Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0069, written 6 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 | 6 Feb 2026 |
|---|---|
| Reference | 2026-0069 |
| Deceased | Roger Smith |
| 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 , Chief Executive Officer, West Suffolk Hospital NHS Foundation Trust 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 October 2023 I commenced an investigation into the death of Roger Knight SMITH aged 80. The investigation concluded at the end of the inquest on 29 January 2026. The conclusion of the inquest was: Narrative Conclusion - Roger Knight SMITH was a much loved and desperately missed member of his Family. He was a man who had a great zest for life, described by his family as amazing, exceptionally intelligent, creative, kind, adventurous and funny. A person who during his life had a significant, positive impact on the lives of those around him. Mr. SMITH’s previous medical history included a diagnosis of cerebral amyloid angiopathy (CAA) following a stroke in 2012. He suffered a further stroke in 2016 which resulted in hospitalisation and from which he made a good recovery. Due to his diagnosis of and treatment for cerebral amyloid angiopathy, Mr. SMITH suffered from an increased risk of suffering from strokes. As a consequence, Mr. SMITH presented as a patient with complex considerations for his clinical care and management. Mr Smith was admitted to West Suffolk Hospital on 14th April 2023 with confusion, hallucinations and generalised weakness. He was treated with antibiotics for a clinical differential diagnosis of infection of uncertain origin. On 28th April he was commenced on steroids for a possible alternative diagnosis of vasculitis. On 1st May he developed slurred speech. A computed tomography (CT) head scan showed new multiple left intracerebral haemorrhages. He was subsequently transferred to the stroke unit where he received treatment in relation to his stroke. He subsequently developed a Clostridium Difficile (C Diff) infection and received treatment in relation to this. The speed of Mr. SMITH’s recovery was adversely affected by the fact that he was unable to engage effectively with the physiotherapy treatment offered. This was because of the inappropriate prescription and administration of baclofen over the period 27th June to the 24th July 2023. Mr. SMITH was discharged on the 21st Regulation 28 – After Inquest Document Template Updated 30/07/2021 August 2023 having been assessed as medically fit for discharge. Mr Smith was readmitted to West Suffolk Hospital on 25th August 2023 with increased bowel motion frequency and drowsiness. A diagnosis of recurrent C. Diff infection was made and treatment for this condition commenced. He was also commenced on low dose tinzaparin for venous thromboembolism (VTE) prophylaxis on the 26th August 2023. Correspondence from treating neurologists at another hospital that formed part of Mr. SMITH’s medical records and which advised against the prescription of anti- coagulation therapy was not followed. Mr. SMITH declined tinzaparin administration on the 27th and 28th August 2023. This did not prompt a discussion between clinicians and either Mr. SMITH or his family as to the reason why he had declined. Nor were alternative forms of management of the VTE risk discussed as had been the case during the 14th April to 21st August 2023 West Suffolk Hospital admission. Seven further doses of tinzaparin were administered to Mr. SMITH over the period 29th August to the 4th September 2023. On 4th September 2023 Mr. SMITH developed a fever, tachycardia, tachypnoea and reduced consciousness level. He was treated for aspiration pneumonia and sepsis. A CT head scan on 5th September 2023 showed a new large right cerebral haemorrhage with interventricular extension. A repeat CT head scan on 7th September 2023 showed an increase in the haemorrhage size and mass effect with midline shift. A palliative care referral was made. Treatment with antibiotics for pneumonia and C Diff. continued. Sadly Mr SMITH deteriorated further and died on 12th September 2023. A postmortem examination of Mr. SMITH’s body established that his medical cause of death was due to Bronchopneumonia arising from immobility due to the effects of the stroke he had suffered on the 4th September 2023. Roger Knight SMITH died due to the effects of suffering a stroke brought about by the administration of tinzaparin over the period 21st August – 4th September 2023. The medical cause of death was confirmed as: 1a Bilateral Bronchopneumonia 1b Immobility 1c Recurring Intracranial Haemorrhages 2 Cerebral Amyloid Angiopathy, Hypertension, Clostridium Difficile Infection and Coronary Arteries Atherosclerosis 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: Important information relating to advice concerning the prescription of anti-coagulation therapy (low weight molecular heparin - LWMH) for venous thromboembolism (VTE) prophylaxis and which was contained in Mr. Smith’s medical records, was not flagged for clinican attention as part of the electronic records management system in use at West Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021 Hospital. This meant that when Mr. Smith was readmitted on the 25th August 2023, this information did not form part of the reviewing consultants considerations around whether to precribe tinzaparin (LWMH) to Mr. Smith for VTE prophalaxis. He subsequently recived 8 doses of tinzaparin which contributed to him suffering a catastrophic stroke that led to his death. During both admissions to West Suffolk Hospital during the period April to August 2023, Mr. Smith and his Family fiercely advocated for considerations associated with his cerebral amyloid angiopathy (CAA) to be taken into account as part of his care and treatment. This occurred during Mr. Smith’s first admission between 14th April and 21st August 2023 with alternative management used to address the VTE risk. This did not occur during Mr. Smith’s second admission from 25th August 2023 and despite Mr. Smith declining tinzaparin on two occasions, the medication continued to be administered without adequate consideration as to why Mr. Smith had declined it or by engaging in consultation with either Mr. Smith or his Family. There was limited input from the West Suffolk Hospital stroke team into Mr. Smith’s care and treatment during the period following his admission on the 14th April 2023 until his stroke on the 1st May 2023. This was notwithstanding Mr. Smith and his Family raising on multiple occasions the increased risk of stroke to Mr. Smith due to his pre-existing CAA condition. Following his stroke on the 1st May 2023, measures taken to diagnose the stroke, move Mr. Smith to a stroke unit and correctly manage his blood pressure in accordance with NICE guidelines were slow, and with respect to blood pressure management, non-concordant with existing national stroke guidance. I am concerned that the West Suffolk Hospital patient records management system is ineffective in accurately highlighting important information which should inform patient care and treatment. I am concerned that communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment. I am concerned that effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA). 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 3rd, 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The Family of Roger Knight Smith I have also sent it to The 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: 06/02/2026 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.
West Suffolk NHS Foundation Trust
Hardwick Lane
Bury St Edmunds
Suffolk
IP33 2QZ
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
WSFT information relating to Regulation 28 Report into the death of Roger Smith
I write further to the report dated 6 February 2026, issued following your inquest into the death of Roger
Smith. West Suffolk NHS Foundation Trust (WSFT) acknowledges HM Coroner’s concerns and is
grateful for the opportunity to outline the actions taken.
In advance of responding to the specific concerns raised in your Report, we would like to express our
deep condolences to Mr Smith’s family. WSFT are keen to assure Mr Smith’s family that the concerns
raised have been listened to, reviewed and reflected upon.
Please find below details of the ongoing work to address your three concerns, which we hope is of some
small comfort to Mr Smith’s family and friends.
Coroner’s Concern 1 - I am concerned that the West Suffolk Hospital patient records management
system is ineffective in accurately highlighting important information which should inform patient care
and treatment.
This concern has been reviewed by the Digital and Medicine teams to explore if it is possible to create
a digital solution for this issue and to consider the process of adding alerts to the electronic patient
record system, known locally as eCare. Unfortunately, based on current system capabilities, it is not
possible to create an automated digital alert within eCare to warn prescribers against anticoagulating
patients with cerebral amyloid angiopathy (CAA).
that eCare does not support a universal
The Digital and Medicines
contraindication‑based alerting function (a digital pop up). Instead, alerts must be built in manually for
every individual drug. This would require bespoke configuration for each anticoagulant (of which there
are many). It is also not possible to group drugs together by class to raise a generic alert either. As a
result, it is not possible to manage a digital alert system at scale.
teams confirm
Furthermore, CAA is not listed as a contraindication for tinzaparin in the BNF (British National Formulary
– which is a comprehensive resource for healthcare professionals, featuring recommended guidance
on prescribing, dispensing, and administering medications), meaning there is no nationally recognised
evidence base on which to construct a “hard‑stop” alert. Implementing such an alert for CAA alone
would set a false expectation that the system can flag all clinical contraindications across all medicines,
which is neither possible nor safe, as prescribing decisions require a clinician’s judgement and a
patient‑specific risk–benefit assessment. When exploring what was possible the Digital team found that
deciding to prescribe anticoagulants involves a complex decision model requiring the weighing up of a
number of factors to balance the risk and benefit specifically relevant in CAA. These considerations
cannot be reliably reduced to automated rules without generating significant alert fatigue or
inappropriate overrides. For these reasons, any adjustment of practice needs to occur through clinical
pathways (e.g., updating VTE assessment guidance) rather than through an electronic prescribing alert.
After exploring the Digital option and ruling this out for the reasons above, in order to address your
concern, WSFT intends to take the following action: -
• WSFT will take forward a clinically‑led change to strengthen the visibility of risk factors within
the existing VTE assessment processes.
As the current eCare system cannot technically support contraindication‑based alerting across
all medications without creating new patient‑safety risks, the Trust will instead work through the
Thrombosis Committee to consider adding an explicit reference within the VTE assessment tool
to prompt clinicians to review “chronic conditions that may increase the bleeding risk (e.g.,
CAA).” This ensures CAA is considered during VTE prophylaxis decision‑making while
remaining consistent with national guidance and system constraints. This clinical‑governance
route will allow any agreed change to be embedded into Trust guidelines.
• The Trust will also strengthen the clarity of nursing roles and responsibilities in recognising and
escalating risks associated with patients who repeatedly refuse medication. Whilst refusals of
medication are documented by nursing staff within the electronic drug chart, this information
does not always reach the prescribing team. To address this gap, the Trust will work with senior
nursing leadership to reinforce expectations around proactive escalation, particularly where
medication is repeatedly refused, or where a patient or family expresses concerns about
treatment risk. This will include reviewing existing nursing handover processes, ensuring nurses
understand when and how to raise medication‑related concerns directly with the medical team,
and identifying opportunities to embed this into local nursing practice guidance. These steps will
complement the technical and clinical governance actions already underway and ensure that
the nursing contribution to safe VTE‑prophylaxis decision‑making is clearly defined and
consistently applied.
• There is also a Quality Improvement Project (QIP) on ‘safer handovers’ currently underway.
Although this project is looking to improve the reported safety and effectiveness of nurse-to-
nurse transfers between adult inpatient wards, part of this involves looking at how essential
information is highlighted. It is hoped this project will improve the quality of records which is
accessible to all healthcare teams and drive-up standards.
We will continue to monitor the effect of these changes outlined above and whether any further steps
are necessary to promote the safe prescribing of medication.
Coroner’s Concern 2 - I am concerned that communication processes at West Suffolk Hospital
between patients and hospital staff (including treating clinicians) are ineffective in affording patients and
their families with adequate opportunity to engage with and inform clinical decisions around their care
and treatment.
Since Mr Smith’s death on 12 September 2023, the Trust has adopted the national Call 4 Concern /
Martha’s Rule programme. As part of this initiative, it introduces a daily structured patient‑wellness
question, enabling both doctors and nurses to engage proactively with patients regarding their condition
and any emerging concerns.
The programme provides a standardised response matrix that supports staff to escalate concerns
consistently and ensures patients and families are afforded regular opportunities to contribute to
decisions about their care. After a successful pilot on wards F7 and G4, demonstrating measurable
improvement in patient–staff communication and early identification of deterioration, Martha’s Rule/Call
for Concern, was implemented at West Suffolk Hospital on 1 May 2024 across all inpatient areas. This
initiative provides patients, relatives, carers and staff with a direct route to request an independent
clinical review if they are worried about a patient’s clinical deterioration and feel their concerns have not
been adequately addressed by the ward team. Between May 2024 and February 2026, the team
received 255 calls. 73 calls were related to clinical deterioration (29%).
The Critical Care Outreach Team (CCOT) is responsible for delivering this service. Their responsibilities
include:
• Receiving all calls.
• Conducting an initial triage to assess the nature and urgency of the concern.
• Attending the relevant ward/inpatient area to speak with the individuals raising the concern.
• Liaising with the ward team to review the situation collaboratively and ensure appropriate clinical
action is taken.
• Referrals to different specialities, including intensive care if deemed necessary.
•
If required, organising/facilitating multidisciplinary teams (MDT) meetings.
This process aims to strengthen patient safety, support open communication and provides an additional
safeguard for patients experiencing clinical deterioration. I am sorry that it was not in place at the time
of Mr Smith’s care.
Coroner’s Concern 3 - I am concerned that effective procedures are not in place at West Suffolk
Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part
of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher
risk of VTE (e.g. CAA).
Another quality improvement project the Trust has focused on is working to standardise board rounds
and huddles to ensure: consistent MDT (multi-disciplinary team) presence; structured information
sharing; and, constructive challenge across medical ward areas. Through the PDSA (Plan, Do, Study,
Act) cycles, the Trust has now implemented a standardised process across general medical wards,
recognising the importance of consistent MDT engagement in supporting safe and effective patient care.
Further review work is underway with the project team to continually assess whether the project is
achieving its aim and to refine the approach further where needed. Ongoing monitoring will continue to
support improvement and help ensure that any improvements made are sustained.
In addition, medical teams have been reminded that the Early Stroke Outreach Team service is available
24/7 to provide support with referrals, including guidance on pathway requirements and assistance with
completing the necessary documentation with targeted internal communications.
To provide some additional assurance about the Trust’s ability to deliver timely specialist stroke team
input, the Trust has been awarded an A rating by the Sentinel Stroke National Audit Programme
(SSNAP) for the past six years. In our last audit, WSFT scored 94 out of 100. SSNAP audit spans the
whole journey and measures how well stroke care is being delivered.
for bringing this important patient safety
Thank you
this
information assists to address your concerns and please do not hesitate to contact us should you need
any further information.
to our attention. We hope
issue
Yours sincerely,
Chief Executive Officer
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