Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0331, written 12 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 | 12 Jun 2026 |
|---|---|
| Reference | 2026-0331 |
| Deceased | Suzanne Fredericks |
| Coroner | Stephen Simblett |
| Coroner area | Essex |
| Organisation named | East Suffolk and North Essex NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 2 |
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. CORONER I am Stephen Simblett, HMC Assistant Coroner, for the coroner area of Essex. 2. DATE OF REPORT 12th June 2026 3. 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. ESNEFT - East Suffolk and North Essex NHS Foundation Trust 2. Addenbrooke's Hospital 3. PFD Regulation 28 NHS You are under a duty to respond to this report within 56 days of the date of this report, namely by August 07, 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. 2 6. SUMMARY OF CORONER’S CONCERN There is a concern as to how clinicians caring for transplant patients in non- specialist hospitals can obtain sufficiently up- to- date blood test results. Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. 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 07 November 2024 I commenced an investigation into the death of Suzanne FREDERICKS aged 41. The investigation concluded at the end of the inquest on 04 June 2026. The conclusion of the inquest was that: The deceased, who had previously had a liver transplant, suffered liver and kidney problems. She was admitted into Colchester General Hospital for treatment. That treatment was unsuccessful and the deceased died in that hospital on 4th November 2024. 9. CIRCUMSTANCES OF DEATH The deceased, who had previously had a liver transplant, suffered liver and kidney problems. She was admitted into Colchester General Hospital for treatment. That treatment was unsuccessful and the deceased died in that hospital on 4th November 2024. The conclusion of the inquest was death by natural causes. The inquest heard that the complexity of this patient and the immuno- suppressant drugs that she was being treated with following her transplant was particularly challenging. The nephrologists and other specialists involved in her care needed extremely contemporaneous and informed medical information about the effects of those drugs on the patients' condition. Some of the treating doctors felt that the time taken to process laboratory results was affecting their ability to advise the appropriate clinical treatment for the deceased. 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: There is a concern as to how clinicians caring for transplant patients in non- specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results. Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning 3 sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved. 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] • Father • Partner • Associate, Clyde and Co (Representing Addenbrookes) • Deputy Claims and Inquest Manager, Addenbrookes Hospital • Legal Manager Claims and Inquests, East Suffolk and North Essex NHS Foundation Trust 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 Stephen Simblett HMC Assistant Coroner Essex 4
2 responses 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.
5 Within a local hospital pathway, CUH's role is to provide, when required, tertiary transplant expertise, specialist advice regarding appropriate pre trough tacrolimus levels and, where clinically indicated, achievable and in accordance with the patient's wishes, to work with the general hospital to facilitate transfer. The Learned Coroner heard evidence of the extensive parallel care Ms Fredericks required from the General Hospital for her acute comorbidities relating to infection, acute kidney injury, dialysis and orthopaedic issues. The identified concerns CUH is grateful for the Coroner's careful summary of the evidence at the conclusion of the inquest, noting the Coroner's recognition of the continuing involvement of CUH's transplant team during the relevant period, including the provision of specialist advice, discussions regarding transfer, and the efforts made to support Suzanne Fredericks' care despite clear barriers to engagement. The concerns in this case relate to the ability of general hospitals to obtain up to date and timely pre trough tacrolimus results. As the Coroner will be aware, Addenbrooke's Hospital is a tertiary centre and, despite this, it has been named as one of the recipients of the Prevention of Future Deaths Report. Accordingly, and in compliance with Regulation 29 of the Coroners (Investigations) Regulations 2013, CUH provides the following response based on the factual matrix available at the time of the inquest. The Response Whilst CUH had the ability to test tacrolimus levels, the samples considered during this inquest were not those for which it was responsible for testing or reporting, save for a single request on 29 October 2024. The laboratory record shows that this request was processed by CUH in a timely manner. The evidence before the inquest indicated that the General Hospital received tacrolimus results on more occasions than the single occasion on which CUH was involved. It therefore appears that the samples were being sent to another organisation for testing during the relevant period, which is ultimately a matter for the General Hospital and the testing laboratory to assure you accordingly. Furthermore, CUH does not have the power to compel the General Hospital to send its samples to CUH laboratories to the exclusion of all others. For these reasons, the identified concern regarding delayed and/or intermittent tacrolimus results is not within CUH's direct control. CUH is therefore not able to ameliorate the risk of death identified in this case. However, CUH recognises the importance of timely tacrolimus monitoring and remains willing to support any wider regional or national work to improve pathways for transplant patients receiving care outside specialist centres. 6 Conclusion In CUH's submission, it is not the appropriate organisation to address the risk of death identified by this inquest. Nevertheless, CUH recognises the importance of the issues identified and will continue to engage constructively with the parties identified, NHS England and any relevant regional or national bodies in relation to wider pathway improvement work. CUH is grateful for the opportunity to respond and remains committed to supporting safe, timely and effective care for transplant patients. Yours sincerely, Chief Medical Officer Consultant Neonatologist and with PaNDR Cambridge University Hospitals NHS Foundation Trust 7
Mr Stephen Simblett HM Assistant Coroner for Essex Essex Coroners Service Ground floor Seax House Essex County Council Victoria Road South Chelmsford CM1 1LX Dear Mr Simblett Colchester General Hospital Turner Road Colchester Essex CO4 5JL 21 August 2026 REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF SUZANNE FREDERICKS WHICH CONCLUDED ON 4 JUNE 2026 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 12 June 2026 (“the Report”). The Report highlighted concerns relating to how clinicians caring for transplant patients in non- specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results. Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved. The information presented below is intended to describe the processes and steps that can be taken by East Suffolk and North Essex NHS Foundation Trust (“ESNEFT”) to mitigate the risk of future deaths and address the concerns you have raised in respect of Colchester General Hospital. 8 TAKING, PROCESSING AND RETURNING SAMPLE RESULTS FOR TRANSPLANT PATIENTS AT COLCHESTER GENERAL HOSPITAL The Renal Unit at Colchester General Hospital are able to process most blood samples for transplant patients but at present are not able to process specialist tests, such as tacrolimus concentration. Colchester General Hospital therefore have to obtain blood samples for such tests and send them to a transplant centre to process and return results. Historically, this approach however is not standard as the blood results have often been sent to the relevant transplant centre where the transplant has taken place, with varying processes for each. The Trust has however taken the decision to standardise the practice and send all blood samples to a single point of contact that has a daily assay for tacrolimus and can prioritise a sample on request. The Trust hopes that the above information demonstrates the steps been implemented to address to the concern in respect of the taking of samples. The Trust are therefore changing the process for testing in Colchester General Hospital in order to reduce this operational risk in the future I would like to personally extend our sincerest condolences to Ms Fredericks’ 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 9
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