  3  months  with  SOPs 
developed and appropriate communications cascaded. 

 Actions in the long term: 

The Trust has an ongoing programme of digital development to implement digital systems to 
support clinical teams to work effectively and safely. 

A project feasibility request has already been raised to assess the need for a digital solution 
to support referral management. This is the route whereby needs are reviewed and scoped to 
develop proposals and business cases to place the need on the Trusts ‘digital roadmap’ (the 
overall programme of work to mature the Trusts digital systems). 

There are several potential existing systems available which may support referral processes 
and  reduce  the  risk  which has been  highlighted  by  this  incident. The ongoing  PSII,  which  is 
likely to be completed by February, will engage clinical teams in outlining a robust and reliable 
referral  process.  This  work  will  be  used  to  evaluate  what  system  is  best  suited  to  support 
management of referrals. 

It is difficult at this stage to give an indication of the timescale for development of any digital 
solution  given  the  need  to  scope  the  process  and  available  systems  as  well  as  the 
prioritisation of funding and scheduling such work. 

Thank you for bringing your concerns to my attention. I hope that you are assured that I have 
taken  them  seriously,  we  are  investigating  them  appropriately  and  we  are  putting  in  place 
systems and processes to reduce future harm. If I can provide any further information, please 
do not hesitate to contact me at the above address. 

Yours sincerely, 

Executive Medical Director 

On behalf of 

, Group Chief Executive