Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0639, written 12 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Feb 2025 |
|---|---|
| Reference | 2025-0639 |
| Deceased | Brigitte Favre |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| 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.
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 2 Chief Executive Officer, West Suffolk Hospital Chief Executive Officer, Suffolk and North East Essex Integrated Care Board 1 CORONER I am Darren STEWART OBE, HM Area Coroner for the coroner area of Suffolk 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 03 February 2025 I commenced an investigation into the death of Brigitte Dominique FAVRE aged 69. The investigation concluded at the end of the inquest on 06 November 2025. The conclusion of the inquest was: Narrative Conclusion - In early 2024 Brigitte Dominique FAVRE was diagnosed with small cell leukaemia, an aggressive form of leukaemia with a high mortality rate. Ms. FAVRE received treatment including chemotherapy which finished in August of 2024. Early indications were that the treatment had been effective in dealing with the cancer. Sadly, in December 2024, Ms. FAVRE suffered a relapse of the cancer and she was admitted to West Suffolk Hospital where she resumed chemotherapy treatment in the hope that the cancer would respond in a similar manner to what had occurred earlier in that year. At the time the first round of chemotherapy was commenced, it was noted that Ms. FAVRE’s sodium levels were low and that this was likely to require further treatment and monitoring. She was admitted to hospital on the 27th December 2024 with significant hyponatremia, which was treated. During this admission she was also diagnosed as suffering from a urinary tract infection which, in addition to managing her sodium levels, impacted on the timing of her second round of chemotherapy which did not then occur until 22nd January 2025. As part of this procedure, there was a degree of extravasation leakage of the chemotherapy drug into the tissue surrounding the site of the injection. Ms. FARVE was discharged on Saturday the 25th January 2025 and returned home. As the discharge occurred on a weekend, oncology input to inform the discharge was not possible, although discharge criteria had previously been set by the treating oncology consultant. On returning home Ms. FAVRE was unable to mobilise effectively and her general condition deteriorated acutely within a short period of time. She was re-admitted to West Suffolk Hospital on 26th January 2025, less than 24 hours following her discharge the day before. It has not been Regulation 28 – After Inquest Document Template Updated 30/07/2021 possible to determine whether the criteria set out by the oncology department for Ms. FAVRE’s weekend or out of hours discharge were met at the time of her discharge on 25th January 2025. Following readmission Ms. FAVRE was diagnosed as suffering from both hospital acquired pneumonia and a further urinary tract infection and she was commenced on broad spectrum antibiotics. Poor record management meant that emergency department staff did not identify the fact that Ms. FAVRE had recently received chemotherapy treatment. As a consequence, post chemotherapy support medications were not administered. This, however did not make a contribution to her death. Ms. FAVRE’s condition subsequently deteriorated further and she developed sepsis. Brigitte Dominique FAVRE died on the 30th January 2025. The effect of the chemotherapy she had been receiving was to reduce her white blood cell count leading to a decreased ability for her immune system to effectively fight off infection and increasing her risk to catastrophic conditions such as sepsis. This is a recognised complication of chemotherapy treatment. It has not been possible to establish whether the failed discharge made a contribution to Ms. FAVRE’s death. Bridget Dominique Farve died due to a recognised complication following the receipt of necessary medical treatment for small cell cancer. The medical cause of death was confirmed as: 1a Neutropenic Sepsis 1b Chemotherapy 1c 1d 2 Small Cell Lung Cancer 4 CIRCUMSTANCES OF THE DEATH Narrative Conclusion see above. 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: The Inquest heard evidence that at the time of Ms. FAVRE’s discharge on the 25th January 2025, no oncology input was available on weekends or out of hours to inform discharge decision making. Criteria had been set by the treating Consultant Oncologist, however the evidence received at Inquest suggested that this was neither known nor followed in relation to Ms. FAVRE’s discharge. I found as a fact that the discharge of Ms FAVRE on the 25th January 2025 was a failed discharge although it was not possible to establish whether the failed discharge made a contribution to Ms. FAVRE’s death. Upon readmission to West Suffolk Hospital on 26th January 2025, poor records management meant that emergency department staff at West Suffolk Hospital did not identify that Ms. FAVRE had recently recieved chemotherapy treatment and as a result chemotherapy support medication Regulation 28 – After Inquest Document Template Updated 30/07/2021 was not administered. Although this made no contribution to Ms. FAVRE’s death, I am concerned that in the case of other patients such a failure may have a different adverse outcome. I therefore have two concerns: 1. The provision of on-call oncology support over weekends and out of hours to inform discharge planning and assist in reducing the incidence of failed discharge amongst cancer patients. 2. The record management in the emergency department, including the ability of emergency department staff to interrogate West Suffolk Hospital records in a timely and consistent manner in order to inform clinical decision making concerning patients who have either recently been discharged or are receiving ongoing outpatient care. 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 January 27, 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 The Family of Brigitte Dominique FAVRE I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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 she 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. 9 Dated: 02/12/2025 Darren STEWART OBE HM Area Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021 Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
26 January 2026 Mr Darren Stewart OBE HM Area Coroner for Suffolk Ipswich Coroner’s Court Beacon House Whitehouse Road Ipswich Suffolk IP1 5PB Dear HM Coroner West Suffolk NHS Foundation Trust Hardwick Lane Bury St Edmunds Suffolk IP33 2QZ Re: Response relating to Regulation 28 Report into the death of Brigitte Dominique Favre West Suffolk NHS Foundation Trust acknowledges receipt of the Regulation 28 Report to Prevent Future Deaths issued following the inquest into the death of Mrs Brigitte Dominique Favre. This is a joint response prepared on behalf of both West Suffolk NHS Foundation Trust (WSFT) and the Integrated Care Board (ICB). In advance of responding to the two specific concerns raised in your Report, we would like to express our deep condolences to Mrs Favre’s family and loved ones. Both the ICB and WSFT are keen to assure the family, and HM Coroner, that the concerns raised have been listened to and reflected upon. On behalf of everyone involved in Mrs Favre’s care, we are sorry that she suffered a failed discharge so close to her death. This must have been incredibly distressing for her family to witness. Please be assured the WSFT team are doing all we can to make sure discharges are safe, timely and appropriate. No one wants any patient to suffer the discomfort of having to come back to hospital so soon after discharge, if at all possible. Please find below details of the ongoing work date to address your two concerns, as well as some additional information which we hope is of some small comfort to Mrs Favre’s family and friends. WSFT RESPONSE Coroner’s Concern 1 - Provision of oncology input over weekends and out of hours to inform discharge decision-making and reduce failed discharges. Clarification of Out-of-Hours Oncology Support The Trust would like to clarify that an out-of-hours oncology telephone advice service is available via a Service Level Agreement with Cambridge University Hospitals (CUH). This has been in existence for over 20 years and provides consultant-level oncology advice. The service is accessed through the Trust’s switchboard. The senior clinician requests to be connected to the doctor on-call for Oncology and the switchboard then make contact with CUH. WSFT is not able to offer a formal out of hours Consultant oncology service, as that would mean increasing the consultant body and resources are not available to achieve this. However, in addition to the formal arrangements, informally all WSFT Oncology consultants are happy to be contacted at any time should advice be required. Despite the system being in place for many years, it is clear WSFT need to raise awareness of the process when dealing with complex discharges and seeking out of hours specialist advice. Therefore, the following action is being taken: - Action o Targeted communication will be shared with ward teams, including nursing and medical staff, to highlight learning from this case and reinforce safe discharge principles for oncology patients. This will be shared through the Medical Director’s bulletin and Departmental Governance Meetings, emphasising: The expectation that oncology advice should be sought prior to the discharge of complex oncology patients when discharge is occurring out of hours or over weekends. A discharge criteria set by oncology consultants must be clearly documented, actively checked, and strictly adhered to prior to discharge and any areas of doubt should prompt engagement with the CUH OOH service. Whilst not directly related, one of the Associate Medical Directors is leading a project to improve the completion of transfer of care summary letters (discharge letters). This work will help improve the discharge process and a side effect is that it should help to reduce failed discharges. This project specifically has implemented new digital solutions to make completion of discharge letters easier, as well as starting to change the way ward and board rounds work to help timely completion of documentation associated with discharge. This will be monitored through the governance processes. Timetable To be completed by March 2026. Coroner’s Concern 2 - Record management in the Emergency Department, including awareness of recent chemotherapy and access to hospital records. The usual process for managing patients who have undergone chemotherapy is that all chemotherapy patients are given a contact card which they can use 24/7 to contact the nurses on G1 if they are concerned. When contacted, the nurses use the UKONS triage tool (national recognised and recommended) to assess patients. Each patient will be allocated a level of clinical priority from the symptoms that they present with and from this, advice can be given. If the patient needs to attend hospital, they are asked to go to the Emergency Department (ED). ED are contacted by the G1 staff to let them know that the patient will be attending. ED also has a dedicated area within the Medical Assessment Area that looks after patients with infections, or who require isolation from infection, since the cubicle has a positive pressure ventilation system. Mrs Favre’s medical records do not confirm if she spoke to the Oncology team prior to her readmission on 26 January 2025. However, her medical records do confirm that she was brought in by ambulance and under the background section the following is specifically documented: “small cell carcinoma- T4 N3 M1c D/c [discharged] from hospital yesterday”. The discharge letter was also available on the system and makes reference to Mrs Favre’s recent chemotherapy. In order to answer this concern, when discussing with senior ED staff about the process of how they review medical records, we would like to share the following by way of clarification for Mrs Favre’s family about the process: “It was known that Mrs Favre was a post-chemotherapy patient, it is noted in the clerking that that patient is a known cancer patient and because the discharge letter was available then it would be known that the patient had been on chemotherapy. I feel this is clearly visible in the ED records. The process for treating a patient given the availability of the e-Care system is not simply to see the patient and treat as though they are a new patient, but to review the patient’s records. I am absolutely positive that this would have been done. Within about 25 minutes of arrival Mrs Favre was being given 2 antibiotics intravenously. The working diagnosis at that stage was a possible meningitis i.e. an infection. I think this is a reasonable first consideration given the clinical presentation and without any new blood results. She was thereafter investigated appropriately and was referred to the medical team for admission.” With regards to the specific concern about the ED teams’ ability to access the wider hospital’s medical records, the ED team confirm: “What you are asking is whether the doctor considered the records before starting treatment, my view would be that this was considered, the doctors deal with septic patients requiring urgent treatment several times per day, we are fortunate that the previous admission records are available on e-Care. I think you can reassure the Coroner that we are aware of the issues of post-chemotherapy patients, Dr Patterson’s contribution to this has been invaluable and we are continuing to relay his message to future generations of doctors.” Mrs Favre, was very unwell and was showing signs of a serious infection (sepsis) and antibiotics were prescribed promptly. In situations like this, the immediate clinical priority is to begin urgent treatment with antibiotics and investigate the source of the infection, as this is potentially life threatening. This urgent treatment would have taken priority over the administration of post chemotherapy medication. However, we are sorry that this was not expressly communicated to Mrs Favre’s family. This would have provided them with a greater understanding about the care being provided and the rationale for it. We apologise for the anxiety that was caused as a result. This was already a very distressing time and we regret this compounded those feelings. ‑ With regards to actions and learning, the Trust’s Emergency Department Governance lead confirms that patients who are admitted via ED with sepsis or potential neutropenic sepsis are identified quickly by a well-established ED triage process and antibiotics are started rapidly, plus fluids and any relevant medications. This is a well-practiced procedure that ED staff are reminded of every few months and the new medical staff at their induction (which is delivered by the Governance Lead himself). The ED Governance Lead goes on to confirm that discharge letters from previous admissions are available to ED clinicians and, as a matter of protocol, refer to these to guide their clinical decision making. We have referenced above in response to the first concern the work being undertaken to improve that aspect of our care which will only help the ED decision making in future. Through our existing governance processes WSFT will continue to monitor this issue. We do this by triangulating data from various sources such as: incidents, complaints, and audit data. We use that to feed into future improvement work and priorities for the future. The team will remain vigilant for learning opportunities around this and similar issues as part of our continuous journey of improvement. ICB RESPONSE The ICB fully acknowledges HM Area Coroner’s concerns in respect of oncology support over weekends at West Suffolk NHS Foundation Trust, and also the patient record management in the Emergency Department, including the ability of Emergency Department staff to interrogate records in a timely and consistent manner. The ICB has responsibility to review and monitor all responses and improvements taken following Regulation 28 reports in respect of the services we commission. This will include the actions taken for improvement as identified in this response. 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 faithfully Your faithfully Chief Executive WSFT Chief Executive SNEE ICB
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