Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0048, written 2 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2026 |
|---|---|
| Reference | 2026-0048 |
| Deceased | Avery Hall |
| Coroner | David Place |
| Coroner area | Sunderland |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
David Place Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Riverview Surgery, Riverview Health Centre, Sunderland The Royal College of General Practitioners (RCGP) 1 CORONER I am David Place, His Majesty’s Senior Coroner for the City of Sunderland 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 14th November 2024 I commenced an Investigation into the death of Master Avery Jake Hall, who died in Sunderland on 13th November 2024 aged 4 days. The Investigation concluded at the end of the Inquest on 23rd January 2026. The medical cause of death was confirmed as: - Ia Hypoxia Ischaemia and diffuse alveolar damage Ib Olygo/anhydramnios and foetal distress Ic Premature rupture of membranes, small placenta with distal villous maldevelopment and low grade foetal vascular malperfusion I gave a narrative conclusion ‘Avery Jake Hall died from complications known to arise when candesartan is used throughout pregnancy particularly in the second and third trimester and his mother had continued to use this medication which had been prescribed to her since 2022 being unaware of the risks it posed due to a combination of unclear and indecisive advice at the outset and no additional advice about the safety of the medication from clinicians involved in her antenatal care.’ 4 CIRCUMSTANCES OF THE DEATH Avery Jake Hall died at Sunderland Royal Hospital on 13th November 2024 having developed global hypoxia and diffuse alveolar damage with hyaline membranes in the lung following his birth as his development in pregnancy had been compromised by reduced amniotic fluid leading to poor lung development and impairment of urine production by the kidneys. During pregnancy Avery's mother had continued to take Candesartan which had previously been prescribed to her to treat HM Coroner’s Courts, City Hall, Plater Way, Sunderland SR1 3AA Tel 0191 5617843 email: coroner@sunderland.gov.uk | web: www.sunderlandcoroner.co.uk migraines. She did not receive definitive advice from clinicians to stop taking it despite various opportunities to do so and this is a medication contraindicated in pregnancy due to risks including foetal renal failure and pulmonary hypoplasia. 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: – Avery’s mother suffered from migraines which were increasing in severity, so she sought advice from her GP when aged 21 years old. She was prescribed Candesartan 4mg by her GP shortly before her 22nd birthday. This was to be taken daily and was placed on a repeat prescription of 28 tablets. The dose was increased to 8mg after 3 months and following a referral, the treatment was endorsed by a Consultant Neurologist at a consultation 4 months after the initial prescription. The evidence revealed that no advice was provided as to the risks of this medication should she be considering having a child. Following a positive pregnancy test in April 2024, Avery’s mother sought advice from her GP about which of her prescribed medications were safe to use during pregnancy. During the telephone consultation with her GP on 11th April 2024 she was given specific advice to avoid using 3 of 6 prescriptions. I am concerned that the evidence highlighted that Avery’s mother was given only generic advice that it was best to avoid all medication during pregnancy but was not given specific advice to stop using Candesartan, and the risk of continuing to take this medication in pregnancy was not identified during this consultation. Although Avery’s mother had a number of attendances with clinicians throughout her antenatal care, the evidence revealed that she was given no additional advice regarding the safety of her medication and, whilst she was advised to seek advice from her GP as the prescriber, she did not feel it was necessary to do so having already had such a consultation in April 2024. Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review. The last repeat prescription being approved only 12 days prior to Avery’s birth. I am concerned that despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription and, in addition to that, there were no warnings placed on the system which would have alerted the clinician approving the request for the repeat prescription that the patient was pregnant thus necessitating a review. I shall be glad to be told of any learning arising from this death and timescales and results of your review. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. Page 2 of 3 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - • Family and their Solicitors and Counsel • South Tyneside and Sunderland NHS Foundation Trust and their Solicitors • Solicitors and Counsel for Riverview Surgery • Care Quality Commission I am also under a duty to send the Chief Coroner and all interested persons, who in my opinion should receive it, 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 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 by the Chief Coroner. 9 Dated this 2nd day of February 2026 Signature: HM Senior Coroner for the City of Sunderland Page 3 of 3
2 responses 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.
Riverview Surgery Riverview Health Centre Borough Road Sunderland SR1 2HJ Mr David Place Senior Coroner for the City of Sunderland HM Coroner’s Courts City Hall Plater Way Sunderland SR1 3AA Dear Mr Place Avery Jake Hall: Prevention of Future Deaths Report I am writing on behalf of the Riverview Surgery in response to your Prevention of Future Deaths Report (PFDR) dated 2 February 2026 in order to provide you with information regarding the further steps we are taking in addition to those set out in the SEA to ensure that there is no recurrence of these devastating events. For completeness, I attach the SEA detailing the steps taken previously. Following receipt of your PFDR, I have considered carefully your concerns and conclusion and revisited the SEA in order to further develop the systems currently in place, to address your concerns. These additional changes are as follows: 1. An SOP has been implemented in relation to prescribing medication to women of child bearing age (15-55 years old). I attach the SOP. A clinical practice meeting has been arranged for 26 February 2026 at which the SOP will be discussed and laminated copies distributed. 2. The SOP goes further than the previous SEA in the following respects: a. It relates to any new medication at the point of initiation. b. If there is a concern as to a medication’s safety in pregnancy, the medication is to be stopped and removed from the repeat and acute list of medications and the patient advised of safe alternative medication. 3. As set out in the SEA, a review of all female patients of child bearing age who are prescribed ARB medication was to be undertaken every 6 months and an alert added to their prescription to stop taking this medication if they become pregnant and to speak to their GP. The frequency of this review has now been increased to 3-monthly in light of the risks of this medication in later pregnancy. In addition, as most prescriptions are now electronic rather than paper copies, the alert will be added to the prescribing instructions section so that it is clearly shown on the label printed for the patient’s medication by the pharmacy when they collect their medication. I wish to make clear that had I known of the BNF warning for candesartan in 2024, I would have given definitive advice that it must be stopped and I would have removed it from the repeat prescription list. The SOP will ensure that patients receive an early alert and counselling in relation to any concerns about their current medications should they become pregnant. Once the patient informs the practice of their pregnancy, an urgent review will take place with a doctor to address their current medication risks, stop medications which are contraindicated or for which there is concern about their safety in pregnancy and advise upon safe alternatives. Had the SOP been in existence in April 2024, it would have led me to stop the 3 medications which the BNF advised avoiding or were contraindicated in pregnancy, namely candesartan, melatonin and lansoprazole, and to remove them from the acute and repeat prescription lists. I have also considered further whether it is possible to identify or flag a pregnant patient when they request repeat medication. This would be an important safeguard for doctors reviewing the two hundred or so repeat medication requests received on a daily basis. Due to their volume and the other priorities for clinicians’ time, it is not practical for the doctor to review each patient’s records when authorising every request. We do not have the technical IT skills at the practice to make changes to the computerised records system and I have therefore contacted our system provider EMIS to ask for their advice and input on whether it is possible, and if so how, to introduce a flag which would identify the pregnancy coding on the patient’s record and link it to the repeat prescriptions for the patient (and ideally include the BNF advice for that medication as well). I hope that this is a proportionate and practical way to address the issue you have raised, which will further strengthen the safeguards in place with the 3 monthly review of all female patients of child bearing age prescribed ARB medication. I wish to make clear how seriously I and the practice take the issues you have raised and hope you are reassured by the steps already undertaken and the further steps which are being undertaken following your PFDR. Yours sincerely, cc CQC Significant Event Start date 3-3-25 Brief summary Patient contacted the surgery via e-consultation on 10-4-24 since she had just found out that she was pregnant and was unsure whether her current medications were safe to continue with during her pregnancy. She had a GP telephone consultation on 11-4-24 where all her medications were checked against the paper version of the BNF number 86 September 2023 – March 2024. She was advised to stop all medications and provided with suggestions as to over the counter alternatives. The practice was informed of a neonatal death at 13-11-24. A Teams meeting with (Quality and Safety Matron, Obstetrics and Gynaecology SRH) and an Obstetrics and Gynaecology Consultant was held at 1430 on 24-3-25. This Teams meeting implicated that the Candesartan which had been taken throughout pregnancy had led to the neonatal death. The date a discussion about the event occurred Practice clinical meeting 6-5-25 Further Practice meeting 8-9-25 @ 1200 – Community Midwife has been invited to attend. A description of the actual event I shared and discussed all the concerns, notably what I had done since learning of the neonatal death and Candesartan (Angiotensin 2 receptor blocking medication/ARB), and what further safeguards can primary care put in place to prevent any reoccurrence. A description of the actual event 1. I shared a summary of events with my Surgery's clinical team. 2. I shared what I had done since becoming aware of the issue with regards to Candesartan. What went well or not The team was deeply upset to learn of this event and were saddened on behalf of the lady and her family. We had an open and very frank discussion as to how it had happened and what safeguards were needed to prevent it from happening ever again. What could have been done differently At the point of initiating the Candesartan medication, adding an alert to the medication and advising the patient to stop if becoming pregnant. Any other colleagues present at the time of the significant event 6-5-25 @ 1200; Practice Nurses ( and on 6-5-25. & ), , Nurse Practitioner ( ) 8-9-25 @ 1200; Practice Nurse ( ), Nurse Practitioner ( ), Salaried GPs ( and Manager ( ), Community Midwife ( ), GP partner ( ), Practice ). Reflections on the event in terms of knowledge skills and performance; safety and quality; Communication, partnership and teamwork; maintaining trust; All information was discussed candidly – everyone agreed that the implemented safeguarding changes were appropriate with no further amendments. What changes have been agreed for me personally and for the team 1. Any patient who advises that they have become pregnant will be alerted to myself via a task from reception so that I can; a. Code that they are currently pregnant, b. Request referral to our Community Midwife and c. Conduct a medication review. If I am unavailable the task will be sent to the on/call GP, all clinicians have been briefed as to the dangers of Candesartan. 2. All clinical staff are now fully aware as to the dangers of Candesartan and since it is a class effect around all ARB medication. 3. All clinical prescribing staff will add a patient alert/warning to the patient's prescription warning all women of childbearing age that Candesartan must be stopped if the patient becomes pregnant. Changes carried out and their effect; 1. I reviewed all women of childbearing age taking Candesartan and indeed taking any ARB medication. 2. All those of childbearing age have had an alert added to their prescription warning them to stop immediately if they become pregnant and to see their GP. 3. Opportunistically all women taking Candesartan or any ARB of childbearing age are verbally warned as to the medication dangers and are advised to stop immediately if they become pregnant. 4. I am now alerted by a task sent from reception upon them being advised by a woman that she has become pregnant, a. I check that they have been coded as being pregnant, b. I check that they have been referred to the Community Midwife, and c. I perform a medication review such that if the patient takes any medication they are asked to book a telephone consultation with myself and if they take no medication then no further action is required. This is fully documented in the patient consultative record. If I am unavailable, then the task is sent to our duty/on-call GP. All our clinical staff are now fully aware as to the dangers of Candesartan, ARBs in general and pregnancy. 5. As a practice we no longer use the paper BNF for medication reviews and now use the electronic version. 6. I have written a letter to the BNF to alert them as to this egregious omission in respect of Candesartan and pregnancy usage. 7. I have highlighted this issue and case within the East Sunderland PCN amongst partnered GPs to disseminate learning points. 8. I have highlighted this concern to our East Sunderland PCN prescribing lead, Sunderland's LMC chair and the Sunderland ICB prescribing lead both for wider learning and safeguarding. The Sunderland ICB prescribing lead will arrange an educational session for all Sunderland GPs in respect of drugs in pregnancy, highlighting ARB medication. 9. I have discussed the issue with our local pharmacist/ who is also a member of the Sunderland's LPC (Local Pharmacy Committee). I was surprised to learn that when a patient claims an NHS exemption from prescription charges, the IT system does not alert the pharmacist as to the reason why. So currently there is no system to alert the pharmacist as to a patient being pregnant. will raise these issues at the next LPC and see if they can organise further training for Sunderland's pharmacists. Reflections: Learning need addressed I am now aware as to the dangers of Candesartan and any ARB in pregnancy. I will now rely solely on the electronic BNF. Method used: Audit of those women taking Candesartan and any ARB medication of childbearing age. Outcome of Activity To put in place robust safeguarding procedures such that this event can never happen again. Outline any further learning or development needs highlighted by the activity Shared both at practice clinical level and wider to PCN/LMC/ICB/LPC. I have alerted the BNF by letter. Audit fully completed 2-10-25 Riverview Surgery Standard Operating Protocol Prescribing to women of childbearing age 15-55yo 1. At the point of initiating any new medication, the medication is checked using the electronic version of the BNF as to its safety if the woman was to become pregnant. 2. If there is concern as to the medication's safety in pregnancy, the patient is both to be counselled and an alert is added to the prescribing instructions. The alert is to state that the medication is to be stopped if the patient becomes pregnant, and to speak to her GP. 3. Upon the patient informing the Practice that she is pregnant a task is sent by the reception team to the on/call GP that day. 4. The on/call GP will code the patient as being pregnant and task reception to refer her to the midwife providing the date of the patient's LMP (last menstrual period). 5. The on/call GP will immediately review the patient medical record; if the patient is taking no medication, then no further action is required. However, if the patient is taking medication, then a task is to be sent to reception requesting an urgent medication review with the patient and a GP. 6. At the point of the urgent medication review with the patient, the GP will establish all taken medications and their dosage. The electronic BNF will be reviewed as to the identified medications and their safety in pregnancy. All contraindicated medications and those where there is concern as to the medication’s safety in pregnancy will be stopped and removed from the repeat and acute list of medications. Dated 5-2-2026 Review date of this SOP is every 2 years
Vice Chair Member Standards Mr David Place His Majesty's Senior Coroner for the City of Sunderland 19 March 2026 Dear Mr Place Regulation 28 Report to Prevent Future Deaths - regarding the death of Master Avery Jake Hall Thank you for asking us to comment on the matters of concern following the sad death of Avery Jake Hall who died on the 13th of November 2024. Our sincere condolences go to his family given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Avery’s loved ones. You have numerous matters of concern relating to this deeply upsetting death. • Continuation of repeat prescribing of Candesartan throughout the pregnancy in spite of the GP’s clinical advice to stop the medication on 11th April 2024. • The lack of specific advice regarding Candesartan in pregnancy and the risks involved. • Missed opportunities to highlight the risks with clinicians through her multiple attendances through her antenatal care. To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training, promoting research and advocating and representing the College and its 56,000 members. Training General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. Within GP Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III Training there is now a mandatory Prescribing Assessment, introduced in 2019, to examine prescribing decisions, assessing against current evidence, considering prescribing in special groups including children, the elderly or in pregnancy. Within the RCGP Womens Health toolkit, the breadth of information resources on prescribing in pregnancy are provided with links, including the Specialist Pharmacy Service, (SPS) https://www.sps.nhs.uk/articles/the-risks-and-principles-of-prescribing-in-pregnancy/ Prescribing in Pregnancy is a specific section within the British National Formulary, (BNF), available online, listing specific concerns for each drug reflecting known evidence from trials and continuing monitoring. Clear advice is given as to whether the medication should be avoided, may have harmful effects or when it is not known to be harmful, with the current advice that Candesartan should be avoided. https://bnf.nice.org.uk/drugs/candesartan-cilexetil/#pregnancy Information resources are readily available to both clinicians via UKTIS and their patient- facing resource BUMPs (Best Use of Medicines in Pregnancy) websites, summarising the current known evidence for medications prescribed for pre-existing conditions prior to pregnancy, as in Candesartan for the indication of migraines. Full monographs are available to healthcare professionals when we register with the site using our nhs.net email address. These pages are updated when new evidence evolves and from my own viewing the current information was last updated https://uktis.org/monographs/use-of-angiotensin-ii-receptor- antagonists-in-pregnancy/ in July 2025 and https://www.medicinesinpregnancy.org/leaflets- a-z/angiotensin-receptor-blockers/ January 2026 on UKTIS and BUMPs respectively. A phone number allows healthcare professionals to contact UKTIS for help and advice if required: 0344 892 0909. Systems GP Information Technology Systems give prescribing alerts at the point of issuing the prescription. There is no single GP IT System and each supplier will have their own prescribing advice software, for example EMIS, SystmOne and Medicus. Communication with these suppliers would be valuable to clarify a system-wide safety net in the event of human error leaving a harmful prescription within repeat medications for a patient coded as being pregnant. The manufacturers DCB0129 hazard log will have a specific hazard identifying medication causing harm, one cause of which is a change in clinical circumstances rendering an existing repeat prescription unsafe. The hazard "controls" (things that reduce the risk) include presenting information to the users at the relevant moments e.g. • When a new codable condition is added which can computably surface a warning, • When a digital prescribing safety check is activated by a user, • When a repeat prescription request is being reviewed prior to being issued, • What systems are in place to identify and manage Alert Fatigue in users Systems do seem to highlight the risks at the point of initiation as a new prescription. It is unclear whether an Alert is raised across all systems for existing repeat prescriptions, such as Candesartan in this case. Exploration of this issue with the suppliers would be valuable to avoid further events. The next layer of safety in prescribing is the dispensing pharmacist, who may refer the prescription back to the prescriber if they identify a risk or concern. This area of the process is beyond the remit of the RCGP. A development that has subsequently become available is the contractual obligation to report such incidents to the Learning From Patient Safety Exercise (LFPSE) established in October 2025, following on from the National Reporting and Learning System, which was utilised predominantly by secondary care health services. Once again, our condolences go to Avery’s parents and family. I hope the comments provide a full picture of where the RCGP can influence the prevention of future deaths within training and continuing professional development. Yours faithfully Vice Chair Member Standards
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