Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0296, written 3 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2026 |
|---|---|
| Reference | 2026-0296 |
| Deceased | David Marriott |
| Coroner | Laurinda Bower |
| Coroner area | Nottingham and Nottinghamshire |
| Organisation named | Nottingham University Hospitals 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 Miss Laurinda Bower, HM Area Coroner, for the coroner area of Nottingham City and Nottinghamshire DATE OF REPORT 3 June 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, Nottingham University Hospitals NHS Trust and , Medical Director You are under a duty to respond to this report within 56 days of the date of this report, namely by July 29, 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 1. Ensure all ED staff are familiar with the British Thoracic Society Guidelines (advising follow up chest x-rays for patients diagnosed with community acquired pneumonia in the presence of risk factors), and ensure the discharging doctors know how to arrange the same for patients being discharged from ED 2. A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED 3. Poor quality discharge summaries, a failure to have in place a system for quality assurance and a failure to share summaries with patients 7. 8. 9. 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. INVESTIGATION AND INQUEST On 22 July 2025, I commenced an investigation into the death of David MARRIOTT, aged 62. The investigation concluded at the end of the inquest on 03 June 2026. The conclusion of the inquest was that David died as a result of lung cancer for which opportunities for earlier diagnosis were missed. CIRCUMSTANCES OF DEATH David Marriott died on 18 July 2025, at City Hospital, Nottingham, as a result of metastatic lung cancer that had been diagnosed in May 2025. There were multiple missed opportunities to have arranged a follow up chest x-ray post his visit to the Emergency Department on 28 February 2024. The missed opportunities were – A failure by the ED Consultant to follow the British Thoracic Society 1. Guidelines in recording a clear plan for a repeat chest x-ray in 4 to 6 weeks, on the basis that David was in the high-risk category for malignancy, and A failure by the ED department to have in place a system for reviewing 2. radiology reports that arrive after the patient has been discharged from ED (in which the radiologist here had recommended a follow up chest x-ray as the differential of malignancy could not be ruled out) A repeat chest x-ray in 2024 probably would have led to an earlier diagnosis of his cancer. However, it is likely that David would not have been a candidate for curative treatment on account of his medical frailty, even in 2024, and therefore the outcome would ultimately have remained his sad death from this disease. 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. Ensure all ED staff are familiar with the British Thoracic Society Guidelines (advising follow up chest x-rays for patients diagnosed with community acquired pneumonia in the presence of risk factors), and ensure the discharging doctors know how to arrange the same for patients being discharged from ED NICE research cites a cancer detection rate of around 2% as a result of follow-up chest x-rays performed after a diagnosis of community acquired pneumonia (CAP). It is therefore imperative that all clinicians when diagnosing CAP and drafting suitable discharge plans, consider the NICE and BTS guidance with regards to follow up chest x-ray for patients with risk factors. NICE is clear that where the patient is in the high-risk category (as David was), the clinician ought to have a discussion with the patient about the need for and benefits of performing a follow up chest x-ray once the infection has resolved to ensure there is nothing sinister. There is no evidence this discussion was held with David. If a follow up chest x-ray is clinically indicated, all clinicians need to be clear on local arrangements for such. If GPs are to be asked to facilitate the booking, this must be made clear as an action for the GP on the discharge summary, within the actions section. Simply writing “GP f/u” in the notes will not suffice. 2. A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED The Emergency Department regularly arrange chest x-rays for patients. Often, the ED Consultant will review the x-ray image in order to inform their management plan, prior to the radiology report being issued. In many instances, the patient will have been discharged from ED prior to the radiology report being made available on the system. I understand this is an acceptable and reasonable practice in ED departments given the high patient footfall, the need to discharge efficiently, and the inevitable time lag between imaging and reporting of non-urgent x-rays. However, of significant concern, is the fact that when the radiology report arrives after the patient has been discharged from ED, the requesting clinician is not required to review the report. In fact, no-one reviews the report to see whether it contains information that should alter the management plan. Here, the radiologist made a clear recommendation that a follow up chest x-ray should be arranged as he could not rule out something sinister under the infection. This report ought to have been considered by the requester, or another clinician on duty, as it would have altered David’s management plan. I am concerned that this is a long-standing issue at NUH. In 2016, the coroner issued a prevention of future death report on this topic. The coroner was assured that the introduction of nervecentre would prevent this situation. The SJCR in this case said, “There is a system failing here regarding review of images [sic reports] once a patient has been discharged from ED. This is a known issue for which solutions have been proposed, including introducing a results sign off session for ED consultants utilising EDP. The current HoS has not progressed with this solution and sadly therefore, further missed imaging results are likely and similar cases of missed opportunities for intervention are guaranteed”. It would seem, therefore, that the Trust has been aware of this risk for some time, but has failed to take action to date to seek to mitigate that risk. I understand that NUH might be an outlier in terms of ED clinicians failing to review electronic results received post-discharge and may well be acting contrary to BMA, RCEM and NHS guidance. The BMA is clear that the ordering clinician has a duty to review test results even where the patient has been discharged (whether bloods, radiology etc) (BMA Acting on electronic test results, 2024). The BMA guidance advises that this task can be delegated within a safe system of work. I understand that many large Trusts have a named Consultant of the day who will review and file all results from the previous day. Others have an IT system that alerts the ordering clinician that the report is ready so they can simply mark it for filing or action. I am not aware of other Trusts locally that simply leave specialist reports and results unread. This is an unsafe practice, and I consider there is a clear risk of future deaths should this practice continue. It seems to me that the duty to proactively promote patient care does not cease once the patient leaves the department. These reports are important and, in some cases, they will contain information that the ED Consultant missed when reviewing the image in a very busy and demanding environment, or could not have been aware of without reviewing the results. 3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such. I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning. I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient. The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified? 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: [please do not use individual’s names, but instead roles/titles] FAMILY GP NUH Trust NUH Medical Examiner Service CQC ICB 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 Miss Laurinda Bower HM Area Coroner Nottinghamshire
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.
Please ask for the Medical Director’s Personal Assistant 29 July 2026 STRICTLY CONFIDENTIAL Miss Laurinder Bower HM Area Coroner for Nottingham City and Nottinghamshire HM Coroner’s Court The Council House, Market Square, Nottingham NG1 2DT Medical Director’s Office 3rd Floor, Trust Headquarters City Hospital Campus Hucknall Road Nottingham NG5 1PB www.nuh.nhs.uk Dear Miss Bower Inquest of David Marriott: - Prevention of Future Death Report [PFDR] Response I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Death Notice issued on 3 June 2026 following the death of Mr David Marriott. May I begin with offering my sincerest condolences to David’s family for their loss. I am deeply sorry for the missed opportunities and issues highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Indeed, the Trust has agreed the resolution of recommendation 2 as a Patient Safety Priority for 2026/27. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the Inquest into the death of David. The actions either taken or planned in response to the learning from the Inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees with Executive oversight. Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust. Yours sincerely Medical Director and Responsible Officer Enc Response to the concerns identified through the PFDR Contents Concerns identified through the PFD ....................................................................................... 2 1.Ensure all ED staff are familiar with the British Thoracic Society Guidelines (advising follow up chest x-rays for patients diagnosed with community acquired pneumonia in the presence of risk factors), and ensure the discharging doctors know how to arrange the same for patients being discharged from ED ........................................................................................................ 3 2.A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED .................................................................................................... 4 3.Poor quality discharge summaries, a failure to have in place a system for quality assurance and a failure to share summaries with patients ........................................................................ 4 Summary .................................................................................................................................. 5 Appendices .............................................................................................................................. 6 Appendix 1 – 4276 Discharge to GP Guidance ........................................................................ 6 Appendix 2 – Doctor Induction ................................................................................................. 6 Appendix 3 - Key Requirements of Closed Loop Systems for ED Imaging review: .................. 6 Appendix 4 - 4192 Management of Authorisation of Provisional Radiology Reports and Addenda to Authorised Reports ............................................................................................... 6 Appendix 5 – 4288 Radiology Digital Pick-Up Codes ............................................................... 6 Appendix 6 – Risk 12594 Radiology results ordered during an Emergency Department (ED) attendance, reported post discharge, will not be reviewed, acknowledged or actioned ........... 7 Appendix 7 Trust training on medical documentation ............................................................... 7 Concerns identified through the PFD The coroner remained concerned that there were outstanding matters giving rise to concern that future deaths will occur, as follows: 1. Ensure all ED staff are familiar with the British Thoracic Society Guidelines (advising follow up chest x-rays for patients diagnosed with community acquired pneumonia in the presence of risk factors), and ensure the discharging doctors know how to arrange the same for patients being discharged from ED 2. A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED 3. Poor quality discharge summaries, a failure to have in place a system for quality assurance and a failure to share summaries with patients 1. Ensure all ED staff are familiar with the British Thoracic Society Guidelines (advising follow up chest x-rays for patients diagnosed with community acquired pneumonia in the presence of risk factors), and ensure the discharging doctors know how to arrange the same for patients being discharged from ED After agreement with GP colleagues in the community interface working group, the confirmed local process for patients discharged from the Emergency Department with pneumonia is for them to see their GP approximately 6 weeks after discharge for a clinical review and a decision about the need for repeat imaging, in line with the British Thoracic Society (BTS) guidance. The clinical review is required for compliance with BTS guidelines. Currently this process has only been agreed for ED discharged patients. Other clinical areas continue with their established local processes. This process is detailed in the “Discharge Back to General Practice from the Emergency Department Guideline” at point 9 (Appendix 1 attached). The guidance has been recirculated to the Emergency Department Medical Team by email and WhatsApp and will be included within Emergency Department Induction sessions. Information sharing with all established ED staff – new process update Multimodal reminders have been sent to ED staff, both those currently working in the department and those working as regular locums, via email and our ED Updates communications group with a PDF of the guideline included as well as a hyperlink to the guideline in the email message. Induction for new starters The College Tutor has confirmed that the governance team cover GP discharge letters at induction in our “Hot Topics” session, and they will ensure that the specifics of the guidance around pneumonia follow-up are included as part of this (attached email Appendix 2). Discharge Summary The ED respiratory speciality interface collaborative team are designing a patient information leaflet to be given to those patients being discharged with pneumonia, based on BTS guidance. This will include patient information about the need to see the GP at 6 weeks for follow-up and why this matters. This leaflet will be completed in Draft Format by end of August 2026 and is expected for publication by October 2026 and can be shared if required. Audit and Quality Assurance A quarterly audit will be designed to review patients discharged from ED with pneumonia to: Quality-assure communication with patients and GPs about need for review at 6 weeks Review rates of follow-up X-rays in line with BTS guidance The audit will be registered and live by September 2026, with first data collection planned to review 2026 Q3 (to follow departmental reminders/induction and information leaflet publication). 2. A failure to have in place a system for reviewing radiology reports that arrive after the patient has been discharge from ED The Trust has acknowledged this system gap as one of its key Patient Safety Priorities for 2026-27 and as part of this has created a Patient Safety Priority Working Group to address it. This group is co- ordinated by corporate governance teams and consists of Emergency Medicine and Radiology senior clinicians, Trust digital leads, patient safety specialists and quality improvement support. Given the scale of the challenges (average 791 daily attends to NUH ED in Q4), the workload is expected to be high and requires complex cross system working with integration into the current digital systems. Completing this work manually with current systems requires additional resource in significant excess of current capacity and is not deliverable or sustainable. The working group intends to create a fully auditable, closed-loop workflow for identifying, reviewing, communicating, escalating, and tracking all imaging investigations requested from the Emergency Department, including studies reported after discharge and studies awaiting reporting, ensuring that every clinically significant imaging finding results in documented clinical review, patient communication where necessary, appropriate follow-up action, and confirmed case closure. The specification is described (in Appendix 3) ED Discharge Imaging Results Follow-Up System The purpose will be to ensure all imaging performed on patients discharged from ED is reviewed once final radiology reports are available, and that any significant findings are acted upon promptly. This work is expected to take up to 18 months but will report monthly to Patient Safety Group. Phases include establishing the size/scope of need, review digital solutions and make any changes to the clinical systems, and address staffing resource requirements to deliver the process. In the interim, the current Conserus and ZZZZ coding (used to indicate unexpected malignancy Appendix 5 4288 – Radiology Digital Pick-Up Codes) processes will cover high-risk conditions or potential cancer diagnoses (Appendix 4). Coupled with the actions to address concern 1, this will offer a balanced/mitigated medium-term risk. This is preferred rather than creating a process in a rapid reactionary manner that would likely be inefficient and fragile with increased medium and long-term risks. 3. Poor quality discharge summaries, a failure to have in place a system for quality assurance and a failure to share summaries with patients To support flow and optimise capacity, ED discharge summaries are primarily autogenerated and are then immediately e-posted to GPs in Nottingham City and Nottinghamshire, where this is possible. Discharge summaries are not provided to patients on paper or electronically, unless e-posting is not available in which case they are printed and posted by the administrative team after attendance. Although there are advantages such as immediacy, cost saving and environmental profile, the Trust acknowledges the lack of written information for patients is a potential risk for some patients. The ED team would prefer to offer written discharge information to discharged patients to support aftercare and provide a record of attendance. Currently, staff do provide information leaflets specific to the relevant condition in many cases; for example, head injury advice leaflets. There is also consideration of using QR codes and weblinks to provide alternate access to this information when feasible within the Trust digital development program. Of note, results of blood tests and imaging from ED are already available to local practices to view through the shared electronic record system NCR (Nottingham Care Record), but it is accepted that additional narrative and patient information could strengthen the quality of communication. In the interim, the Trust has already taken feedback and held discussions with GP colleagues to establish the preferred content of e-posted letters for patients discharged from the Emergency Department back to their care, leading to an agreed template. ED colleagues are completing pharmacy team feedback regarding discharged medication documentation to update the agreed template for improved medicines safety and this is expected to be completed by end July 2026. Nervecentre will then require system updates to include a full clinician summary of attendance which will auto generated for those patients discharged directly from ED (as clinically appropriate). Integration of digital systems remains complex but the digital team are exploring the possibility of automatically sending a copy of the ED discharge letter to the patient via Synertec (would enable electronic delivery +/- printed copy if not read electronically). It is expected that this work will be completed in October 2026 and an update can be provided. Education on Medical Documentation The Trust now provides training on medical documentation as a fixed session in the annual Foundation Doctor Induction and in Resident Doctor teaching, including discharge summaries (applicable Trustwide, not just ED). The materials will be further reviewed and updated prior to the October 2026 delivery in response to this case and will emphasise the importance of robust follow up arrangements and what can reasonably be delivered by community colleagues and what needs to be delivered by NUH (current materials provided in Appendix 7). The Acute Deterioration Improvement Team will also provide an NUH intranet page with the resources. Summary The actions outlined above are intended to address the concerns identified in the Prevention of Future Deaths report. I hope this response provides both you and the family reassurance of the Trust’s commitment to learning from this case and to strengthening the safety and quality of care for our patients. Appendices Appendix 1 – 4276 Discharge to GP Guidance Discharge to GP guideline.pdf Appendix 2 – Doctor Induction Re_ Doctor induction and GP discharge letters_pneumonia follow-up.eml Appendix 3 - Key Requirements of Closed Loop Systems for ED Imaging review: Automatically identify discharged ED patients with imaging investigations (X-ray, CT, MRI, Ultrasound). Generate a daily list of: Imaging not reported at discharge. o o Final reports issued after discharge. o Significant discrepancies between ED interpretation and radiology report. Ensure all flagged reports are reviewed by an appropriate clinician (e.g. ED consultant or nominated reviewer). Categorise findings by urgency and determine required actions. Facilitate follow-up actions, including: o Contacting patients. o Notifying GPs. o Arranging ED review, outpatient follow-up, or further investigations. Maintain a clear audit trail of: o Report availability. o Review date and reviewer. o Actions taken. o Communication attempts and outcomes. Track outstanding cases and automatically escalate overdue reviews or uncompleted actions. Support governance through regular monitoring and audit. Appendix 4 - 4192 Management of Authorisation of Provisional Radiology Reports and Addenda to Authorised Reports 4192.pdf Appendix 5 – 4288 Radiology Digital Pick-Up Codes 4288.pdf Appendix 6 – Risk 12594 Radiology results ordered during an Emergency Department (ED) attendance, reported post discharge, will not be reviewed, acknowledged or actioned This risk is drafted and waiting approval through the governance processes. Expected at specialty governance August 2026 for RMOG September 2026. Appendix 7 Trust training on medical documentation Medical Documentation F1 f2.pptx Dates for teaching are: F1 20 October 2026 12:00-13:30 City Postgraduate Centre 27 October 2026 12:00-13:30 QMC Postgraduate Centre F2 22 October 2026 13:00-14:00 QMC Postgraduate Centre 29 October 2026 13:00-14:00 City Postgraduate Centre END***
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