Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0003, written 5 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jan 2026 |
|---|---|
| Reference | 2026-0003 |
| Deceased | Suzanne Pemberton |
| Coroner | Sean Horstead |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Essex Partnership University NHS Foundation Trust · East Suffolk and North 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 1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer, East Suffolk and North Essex NHS Foundation Trust CORONER I am Sean Horstead, area coroner, for the coroner area of Essex 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. INVESTIGATION and INQUEST On 16th September 2024 I commenced an investigation into the death of Suzanne Pemberton, aged 61 years’. The investigation concluded at the end of the inquest on the 16th December 2025. Suzanne Pemberton died on the 16th September 2024 at Colchester General Hospital (CGH), Turner Road, Colchester, Essex from a cause of death confirmed as: (1a) pneumonia and sepsis (joint causes), arising from (1b) exacerbation of long-standing bronchiectasis; on a contributory background of (2): severe depressive disorder, malnutrition and chronic frailty. The Conclusion of the inquest was a Narrative Conclusion focussed on those aspects of the inadequate care, management and treatment provided by Essex Partnership NHS Foundation Trust (EPUT) that probably more than minimally contributed to the death. CIRCUMSTANCES OF THE DEATH Over the course of a two-year period preceding her death, there were a number of opportunities for (EPUT) staff and clinicians to escalate concerns regarding Suzanne’s mental health, as raised by those treating her in primary and secondary care for her complex physical medical needs arsing, principally, from her chronic Bronchiectasis. 1 Suzanne’s lack of concordance with her mental and physical health medication informed a pattern of repeated and extended periods of admission as an in- patient to treat her lung infections which, over time and following each hospital discharge, to chronic and sustained deconditioning consequent upon depleted nutritional and physiological reserves This, in turn, directly contributed to the exacerbation of her chronic lung condition, leading to repeated infections and, ultimately, the fatal pneumonia and sepsis. that non-concordance - led - in The evidence confirmed that by the time of her final admission to CGH on Thursday 12th September 2024, such was the extent of the depletion of her physical and nutritional frailty and deconditioning, that Suzanne’s death on Monday 16th September was unlikely to be avoidable. reserves and consequent extreme It was apparent, however, that from her admission through until the day of her death on 16th September Suzanne had not been fully assessed in person by the CGH Dietetic team, notwithstanding that she had been referred to dietitians on Friday 13th at 09:01 hours and then re-referred, the same day, at 10:09 hours and had been deemed, when later triaged, as a Category 2 priority to be seen within 24 hours. 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 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. – Although, in the specific circumstances of this case, the delay in the provision of an in-person dietetic assessment was not a probable causative factor in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated: “At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.” (Emphasis added). The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The Professional Lead further reconfirmed, in terms, that outside of those hours there is simply no specialist dietetic service or cover of 2 any kind at all for patients at CGH. In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic Team for a new business case for funding having not been taken forward). The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team). She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths. 6 7 8 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 2nd March 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The husband and son of the deceased; Essex Partnership University NHS Foundation Trust; Suzanne’s GP; 3 Suzanne’s Consultant Psychiatrist, based at Cambridgeshire University Hospital NHS Foundation Trust. 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. She 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 05.01.2026 HM Area Coroner for Essex Sean Horstead 4
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.
Mr Sean Horstead Area Coroner for Essex Essex Coroners Service Seax House Essex County Council Victoria Road South Chelmsford CM1 1LX Dear Mr Horstead Colchester District General Hospital Turner Road Colchester CO4 5JL 3 March 2026 REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF SUZANNE PEMBERTON WHICH CONCLUDED ON 16 DECEMBER 2025 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 5 January 2026 (“the Report”). The Report highlighted concerns relating to the specialist dietetic service or cover of any kind at all for patients at Colchester General Hospital outside of weekday working hours, i.e. between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The information presented below is intended to describe the actions which have been taken/are being taken by the Trust to mitigate the risk of future deaths and address the concerns you have raised. RESOURCE ALLOCATION As an Acute Medical Trust, East Suffolk and North Essex NHS Foundation Trust (“ESNEFT”) provide a wide range of services to patients, some of which necessitate 7-day coverage, while others do not mandate a permanent presence within a 7-day period. ESNEFT must manage these competing service needs within the constraints of finite funding availability across all its services. In relation to the specialist dietetic service provision, the Trust has reviewed its position and maintain that the provision of dietetic support in the acute setting is best administered through clinical service during the weekday working hours, and robust care plans and enteral feeding starter regimes which are available for all staff to follow outside of weekday working hours. ACTIONS BEING TAKEN BY THE TRUST To ensure that patients who may need dietetic input outside of the weekday working hours receive the right care, the Trust has undertaken a project to ensure all relevant ward areas receive consistent and compliant training related to dietetic care planning. The Trust has, through the implementation of a new electronic patient record system, the capability to monitor adherence and compliance with dietetic care planning in real time. This will now make up part of the Trust’s audit programme. This audit has been registered formally within the 2026/27 Audit Programme, which will enable regular audit cycle to give assurance on compliance and learning opportunities and feedback to the Division/Trust on areas of concern. A therapeutic review of processes is being carried out across both sites to ensure policies, procedures and practices are in line with current guidance and are implemented in a consistent approach throughout the Trust. The dietetics team are also seeking to develop an escalation process for out of hours periods, which will be compliance audited regularly. The Trust hopes that the above information demonstrates the actions being implemented by the Trust and adequately responds to your concerns I would like to personally extend our sincerest condolences to Suzanne’s family for their loss. If I can be of further assistance, please do not hesitate to contact me. Yours sincerely Interim Chief Executive Officer East Suffolk & North Essex NHS Foundation Trust
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