Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0059, written 4 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 | 4 Feb 2026 |
|---|---|
| Reference | 2026-0059 |
| Deceased | Lauren Moret-Dell |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | West Suffolk 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 2 , Chief Executive, West Suffolk NHS Foundation Trust , Chief Executive, 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 17 January 2024 I commenced an investigation into the death of Lauren Rae MORET- DELL aged 32. The investigation concluded at the end of the inquest on 21 November 2025. The conclusion of the inquest was: Narrative Conclusion - Lauren Rae MORET-DELL was a much loved and desperately missed member of her Family. A person who during her relatively short life, cut so tragically short, had a significant, positive impact on the lives of those around her. Mrs. Moret-Dell presented to West Suffolk Hospital Emergency Department on 23rd December 2023 after she developed symptoms of nausea with incoordination and slurred speech. She had a background history of type 1 diabetes mellitus with proliferative retinopathy for which she had undergone laser treatment. Neurological examination was unremarkable. A Computed Tomography (CT) head scan showed no abnormalities. Her symptoms were considered likely to be due to poor glucose control. A Transient Ischaemic Attack (TIA) was considered an unlikely but possible cause of her symptoms. She was commenced on aspirin. A plan was made for Mrs. Moret-Dell to be referred to the TIA clinic which subsequently was not made through the correct pathway. On 3rd January 2024 Mrs Moret-Dell’s GP surgery contacted West Suffolk Hospital asking them to confirm whether she had a TIA clinic appointment booked. The TIA clinic team received a request to review Mrs Moret-Dell on 4th January 2024 contacting her in turn on 5th January 2024 offering her an appointment that day, which Mrs Moret-Dell was unable to attend. An appointment was arranged for 11th January 2024. In the early hours of 8th January 2024 Mrs Moret-Dell collapsed at home when getting out of bed. She was attended by ambulance paramedics who found her to be alert, have left sided weakness and slurred speech. She was admitted by ambulance to the West Suffolk Hospital emergency department. A CT head scan showed no abnormalities. She then developed bilateral arm and leg weakness, Regulation 28 – After Inquest Document Template Updated 30/07/2021 was unable to speak and had a progressive deterioration in her consciousness level requiring intubation and admission to the intensive therapy unit. A CT angiogram (CTA) was obtained which showed occlusion of the left internal carotid artery (ICA). Mrs Moret-Dell was discussed with the Addenbrookes Hospital stroke team and transferred on the afternoon 8th January 2024 for further assessment for possible thrombectomy in a late (6-24 hour) time window. A repeat CT angiography at Addenbrookes Hospital showed right anterior circulation artery and distal right middle cerebral artery occlusions as well as the left ICA occlusion. A CT perfusion scan showed bilateral hemispheric ischaemic strokes with no salvageable tissue and a thrombectomy was therefore not undertaken. Mrs Moret-Dell was transferred to the neurocritical care unit where she sadly died on 10th January 2024. A postmortem examination of Mrs. MORET-DELL’s body established that her medical cause of death was due to a Bilateral Embolic Stroke. Lauren Rae MORET-DELL died due to the effects of a Bilateral Embolic Stroke, a naturally occurring condition. The medical cause of death was confirmed as: 1a Bilateral Embolic Stroke 2 Type 1 Diabetes Mellitus 4 CIRCUMSTANCES OF THE DEATH Narrative Conclusion see part 4 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: West Suffolk Hospital NHS Foundation Trust During the course of the Inquest evidence was heard that neither the treating consultant, nor specialist doctors working in the team that treated Mrs. Moret-Dell on the 23rd December 2023 were proficient in the process to make referrals to the Transient Ischaemic Attack (TIA) Clinic. Evidence was also heard as to the importance of timely referrals to the TIA clinic in line with National Institute of Clinical Excellence (NICE) Guidance. Although the failure to refer Mrs. Moret-Dell to the TIA Clinic in a timely manner was not causative of her death, I am concerned that in another case the failure to correctly understand and implement TIA Clinic referrals in a timely manner gives rise to a risk of death. Suffolk and North East Essex Integrated Care Board Evidence was heard at the Inquest that the out of hour provision for stroke care did not include West Suffolk Hospital based stroke consultant input, this being obtained either through an approach to Addenbrookes Hospital, Cambridge, or other specialist hospitals in London. Due to the distances and time involved to Regulation 28 – After Inquest Document Template Updated 30/07/2021 subsequently transport patients to specialist centres, the lack of access to stroke consultant input adversely impacts on the treatment of stroke patients during out of hours. I am concerned that the lack of commissioned stroke consultant input during out of periods at west Suffolk Hospital gives rise to a risk of death. 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 April 1st, 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 of Lauren Rae MORET-DELL I have also sent it to Care Quality Commission who may find it useful or of interest. 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. 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. 9 Dated: 04/02/2026 Darren STEWART OBE HM Area Coroner for Suffolk 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.
31 March 2026 Mr Darren Stewart, OBE HM Area Coroner for Suffolk Ipswich Coroner’s Court Beacon House Whitehouse Road Ipswich Suffolk IP1 5PB Dear Mr Stewart West Suffolk NHS Foundation Trust Hardwick Lane Bury St Edmunds Suffolk IP33 2QZ Response relating to Regulation 28 Report into the death of Mrs Lauren Moret-Dell We write further to the report dated 4 February 2026, issued following your inquest into the death of Mrs Moret-Dell. This is a joint response prepared on behalf of both West Suffolk NHS Foundation Trust (WSFT) and the Suffolk and North East Essex Integrated Care Board (ICB). Both organisations acknowledge HM Coroner’s concerns and are grateful for the opportunity to outline the actions taken to address them. In advance of responding to the specific concerns raised in your report, we would like to express our deep condolences to Mrs Moret-Dell’s family. We are keen to assure Mrs Moret-Dell’s family that the concerns you have raised have been listened to, reviewed and reflected upon. Please find below details of the ongoing work to address your concerns, which we hope is of some small comfort to Mrs Moret-Dell’s family and friends. WSFT Response Matter of Concern: TIA referral HM Coroner expressed concern that clinicians involved in Mrs Moret Dell’s care on 23 December 2023 were not proficient in the process to make referrals to the Transient Ischaemic Attack (TIA) Clinic, leading to an incorrect referral route being used. ‑ The following 6 actions have been taken by the Stroke team at WSFT in respect of this matter to address your concern: - 1 Immediate reinforcement of correct TIA referral pathway Following the identification of the incorrect referral route, Sister Joana Proenca (Lead Nurse, ESOT) immediately contacted the responsible medical team to clarify the correct TIA referral process with them. Through those discussions she has directed them to the appropriate resources on the Trust’s intranet and the learning has been shared widely throughout the medical team on the Acute Assessment Unit (AAU). 2 Updated guideline including flow diagrams The Trust has updated the TIA referral guideline to improve clarity around the process. It has also introduced new flow diagrams and streamlined the actual referral process. These have been circulated across Medical, Surgical and Emergency Medicine teams. 3 Education, training, and induction improvements The guideline referred to above has been added to the induction programme for all incoming Medical Registrars so that each new cohort of resident doctors will be taught the correct referral process for when a TIA is suspected. In addition to the above we have undertaken the following: - • The Stroke referral processes are reinforced within the Emergency Department mandatory training. • An e learning video and presentation has been created to support early identification of stroke/TIA. ‑ 4 Communication reminders Trust The Stroke team have conducted targeted internal communications to other areas including ED and medical teams, to remind them about the referral pathway. wide ‑ 5 24/7 access to ESOT for referral guidance Medical teams have been reminded that the Emergency Stroke Outreach Team (ESOT) is contactable 24/7 for support with referrals and can assist with form completion and pathway guidance at any time of the day. A review of how effective the TIA referral process is after this event has confirmed that this was an isolated incident. 6 Public awareness and professional reinforcement activities On World Stroke Day, additional internal communications are delivered Trust wide, reinforcing the #ActFAST message. This also now includes emphasising timely TIA referrals. The next initiative is planned for May 2026 with the support from the Stroke Association, where the issue will be raised again. ‑ Matter of Concern: Out of Hours Stroke Consultant Access Although this specific concern is addressed to the ICB, who have responded below, we hope the following information is of assistance to HM Coroner. We hope this information provides additional assurance and supplements the detail below. The Emergency Stroke Outreach Team, including a stroke specialist nurse, are present 24 hours a day, 7 days a week in hospital. In addition to this, WSFT has access to a telemedicine service, whereby a telemedicine consultant is available remotely between 17:00–08:00 hours on weekdays, and 24 hours on weekends and bank holidays. This is primarily to support thrombolysis making. The consultant can remotely review scans, check a patient’s history, examination decision findings, and speak with the patient in real time if required. ‑ Since Mrs Moret-Dell’s case, decisions regarding both thrombolysis decisions and mechanical thrombectomy referrals are made by the telemedicine stroke consultant. This service is not universally available and is provided only to patients who meet the eligibility criteria for one or both treatments. ‑ As with most district general hospitals, WSFT does not have a local stroke consultant available to discuss all stroke referrals 24/7. However, since this case, the team have incorporated in their stroke specialists’ handover, the process of mentioning any atypical cases that were reviewed overnight. Those cases are discussed at 09:00 hours when the stroke specialist doctor starts the shift. In addition to this, the WSFT stroke consultants have agreed to be contactable during night hours for advice where a patient shows atypical or complex symptoms—even outside eligibility windows. We hope this provides assurance that stroke nurses and medical teams have rapid access to senior support. Matter of Concern: Introduction of CT Perfusion imaging CT perfusion scanning is now available 24/7, enabling an extended treatment window for thrombectomies in patients who have experienced symptoms up to 9 hours from the onset time. I hope it is clear from the above that WSFT recognises the importance of timely diagnosis and escalation in suspected TIA and stroke cases. We are committed to strengthening staff awareness, improving out hours senior support, and enhancing diagnostic capability wherever possible. of ICB Response ‑ ‑ The ICB fully acknowledges HM Area Coroner’s concerns in respect of lack of commissioned stroke consultant input for out of hours stroke services at West Suffolk NHS Foundation Trust. The West Suffolk Hospital has specialist 24/7 consultant cover for all patients presenting with a new or possible stroke. This is provided through the regional telemedicine service to assess whether patients are candidates for thrombolysis or thrombectomy. However, in line with most district general hospitals, this provision is not on site. The ICB is currently reviewing the stroke specification for WSFT in order to understand what should be in place in line with current NHS standards. We will be working with the Trust to gain assurance the service provision is strengthened to reduce risk and delays in transferring patients to specialist neurological centres. In addition, 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 sincerely, Yours sincerely, Chief Executive, WSFT Chief Executive, SNEE ICB
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