Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0195, written 2 Apr 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 Apr 2026 |
|---|---|
| Reference | 2026-0195 |
| Deceased | David Abbot |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 07 June 2024 I commenced an investigation into the death of David ABBOTT aged 72. The investigation concluded at the end of the inquest on 06 March 2026. The conclusion of the inquest was: Narrative Conclusion - David ABBOTT is remembered by his family as a ‘gentle giant’, kind, calm natured and devoted to his Family. Mr. ABBOTT was a 72-year- old man who enjoyed an active, healthy lifestyle prior to undergoing surgery on the 25th October 2023 at West Suffolk Hospital for a Transurethral Resection of his Prostate (TURP). In addition to an enlarged prostate his previous medical history included essential hypertension which was controlled through medication. Mr. ABBOTT had initially been scheduled for the TURP procedure in September 2023, however elevated blood pressure readings meant that this was rescheduled to the 25th October 2023 following adjustments to his medication which were successful in returning his blood pressure to within his target levels. The TURP procedure was successfully completed and Mr. ABBOTT was discharged the following day. Prior to his discharge, Mr. ABBOTT received advice ‘that he should not have to put any pressure or weight bear’. Mr. ABBOTT interpreted this as meaning he should keep off his feet and not mobilise, something which is contraindicated for post-operative patients following a TURP procedure. There was no medical rationale recorded for this advice and it was not indicated by any condition recorded in Mr. ABBOTT’s medical records. Nor was this advice included within the discharge documentation sent by the hospital to Mr. ABBOTT or his GP. Upon discharge, Venous Thromboembolism (VTE) Prophylaxis was not prescribed (it was not indicated) nor advice given in relation to the use of anti-embolism (TED) stockings. Following discharge, Mr. ABBOTT quickly developed discomfiture with breathing and experienced periods of back pain. This was initially likely to be due to a reaction to the general anaesthetic from the TURP procedure and an infection he contracted whilst in hospital. After the 30th October 2023, it is likely that small pulmonary emboli, which had propagated from Deep Vein Thrombosis (DVT) in his left or right calves, also contributed to these symptoms. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Between the 26th October and the 30th October 2023, Mr. ABBOTT acted on the discharge advice and did not mobilise, instead resting and keeping off his feet. It is likely that this contributed to him developing DVT in his lower legs. On the 30th October 2023 Mr. ABBOTT returned to hospital for an outpatient procedure to remove a catheter. This was performed without issue. Mr. ABBOTT continued to experience breathlessness and general weakness giving rise to him calling his GP practice on the morning of the 29th November 2023 seeking a consultation with a GP. He was called back at 09.46 hours by a GP who proceeded to conduct a telephone consultation. The outcome of this consultation was a diagnosis of an infection, likely to be upper respiratory and for which antibiotics were prescribed. He was advised to contact 999 in the event that his condition worsened. At around 15.05 hours Mr. ABBOTT called 999 complaining of respiratory distress. Ambulance attended his residence at 15.18 hours where Mr. ABBOTT was found collapsed and in cardiac arrest. Resuscitation attempts were commenced, however these were unsuccessful and Mr. ABBOTT was pronounced deceased at the scene. A postmortem examination determined Mr. ABBOTT died from the effects of a Pulmonary Embolism, a naturally occurring condition. It is likely that shortly before 15.00 hours on the 29th November 2023, Mr. ABBOTT suffered a massive pulmonary embolism which led to his death. The medical cause of death was confirmed as: 1a Pulmonary Embolism 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 Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was to not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings. At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable, impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a Regulation 28 – After Inquest Document Template Updated 30/07/2021 follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible., By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptable to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs. I am concerned that one or both of the following has occurred: a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge. If this is the scenario, there would appear to be no assurrance mechanism in place to identify and remedy any error. I am further concerned that the 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. 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 28, 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 The Family of Mr. ABBOTT Unity Healthcare 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 02/04/2026 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.
15 June 2026
Darren Stewart
HM Area Coroner for Suffolk
Ipswich Coroner’s Court
Beacon House
Whitehouse Road
Ipswich
Suffolk
IP1 5PB
West Suffolk NHS Foundation Trust
Hardwick Lane
Bury St Edmunds
Suffolk
IP33 2QZ
www.wsh.nhs.uk
Dear HM Coroner,
WSFT information relating to Regulation 28 Report into the death of
David Abbott
I write further to the Regulation 28 Report dated 2 April 2026 issued following your inquest into the
death of David Abbott. West Suffolk NHS Foundation Trust (WSFT) acknowledges HM Coroner’s
concerns and is grateful for the opportunity to outline the actions taken and those ongoing to reduce
the risk of future deaths.
In advance of responding to the specific concerns raised in your Report, we would like to express our
deep condolences to Mr Abbott’s family and loved ones. WSFT are keen to assure the family, and HM
Coroner, that the concerns raised have been listened to and reflected upon.
Please find below details of the ongoing work to address your concerns, which we hope is of some
small comfort to Mr Abbott’s family and friends.
The wrong advice has been provided to a patient on discharge which has exposed them to
1.
increased risk.
We acknowledge the concern regarding the provision of incorrect or potentially misleading discharge
advice, specifically the distinction between “avoiding heavy
lifting” and “avoiding weight
bearing/mobilisation.”
This case has been formally discussed at the Urology Governance Afternoon, ensuring dissemination
of learning across the team and reinforcing the importance of clear and accurate discharge advice.
Since 2024, a standardised discharge summary process has been implemented within the Trust. This
utilises #tag functionality, allowing clinicians to insert pre-approved, standardised advice directly into
discharge documentation.
This replaces previous practice where advice may have been manually copied and pasted from ward
notes. The use of standardised text reduces variability and the risk of misinterpreted, incorrect or
inconsistent instructions.
Junior doctors receive training on the use of #tags during their induction, ensuring early awareness and
consistent application in clinical practice.
Patients undergoing TURP procedures receive written information leaflets at pre-assessment, which
includes guidance on post-operative activity. This information leaflet gives the following guidance:
“You should avoid heavy lifting or strenuous exercise for about a month”.
The #tag functionality in the discharge letter provides the following information to supplement the
information leaflet given at pre-assessment:
“Following your general anaesthetic: for 48 hours - do not drive a car / motorbike, ride a bicycle,
operate power tools or heavy machinery. Do not make vital decisions or sign legal documents.
Do not stand up quickly as you may become light-headed. Do not smoke, drink alcohol, take
recreational drugs or sleeping tablets. You may feel sick or vomit.
It is normal to see some blood and debris in the urine for the next few weeks. Drink 2-3 litres of
watery fluid / day, for the next 48 hours, to flush this out (unless you have been recommended
to be fluid restricted for other reasons).
You may notice some burning, increased urinary frequency and pain in the lower abdomen, but
this usually settles over the next few days, and pain can be treated with Paracetamol.
Some loss of control is common in the early days, so it is helpful to start pelvic floor exercises
as soon as possible; these can improve your control when you get home. The symptoms of an
overactive bladder (frequent & urgent urination) can take up to three months to settle, whereas
the flow of urine is usually improved immediately.
If bleeding is heavy, you see blood clots in the urine, you have temperature above 37.5 degrees
Celsius, your urine is cloudy / smelly, or you are unable to pass urine, please return to A&E for
review.
If your work involves heavy lifting or manual work you should ask for a sick note or altered duties
for 4 weeks to avoid heavy exertion and reduce the risk of further bleeding.
If you are discharged with a catheter, we will arrange for this to be removed at the Johanna Finn
Unit.
Your tissue samples will be analysed routinely in the laboratory, and your surgeon will contact
you with the results of this.
You will be contacted by the Urology Specialist nurses over the telephone, around 3 months
after your surgery. If you have further questions before then please contact your GP or the
Urology Specialist nurses on
.”
2. Inadequate record keeping has resulted in inaccurate records being maintained in relation to
important advice provided to patients on discharge. If this is the scenario, there would appear
to be no assurance mechanism in place to identify and remedy any error.
This incident has reinforced the importance of clear verbal and written communication at discharge.
Improving the quality of discharge letters has been a project over the last 18 months led by the
Associate Medical Director
. This has focussed on initially identifying the
barriers and the work to address them.
Through this project the barriers identified: -
• Usability of software
• Lack of workstations
• Lack of instructions
• Need for dedicated time
To address this, consultants have been requested to take ownership of the discharge process and
provide check and challenge where appropriate of draft discharge letters.
The digital team have now rectified the digital barriers and have tried to implement the enablers. We
have also put in place methods to ensure compliance can be monitored by Clinical Directors and
Clinical Leads. It is advised that this data should be discussed at departmental and divisional
governance meetings.
This is to enable staff to recognise the importance of discharge letters and rectify issues that lead to
incomplete discharge letters.
Recently, as a continuation of this project, WSFT is exploring how best it can utilise the “write to me
rather than about me” paradigm. This has been advocated by the Academy of Medical Royal Colleges
since 2018 and has just been updated. A link to the further guidance can be found here:
https://www.aomrc.org.uk/wp-content/uploads/2026/02/Please_write_to_me_0226.pdf
The “write to me” concept has been extensively discussed at senior medical leadership over the past
few years, especially in the concept of recording shared decision making. We are now exploring ways
to role this out more widely across the Trust.
3. I am further concerned that the 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.
As reported previously, we would like to highlight the continued work introducing the national ‘call for
concern’ and Martha’s rule programme. Since Mr Abbott’s death on 29 November 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.
The Critical Care Outreach Team (CCOT)
responsibilities include:
is responsible for delivering this service. Their
• 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.
In addition to the above, since April 2026 WSFT has extended its visiting hours from 10am to 8pm. This
will support improved communication with relatives and patients, as the next of kin can be present
during ward rounds and thus increasing the opportunity for face-to-face communication with
consultant teams.
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 Abbott’s care.
Learning from this case has been shared within the department to increase awareness and improve
clinical communication practices. Furthermore, an inquest learning bulletin will be shared to
disseminate learning further through our Mortality Oversight Group and the Medical Director’s
Bulletin.
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,
Chief Executive Officer
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