Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0275, written 20 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 May 2026 |
|---|---|
| Reference | 2026-0275 |
| Deceased | Isaac Arrowsmith |
| Coroner | Victoria Davies |
| Coroner area | Cheshire |
| Organisation named | East Cheshire NHS Trust |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. 2. 3. CORONER I am Victoria DAVIES, Area Coroner, for the coroner area of Cheshire. DATE OF REPORT 20 May 2026 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. 4. THIS REPORT IS BEING SENT TO 1. Chief Executive, East Cheshire NHS Trust You are under a duty to respond to this report within 56 days of the date of this report, namely by July 16, 2026. I, the coroner, may extend the period if an appropriate application is made. 5. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 6. SUMMARY OF CORONER’S CONCERN The circumstances of Isaac’s death gave rise to concerns that learning from his death has not been appropriately captured and acted upon. These concerns are detailed below. 7. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. 8. INVESTIGATION AND INQUEST On 5 January 2026 I commenced an investigation into the death of Isaac Charles ARROWSMITH aged 19, who died on 2 January 2026. The investigation concluded at the end of the inquest on 20 May 2026. The conclusion of the inquest was: Died as a result of natural causes. Had Isaac been in hospital at the time of his deterioration, as he should have been, he would not have died when he did. The cause of death was 1a pulmonary embolus due to 1b deep vein thrombus and in part 2 haemoglobin Rainier disease. CIRCUMSTANCES OF DEATH 9. Isaac Arrowsmith, age 19, had a background medical condition of haemoglobin Rainier disease which put him at higher risk of developing blood clots. On 19 December 2025 Isaac was taken to Macclesfield District General Hospital by ambulance with chest pain and finding it difficult to breathe. His symptoms were largely consistent with either a chest infection or a pulmonary embolism. He was assessed and diagnosed with pneumonia, before being discharged home with antibiotics. No testing was done to exclude a pulmonary embolism. He reattended later that day as he had begun coughing up blood and was again discharged. On 31 December Isaac saw his GP who felt that a chest infection did not fully explain his ongoing symptoms, particularly given his background medical condition, and referred him for further tests. Before these could be undertaken, Isaac attended hospital again, as he was now coughing up more significant amounts of blood. He was assessed and again was felt to have a chest infection, but the doctor wanted additional investigations to assist given his lack of improvement despite treatment. A decision was made to send Isaac home, under the care of the respiratory virtual ward team for follow up in 48 hours. No referral was made to the virtual ward team that day and, had it been, it would not have been accepted and Isaac would have been admitted to hospital. Later that evening Isaac attended hospital for the fourth time as he again was coughing up further amounts of blood, and had been advised to return if this was the case. He remained in the emergency department for several hours before being clerked by the medical team in the early hours of 1 January 2026, and was sent back to the emergency department waiting room, awaiting Isaac was not made aware of the plan, consultant review on the ward round. or updated on when he would be seen. He was not seen on 1 January before he left the department at 20.45. On 2 January, Isaac deteriorated at home, becoming confused, struggling to breathe and incomprehensible. On arrival of his father, an ambulance was called and, whilst awaiting an ambulance, Isaac stopped breathing. Full resuscitation was given by attending paramedics but sadly this was unsuccessful and Isaac’s death was confirmed at 15.57. Had Isaac been admitted to hospital on 31 December, he would have been in hospital at the time of his deterioration on 2 January and would have been successfully resuscitated. The lack of referral to the virtual ward team and misunderstanding as to suitability for the team caused or contributed to Isaac’s death. I made findings that there was a lack of weight given to Isaac's underlying haematological condition and the linked risk of a clot and as such a lack of appropriate consideration of a blood clot, but it cannot be said on balance of probabilities that this caused or contributed to Isaac's death. 10. CORONER’S CONCERNS During the course of the inquest I heard evidence 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: 1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient has haemoglobin Rainier disease. I heard evidence that there was a base level of understanding amongst the emergency department team at the hospital, whereby they knew it was high red blood cells and this increased the risk of clots, but all were falsely reassured by Isaac's almost normal haemoglobin and haematocrit, the recent venesection and that Isaac was on aspirin. false reassurance and I have not heard any evidence from the trust as to how they are going to share this learning. Clearly, all clinicians cannot know the ins and outs of all rare conditions, but I was not assured or any process whereby they are aware that they need to seek further advice. I heard evidence from the Christie Hospital that they are producing an alert card for their patients to give to clinicians in emergency department settings which will assist, but not all patients will be under the Christie or have the alert card in all circumstances. I heard evidence that these are 2. Failure to identify the key causative issue in the Trust's internal investigation or internal processes The court, and most importantly Isaac's parents, became aware for the first time during the course of the evidence that the referral to the virtual ward had not been made on 31 December, and that had it been, Isaac would not have been accepted and he would have therefore remained in hospital. He would have been in hospital when he deteriorated on 2 January and would therefore have been given full, successful, resuscitation at the time, such that he would not have died when he did. There had been an internal multi disciplinary review tool undertaken which had not identified this issue. This was not a complex issue to identify, and was identified very quickly by the trust's legal team when asked during the course of the evidence. statement which suggests this was a genuine mistake, made on the back of an assumption. As well as showing lack of critical analysis, it shows a lack of understanding of the virtual ward service. The latter I understand is being addressed by the trust in light of the evidence heard at the inquest but I heard no evidence to suggest that the quality of investigation or analysis is being improved. Whilst the inquest investigation is distinct to the trust investigation, the court is reliant to a large extent on the findings and disclosures made by the trust, taking into account they have a duty of candour and a duty to the court. very important issue in care, and, if this is the case for other investigations, the opportunity to learn from issues and put in place action to prevent future deaths is lost. I am concerned that the investigation process has failed to highlight a I have received a My concern has been compounded by details of an inquest I heard on 18 May, the day before Isaac's inquest, in which questions arose about the trust's internal processes, transparency and learning and the trust legal team is aware of those details. That inquest is not the subject of this report but is additional context to the concern raised. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to Isaac’s parents, and the Care Quality Commission. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Victoria DAVIES Area Coroner for Cheshire
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.
Office of the Chief Medical Officer
Trust Headquarters
New Alderley House
Macclesfield District General Hospital
Victoria Road
Macclesfield
Cheshire
SK10 3BL
Date: 15th July 2026
Ms Victoria Davies
Area Coroner
Cheshire Coroner's Court
Museum Street
Warrington
WA1 1JX
Dear Ms Davies
Re: Inquest into the death of Mr Isaac Arrowsmith
I write regarding the inquest into the death of Mr Arrowsmith which concluded on 20th May 2026 in
which you issued a Regulation 28 Report to Prevent Future Deaths.
May we take this opportunity to express our sincere condolences to the family of Mr Arrowsmith.
I understand that the Regulation 28 Report was issued to East Cheshire NHS Trust because of your
concerns in two distinct but related areas. The first relates to the recognition and consideration of the
thrombotic risk in patients with Haemoglobin Rainier disease. The second relates to the Trust's
investigation, review and learning processes, specifically the failure to identify the key contributory
issue prior to the inquest, raising concerns regarding the effectiveness of internal investigation
arrangements in identifying, capturing and acting upon learning from patient safety incidents.
In collaboration with the acute medical team and the Patient Safety team, the Trust has carefully
considered your report. We have outlined below our response and the actions which the Trust will
undertake to reduce the risk of further harm. For clarity these are presented below in two subsections:
1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient
has haemoglobin Rainier disease.
2. Failure to identify the key causative issue in the Trust's internal investigation or internal
processes
Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient
has haemoglobin Rainier disease.
The Trust has carefully considered the Coroner’s concern regarding the recognition of thrombotic risk
in patients with rare haematological conditions, and the evidence that clinicians were reassured by
factors including normal haemoglobin and haematocrit levels, recent venesection and aspirin therapy.
The Trust recognises that clinicians will inevitably encounter uncommon conditions during their
practice and that safe care depends upon recognising when a patient's presentation, underlying
diagnosis or risk profile should prompt escalation, specialist consultation or further investigation.
The Trust recognises that a specific learning point from this case relates to awareness of thrombotic
risks associated with rare haematological disorders. On further review of Isaac’s case, the Trust
considers that this extends beyond knowledge of a single condition and relates to the cognitive
processes that influence diagnostic reasoning when patients present with uncommon or complex
underlying disorders. This is reflective of a broader patient safety issue relating to diagnostic
overshadowing and cognitive bias in clinical decision-making. Diagnostic overshadowing occurs
when a clinician misattributes new signs and symptoms to a patient’s pre-existing condition or illness.
This influences clinical judgement in a way that can unintentionally limit the active consideration of
alternative explanations for symptoms, reassessment of ongoing risks, thereby reducing the likelihood
that an alternative diagnosis will be identified.
The Trust has therefore taken a systems-based approach to identifying improvement actions that
improve awareness amongst clinicians of diagnostic overshadowing and reinforcing the importance
of seeking specialist advice when caring for patients with uncommon or complex disorders. Along
with the need for systems and processes to support healthcare professionals with their decision-
making where possible.
Improvement actions involve the following:
1. Awareness raising campaign: To raise awareness of diagnostic overshadowing and provide staff
with a practical strategy to challenge assumptions and consider alternative diagnoses, this
includes the following;
• Learning article in the staff electronic newsletter – summarising Isaac’s case and the main
learning points, linking into the ‘PAUSE before you Diagnose’ initiative. This article was
published in the electronic newsletter on 6th July 2026.
• Screen saver - Display of the 'PAUSE Before You Diagnose' message across Trust devices
to reinforce the campaign and encourage staff to apply the mnemonic in daily clinical practice.
This screensaver is scheduled to be published across all trust devices for a week on 20 July
2026.
• Video podcast - Development of a short educational podcast bringing together the learning
from Isaac's case as an example of diagnostic overshadowing, the principles of the 'PAUSE
Before You Diagnose' initiative, and guidance on when clinicians should seek specialist advice
or expert opinion when assessing patients with uncommon, complex or rare conditions. This
will be available on the Trust intranet CONNECT and sent out in a general email
communication to all staff. This podcast was filmed on 10 July 2026 and shared with staff in
the electronic newsletter on 13th July 2026
• Poster campaign - Trust-wide promotion of the 'PAUSE Before You Diagnose' initiative,
encouraging staff to consciously pause and reflect before attributing symptoms to a patient's
existing diagnosis or condition. The campaign incorporates the PAUSE mnemonic as a type
of cognitive debiasing tool, (see picture below)
The mnemonic is designed to promote diagnostic curiosity, reduce cognitive bias and diagnostic
overshadowing, and provide a structured approach to clinical reasoning that helps facilitate safer
clinical decision-making. These posters were put up in the Emergency Department and all ward areas
on 26 June 2026.
2. Strengthening education: The learning from this case extends beyond knowledge of a single rare
condition and highlights the importance of supporting clinicians to recognise potential cognitive
biases that may influence clinical decision-making. The Trust is therefore strengthening its current
continuing education programme by;
• Providing a dedicated educational session on the Trust's Grand Round programme, to be
delivered jointly with a Consultant Haematologist from The Christie. This session will focus
on haematological conditions (including Haemoglobin Rainier Disease) associated with
increased thrombotic risk, with learning from Isaac's case being used as an example to
illustrate the challenges associated with recognising and managing uncommon but
clinically significant risks. This session has been booked for 21 October 2026.
•
• Developing and delivering a focused cognitive bias awareness and debiasing session for
Emergency Department clinicians. This training will explore the impact of cognitive bias on
clinical decision-making, including diagnostic overshadowing, false reassurance and the
influence these factors can have on risk assessment, escalation and diagnostic reasoning.
This session is aimed to be delivered by 30 September 2026.
Incorporating education relating to cognitive bias, diagnostic overshadowing and clinical
debiasing strategies within its local undergraduate medical education programme. Isaac's
case will be used as a learning example to demonstrate how systems factors, human
factors and cognitive processes can influence clinical decision-making, reinforcing the
importance of maintaining diagnostic curiosity and seeking specialist advice when
managing patients with rare, complex or high-risk conditions. This education will be added
to the undergraduate medical education programme by 30 September 2026.
3. Digital Clinical System (DCS) / Electronic Patient Record (EPR) optimisation in relation to VTE:
As part of the Trust's systems-based response to this case, consideration was given to how the
functionality of the DCS could be further optimised to support clinicians in identifying and managing
patients with an increased risk of venous thromboembolism (VTE). This review extended beyond the
feasibility of implementing electronic alerts and included consideration of the existing VTE risk
assessment process, the visibility of VTE-related information within the EPR, and opportunities to
strengthen clinical prompts that support decision-making.
The Trust therefore undertook a review with the Lead Digital Nurse and the Trust VTE Group.
During this review, the feasibility of introducing an electronic alert for patients deemed to be at
increased risk of VTE was also explored. However, it was concluded that implementation of such an
alert was not feasible. This is due to there being a wide range of medical conditions, comorbidities
and clinical factors that may increase an individual's risk of thrombosis, often in varying combinations
and with different levels of significance. As a result, it would be challenging to define clear and reliable
criteria that would accurately identify all relevant patients who would require an ‘increased risk of VTE’
alert to be added to their EPR.
Furthermore, the Trust was mindful of the recognised risk of alert fatigue, whereby excessive numbers
of electronic alerts may result in important alerts receiving less attention from clinicians. The Trust
therefore concluded that introducing a broad VTE risk alert could inadvertently reduce the overall
effectiveness of the system to support clinical decision-making in this context.
Consequently, the Trust's improvement work has focused on enhancing the functionality of the
existing VTE risk assessment within the Electronic Patient Record, including exploration of an
additional assessment prompt relating to balancing the individual patient’s clotting and bleeding risk
and improving the visibility of VTE-related information within the patient record. This will strengthen
system support for clinical decision-making without creating an alert burden. This work is currently
being progressed with the Trust's Digital team in conjunction with Mid Cheshire Hospitals NHS
Foundation Trust and the Digital Clinical System suppliers, Meditech. A meeting has been scheduled
for 17th July 2026 to progress this.
Failure to identify the key causative issue in the Trust's internal investigation or internal
processes.
The Trust acknowledges and has carefully considered the concerns raised by the Coroner regarding
the identification of issues relating to the referral to the Virtual Ward service, the effectiveness of the
Trust's internal review processes, and the potential implications for organisational learning. The Trust
wishes to sincerely apologise to Isaac’s family and the Coroner that the key causative issue was not
identified in the investigation and that this was not communicated to them in advance of the inquest.
The Trust recognises the significance of these concerns, particularly in the context of ensuring that
patients, families, staff, the Coroner and the wider public can have confidence in the Trust's ability to
identify care delivery issues, undertake robust and objective investigations, learn from adverse
events, and implement meaningful improvements. The Trust fully accepts its responsibilities under
the Duty of Candour as set out within Regulation 20 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014, and its wider obligations to act in an open, honest and
transparent manner with patients, families, regulators and the Coroner.
The Trust is committed to continually reviewing and strengthening its patient safety systems and
recognises the valuable opportunity for learning presented through this Prevention of Future Deaths
Report. The Trust is focused on ensuring that opportunities for learning are identified and acted
upon so that care for patients continues to improve, risks are reduced wherever possible, and staff
are supported to deliver safe and effective care.
In Isaac's case, an Initial Patient Safety Review was undertaken and presented to the Trust's Incident
Investigation Check and Review Meeting. Following multidisciplinary discussion, it was agreed that
the case met the criteria for a Patient Safety Review and that a multidisciplinary team (MDT) review
would be the most appropriate methodology to further explore the circumstances of the case and
identify any opportunities for learning.
The MDT review was subsequently completed and presented through the Trust's governance
processes for executive review and approval.
On reflection, the Trust notes that whilst the review included representation from the Emergency
Department and Respiratory Medical teams, representation from the Virtual Ward team and nursing
staff was not sought as part of the review process. The Trust recognises that the inclusion of all
relevant professional groups and services involved in a patient safety event supports a more
comprehensive understanding of the factors influencing care and the identification of learning
opportunities. It is likely that had a member of the Virtual Ward clinical team been part of the MDT
process that the lack of formal referral would have been identified. The following improvement actions
have been put in place to address this:
1. The Trust will obtain and/or gain access to all relevant healthcare records as part of any patient
safety investigation to ensure that all relevant information is considered as part of the review
2. The introduction of a standard MDT review commissioning email template which specifies the
required clinical specialities and professional groups contributing to each review
3. Development of an MDT review quick-reference guide to provide staff with clear and
consistent guidance on undertaking patient safety MDT reviews, which is due to be completed
by 20 July 2026
4. The MDT review report template is being reviewed and will be updated to include specific
prompts relating to the review of clinical referral processes and other key areas of enquiry,
which is due to be completed by 20 July 2026
5. Delivering focused bitesize MDT review and After Action Review training through specialty
and departmental meetings to strengthen staff knowledge and promote a consistent approach
to reviews, complemented by the Trust’s dedicated full-day Patient Safety Investigation
training programme
6. Embed MDT review training as an ongoing educational resource and support Clinical Leads,
Senior Sisters and Matrons to cascade learning throughout clinical teams
This will ensure that all appropriate specialties are in attendance at future MDT reviews enabling all
issues to be identified and can be taken forward for analysis and identification of lesson learning.
The Trust has also taken steps to assure itself that learning opportunities are identified wherever care
is delivered across healthcare organisational boundaries, for example with Virtual Ward and
Telehealth services. This includes undertaking patient safety review and investigation work, in
collaboration with partner organisations, where circumstances indicate there may be opportunities to
strengthen shared learning and understanding across services and the wider integrated health
system.
All of these actions have been incorporated into the enclosed formal action plan, which will be
monitored through the Patient Safety Incident Oversight (PSIO) Meeting. The PSIO Meeting has
executive oversight and will provide assurance regarding the implementation, progress, and
effectiveness of the actions to support sustained improvement in patient safety review processes
across the Trust.
The Trust welcomes the opportunity to learn from the circumstances surrounding Isaac's death and
the concerns identified through the inquest process. We are committed to ensuring that the learning
is embedded across the organisation, supporting improvements that benefit future patients, families
and staff while strengthening the quality and safety of the services we provide. We hope the above
offers you assurance of the Trust’s ongoing commitment to managing patient safety risks and
continually improve the services we provide.
Yours sincerely
Chief Medical Officer
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