Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0135, written 9 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Mar 2026 |
|---|---|
| Reference | 2026-0135 |
| Deceased | Terrence Frost |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | 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 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 East Suffolk & North Essex NHS Trust 1 CORONER I am Nigel Parsley, Senior 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 22nd July 2024 I commenced an investigation into the tragic death of- Terrence FROST The investigation concluded at the end of the inquest on 5th March 2026. The conclusion of the inquest was that:- Terrence Frost, died as the result of natural causes The medical cause of death was confirmed as: 1a 1b 1c 2 Acute Pulmonary Oedema Cardiomegaly, Congestive Cardiac Failure Coronary Artery Disease, Systemic Atherosclerosis Sepsis of Uncertain Origin, Diabetes Mellitus (Type 2) 4 CIRCUMSTANCES OF THE DEATH Terrence Frost’s death was verified at 00:26 on 18th July 2024, at the Ipswich Hospital, in Ipswich, Suffolk, although Terrence’s death had occurred earlier at approximately 22:20 on 17th July 2024. On the 11th July 2024 Terrence was admitted to the Ipswich Hospital for an elective surgery (angioplasty) to improve the blood flow to his left leg and foot. Terrence was discharged on the following day 12th July 2024. On the 14th July 2024 Terrence was admitted again to the Ipswich Hospital with abdominal pain and rectal bleeding. No diagnosis was made, and as this settled spontaneously, Terrence was discharged again on the 15th July 2024. On the 16th July 2024, due to concerns raised by his family, a GP’s Paramedic conducted a home visit, and following subsequent concerning blood test results Terrence was told to go back to Ipswich Hospital as a failed discharge. After a prolonged period in the Accident and Emergency department Terrence was readmitted to the Ipswich Hospital. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Despite testing, no definitive diagnosis was made during Terrence’s final admission, and Terrence appeared reasonably stable until he suffered a sudden collapse and cardiac arrest at 21:22 on the 17th July 2024. A subsequent postmortem examination identified that Terrence suffered from significant cardiac disease (cardiomegaly and coronary artery disease) and significant vascular disease (systemic atherosclerosis). The pathologist identified that his clinical markers identified that sepsis played a factor in Terrence’s death, although evidence of any infection could not be found. 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: Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16th July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance. The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit. In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission. After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre- alert the Accident and Emergency department to his arrival. The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through. As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival. Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival. I am further concerned that evidence was heard from a clinician based at Regulation 28 – After Inquest Document Template Updated 30/07/2021 the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult, with internal hospital telephone calls frequently going unanswered. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 04 May 2026 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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 1. Terrence’s next of kin I am 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. 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 09/03/2026 Nigel PARSLEY HM Senior 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.
Mr Nigel Parsley Senior Coroner for Suffolk Suffolk Coroners Service Beacon House Whitehouse Road Ipswich Suffolk IP1 5PB Dear Mr Parsley Ipswich Hospital Heath Road Ipswich IP4 5PD 30 April 2026 REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF TERRENCE PERCY FROST WHICH CONCLUDED ON 5 MARCH 2026 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 9 March 2026 (“the Report”). The Report highlighted concerns relating to the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department, which may lead to future deaths in cases where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Mr Frost’s had at the time of his arrival. The information presented below is intended to describe the actions which have been taken by the Trust to mitigate the risk of future deaths and address the concerns you have raised. COMMUNICATIONS WITH MEDICAL ASSESSMENT UNIT/EMERGENCY DEPARTMENT PRIOR TO OCTOBER 2025 At the time of Mr Frost’s attendance, the Registrars on shift in the Medical Assessment Unit would hold a bleep. This bleep was used to receive calls from both internal and external users seeking guidance regarding the management of patients deemed to require possible management in the Medical Assessment Unit. This resulted in a significant demand and often led to long wait times for call connections, when the medical team were already responding to another call. COMMUNICATIONS WITH MEDICAL ASSESSMENT UNIT/EMERGENCY DEPARTMENT SINCE OCTOBER 2025 In October 2025, the Trust implemented a new electronic patient record system, Epic. This new electronic patient record system allows internal users to send secure messages to each other on patient records within the system. This has created a new line of communication internally and has reduced the pressure for response from the medical team for the Medical Assessment Unit providing an alternative means of communication for internal users. The bleep in the Medical Assessment Unit is now only used for external calls into the departments, increasing the capacity to answer calls in a timely manner and resulting in shorter call waiting queues. GUIDANCE GIVEN TO BLEEP HOLDERS During the Medicine Divisional staff meetings, the Divisional Director has reiterated the importance of answering the bleep calls in a timely manner, to those members of staff who hold the bleep. ACCESSING AMBULANCE SERVICE FOR CONVEYING TO HOSPITAL In circumstances where a patient is deemed to have suspected sepsis or be in a life-threatening condition presenting to a primary care provider, the expected course of action would be for the primary care provider to seek ambulance attendance to convey the patient to hospital. This would result in the ambulance service pre-alerting the Emergency Department of the patient’s attendance, through a designated hot line for ambulance pre-alerts. This enables the Emergency Department to obtain relevant information about patients, their reason for attendance, any risks, initial treatment and vital signs ahead of their arrival. The Trust hopes that the above information demonstrates the actions that have been implemented by the Trust and adequately responds to your concerns I would like to personally extend our sincerest condolences to Mr Frost’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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