Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0163, written 18 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 | 18 Mar 2026 |
|---|---|
| Reference | 2026-0163 |
| Deceased | Edna Wiggett |
| Coroner | Robin Weyell |
| Coroner area | Norfolk |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | East of England Ambulance Service NHS 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: AOC- Patient Safety Specialist East of England Ambulance Service NHS Trust Whiting Way Melbourn Cambridgeshire SG8 6NA 1 CORONER I am Robin Weyell assistant coroner, for the coroner area of Norfolk 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 2025 I commenced an investigation into the death of Edna May WIGGETT aged 85. The investigation concluded at the end of the inquest on 13 March 2026. The medical cause of death was: 1a) 1b) 1c) 1d) Heart Failure Osteoporotic Fractured Neck of Femur (Operated 27.9.25); New Atrial Fibrillation Fall with Long Lie 2) Hypertension; Chronic Kidney Disease; Frailty The conclusion of the inquest was: Edna May Wiggett never recovered from essential surgery for a fractured hip and other injuries following an earlier fall at her home. The long wait she had lying on the floor waiting for an ambulance before her admission more than minimally contributed to her death. 4 CIRCUMSTANCES OF THE DEATH On Twenty-Ninth September 2025 at Norfolk and Norwich University Hospital, Colney Edna May Wiggett died from heart failure following surgery after she had had a fall at home. The long wait she had lying on the floor waiting for an ambulance more than minimally contributed to her death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (1) the failure to re-triage Mrs. Wiggett’s case and consider a re-classification following receipt of a second call providing relevant information (an increase in pain) leading to delays in the dispatch of an ambulance. 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 May 13, 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Edna May Wiggett I have also sent it to Department of Health and Social Care Care Quality Commission HSSIB Healthwatch Norfolk NHS England 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 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 by the Chief Coroner. 9 Dated: 18/03/2026 Robin WEYELL Assistant Coroner for Norfolk County Hall Regulation 28 – After Inquest Document Template Updated 30/07/2021 Martineau Lane Norwich NR1 2DH 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.
East of England Ambulance Service NHS Trust EEAST Whiting Way Melbourn SG8 6NA HM Assistant Coroner Robin Weyell Norfolk Coroner’s Office 5 May 2026 Dear HM Coroner Robin Weyell I am writing further to the inquest into the death of Edna May Wiggett, which concluded on 13 March 2026. I understand you did not call any live witnesses from EEAST to attend the inquest in respect of the handling of the 999 calls on 19 and 20 September 2025, however you did request an investigation report to address the management of the calls shortly before the inquest. This investigation report identified that, although the first 999 call received for Mrs Wiggett was triaged correctly and appropriately managed, there was a missed opportunity in respect of the second 999 call to re-triage the call based on her changing presentation. The report further confirms that EEAST was under significant operational pressure that night, arising from high call demand and delays in ambulance handovers at acute hospitals across the region. Following the inquest you issued a Regulation 28 (Preventing Future Death) report to EEAST outlining your concern that 1) the failure to re-triage Mrs Wiggett’s case and consider a re- classification following receipt of a second call providing relevant www.eastamb.nhs.uk information (an increase in pain) led to delays in the dispatch of an ambulance. A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration. Please do not hesitate to contact me should you require any further information. Yours Sincerely, Chief Executive Chief Executive: Neill Moloney Chair: Mrunal Sisodia OBE www.eastamb.nhs.uk
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