David Fenn
PFD Report
Partially Responded
Ref: 2026-0145
Coroner's Concerns (AI summary)
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to challenge decisions, leading to critical omissions in care.
View full coroner's concerns
On the 28th January 2025:
1) Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed.
2) An early Consultant Review was not sought.
3) The later attempt to seek the Consultant's views was hampered by the use of a mobile phone which had poor signal in the operating theatre and crucial information was not fully imparted/understood.
4) The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.
5) An alternative Consultant's opinion was not sought.
6) The Multi Disciplinary Team meeting the following morning did not discuss Mr Fenn's case when it should have.
1) Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed.
2) An early Consultant Review was not sought.
3) The later attempt to seek the Consultant's views was hampered by the use of a mobile phone which had poor signal in the operating theatre and crucial information was not fully imparted/understood.
4) The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.
5) An alternative Consultant's opinion was not sought.
6) The Multi Disciplinary Team meeting the following morning did not discuss Mr Fenn's case when it should have.
Responses
Action Taken
• The Trust implemented a new electronic patient record system, Epic, in October 2025. • The system consolidates patient notes into one record for clinical and administrative data. (AI summary)
• The Trust implemented a new electronic patient record system, Epic, in October 2025. • The system consolidates patient notes into one record for clinical and administrative data. (AI summary)
View full response
Dear Mr Brookes
REGULATION 28 TO PREVENT DEATHS - INQUEST TOUCHING UPON THE DEATH OF DAVID JAMES FENN, INQUEST 25 FEBRUARY 2026
I write on behalf of ESNEFT in response to the Prevention of Future Deaths Report dated 27 February 2026, issued pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the coroners (Investigations) Regulations 2013.
The concerns identified relate to a poor communication between the On-Call Consultant and the Registrar, which resulted in the discharge of the deceased from hospital, when he should have been admitted.
The Trust fully recognises the importance of clear and direct communications, especially when matters are being escalated to consultants for their clinical input.
The Trust remains committed to continuous improvement in the quality and safety of care provided to patients and their families.
The information presented below is intended to describe the actions which have been taken/are being taken by the Trust to mitigate the risk of future deaths and address the concerns you have raised.
SEPSIS 6 PATHWAY
When a patient’s NEWS score is calculated as being above 2, the treating clinician needs to answer several sets of questions about the patient’s presentation, to determine whether the ‘sepsis 6 bundle’ should be commenced. The bundle should begin within 1 hour of recognition.
Prior to October 2025 when implementing the Sepsis 6 pathway, Trust clinicians were guided by a flow sheet document placed on each patient file. The document had to be completed by hand and then signed off by the consultant prior to the bundle being started.
Since October 2025, the Trust has implemented a new electronic patient record system, Epic. The Trust has consolidated a vast number of separate systems into one sole system that encompasses all the patient notes. This provides unified, one record per patient for all clinical and administrative data. The impact for patients is as follows: Safer care Better appointment coordination Access via MyChart Improved outcomes Less repetition A lifelong record Secure storage Better communication Streamlined care MyChart app for health record visibility, including a proxy access option Documents and processes which historically were in paper format are now electronic.
With regards the Sepsis 6 pathway, Epic prompts the user to consider sepsis and provides data entry fields to be completed, replacing the flowsheet. The clinician entering the information cannot move past the fields without completing them correctly and following through with the treatment plan. Where the data has not been entered correctly, or not
completed in full, Epic will send a notification to a senior team member to enable an intervention.
Epic is auditable, the Trust completes a monthly data collection for the accountability framework. Sepsis 6 compliance is measured at ward, division and Trust level. Any identified non-compliance is subject to review and appropriate remedial action through divisional governance processes.
The Trust has delivered and continues to deliver sepsis identification and action training for all staff on all wards and at all levels, as per Trust policy. The training is mandatory, forming part of all Trust inductions, with top up training sessions provided whenever there is a need.
REVIEWS AND COMMUNICATION
A clinical governance presentation took place on 13 January 2026, wherein this matter was discussed at length. The Trust is satisfied that the methods of escalation and communications in place are appropriate and that patient safety remains a priority.
Staff are actively encouraged to seek second opinions and escalate beyond their direct supervisors when they have concerns about their patients. There are consultants available 24/7, any of whom can be contacted for an opinion. Furthermore, staff can escalate as high as medical director level should they need to. Staff are encouraged to speak up from the point when they join the Trust, and this message is repeated in various forms throughout their employment.
Due to Epic EPR being a ‘live’ medical record, when a consultant is asked to review a patient, they are able to access real time medical notes from any Trust device. This means that the consultant can review remotely, whether that be from another part of the Trust, or from home if they are on call.
It is common practice within the NHS (not just within the Trust) for consultants on call to be contacted for review when they are already engaged with a patient or carrying out surgery. An on-call consultant can be contacted in several ways (depending upon the urgency), the
doctor can come to the theatre in person, they can call using Wi-Fi calling on a mobile phone or land line and Epic EPR has an inbuilt communication platform which enables easier communication and escalation of patient concerns.
If the consultant is carrying out surgery, they are able to see the most recent observations/blood results of any patient on a screen within the theatre. These can be reviewed by the consultant directly or relayed to him by one of the theatre team. It is for the consultant to determine whether they are able to carry out the review at that time. If they cannot, then there are other escalations pathways, or if the patient is stable then the review should wait until the consultant is available, with escalation pathways remaining available should the patient deteriorate.
In addition to the above, the Trust has implemented ‘Martha’s Rule’, which allows patients, families, carers and staff to request a rapid clinical review if they are concerned about a patient’s deteriorating condition. It covers communication issues and ensures that concerns about medication, investigations, or discharge planning are resolved. The three core elements of the Rule are:
1. Daily Patient Check-ins: Patients are asked at least daily about their condition, and responses are acted upon in a structured manner.
2. Rapid Review Access: Staff, patients, families, or carers can request a review from a different clinical team if concerns about deterioration are not being assessed.
3. Escalation Pathways: Hospitals provide clearly advertised routes, including dedicated phone numbers, to activate a rapid review.
KNEE MDT LIST
From May 2026 Epic will be able to auto-populate the next morning trauma list from the patient’s referred to the Trauma and Orthopaedic team, removing the risk of ‘human error’ in having to manually add or change the patients on a list.
The Trust hopes that the above information demonstrates the actions being implemented by the Trust and adequately responds to your concerns.
I would like to personally extend our sincerest condolences to David’s family for their loss.
If I can be of further assistance, please do not hesitate to contact me.
REGULATION 28 TO PREVENT DEATHS - INQUEST TOUCHING UPON THE DEATH OF DAVID JAMES FENN, INQUEST 25 FEBRUARY 2026
I write on behalf of ESNEFT in response to the Prevention of Future Deaths Report dated 27 February 2026, issued pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the coroners (Investigations) Regulations 2013.
The concerns identified relate to a poor communication between the On-Call Consultant and the Registrar, which resulted in the discharge of the deceased from hospital, when he should have been admitted.
The Trust fully recognises the importance of clear and direct communications, especially when matters are being escalated to consultants for their clinical input.
The Trust remains committed to continuous improvement in the quality and safety of care provided to patients and their families.
The information presented below is intended to describe the actions which have been taken/are being taken by the Trust to mitigate the risk of future deaths and address the concerns you have raised.
SEPSIS 6 PATHWAY
When a patient’s NEWS score is calculated as being above 2, the treating clinician needs to answer several sets of questions about the patient’s presentation, to determine whether the ‘sepsis 6 bundle’ should be commenced. The bundle should begin within 1 hour of recognition.
Prior to October 2025 when implementing the Sepsis 6 pathway, Trust clinicians were guided by a flow sheet document placed on each patient file. The document had to be completed by hand and then signed off by the consultant prior to the bundle being started.
Since October 2025, the Trust has implemented a new electronic patient record system, Epic. The Trust has consolidated a vast number of separate systems into one sole system that encompasses all the patient notes. This provides unified, one record per patient for all clinical and administrative data. The impact for patients is as follows: Safer care Better appointment coordination Access via MyChart Improved outcomes Less repetition A lifelong record Secure storage Better communication Streamlined care MyChart app for health record visibility, including a proxy access option Documents and processes which historically were in paper format are now electronic.
With regards the Sepsis 6 pathway, Epic prompts the user to consider sepsis and provides data entry fields to be completed, replacing the flowsheet. The clinician entering the information cannot move past the fields without completing them correctly and following through with the treatment plan. Where the data has not been entered correctly, or not
completed in full, Epic will send a notification to a senior team member to enable an intervention.
Epic is auditable, the Trust completes a monthly data collection for the accountability framework. Sepsis 6 compliance is measured at ward, division and Trust level. Any identified non-compliance is subject to review and appropriate remedial action through divisional governance processes.
The Trust has delivered and continues to deliver sepsis identification and action training for all staff on all wards and at all levels, as per Trust policy. The training is mandatory, forming part of all Trust inductions, with top up training sessions provided whenever there is a need.
REVIEWS AND COMMUNICATION
A clinical governance presentation took place on 13 January 2026, wherein this matter was discussed at length. The Trust is satisfied that the methods of escalation and communications in place are appropriate and that patient safety remains a priority.
Staff are actively encouraged to seek second opinions and escalate beyond their direct supervisors when they have concerns about their patients. There are consultants available 24/7, any of whom can be contacted for an opinion. Furthermore, staff can escalate as high as medical director level should they need to. Staff are encouraged to speak up from the point when they join the Trust, and this message is repeated in various forms throughout their employment.
Due to Epic EPR being a ‘live’ medical record, when a consultant is asked to review a patient, they are able to access real time medical notes from any Trust device. This means that the consultant can review remotely, whether that be from another part of the Trust, or from home if they are on call.
It is common practice within the NHS (not just within the Trust) for consultants on call to be contacted for review when they are already engaged with a patient or carrying out surgery. An on-call consultant can be contacted in several ways (depending upon the urgency), the
doctor can come to the theatre in person, they can call using Wi-Fi calling on a mobile phone or land line and Epic EPR has an inbuilt communication platform which enables easier communication and escalation of patient concerns.
If the consultant is carrying out surgery, they are able to see the most recent observations/blood results of any patient on a screen within the theatre. These can be reviewed by the consultant directly or relayed to him by one of the theatre team. It is for the consultant to determine whether they are able to carry out the review at that time. If they cannot, then there are other escalations pathways, or if the patient is stable then the review should wait until the consultant is available, with escalation pathways remaining available should the patient deteriorate.
In addition to the above, the Trust has implemented ‘Martha’s Rule’, which allows patients, families, carers and staff to request a rapid clinical review if they are concerned about a patient’s deteriorating condition. It covers communication issues and ensures that concerns about medication, investigations, or discharge planning are resolved. The three core elements of the Rule are:
1. Daily Patient Check-ins: Patients are asked at least daily about their condition, and responses are acted upon in a structured manner.
2. Rapid Review Access: Staff, patients, families, or carers can request a review from a different clinical team if concerns about deterioration are not being assessed.
3. Escalation Pathways: Hospitals provide clearly advertised routes, including dedicated phone numbers, to activate a rapid review.
KNEE MDT LIST
From May 2026 Epic will be able to auto-populate the next morning trauma list from the patient’s referred to the Trauma and Orthopaedic team, removing the risk of ‘human error’ in having to manually add or change the patients on a list.
The Trust hopes that the above information demonstrates the actions being implemented by the Trust and adequately responds to your concerns.
I would like to personally extend our sincerest condolences to David’s family for their loss.
If I can be of further assistance, please do not hesitate to contact me.
Sent To
- Colchester General Hospital
- East Suffolk and North Essex NHS Foundation Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
13 May 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 18 February 2025 I commenced an investigation into the death of David James FENN aged 68. The investigation concluded at the end of the inquest on 25 February 2026. The conclusion of the inquest was Natural Causes and it found that: "On 12th February 2025 at Colchester General Hospital, Turner Road, Colchester, Essex, David James FENN died of multi-organ failure secondary to septicaemia which was a consequence of septic arthritis of the left knee (against a background of several other significant contributing comorbidities)."
Circumstances of the Death
Hospital referral
David Fenn, a 68 years old gentleman, was admitted into A&E Dept of Colchester General Hospital on 1st February 2025 with suspected sepsis / septic left knee arthritis. He had a history of previous Total Knee Replacement followed by multiple revision surgeries over many years. His past medical history included Liver Cirrhosis with Portal Hypertension, Advanced Kidney disease Stage, and Atrial Fibrillation (on Edoxaban). Following urgent surgery on 2nd Feb he was admitted to the ICU where he required multiorgan support and antibiotics for severe sepsis but he progressively deteriorated. After ongoing family discussions about his severe condition, he was palliated due to progressive multiorgan failure and failure to respond to treatment. Sadly he died on 12th February 2025 at 10.23 hrs. The Medical Cause of Death was found to be : 1 a) Multi-Organ Failure.. 1 b) Septicaemia 1 c) Septic Arthritis Left Knee
2) Liver Cirrhosis, Portal Hypertension, Advanced Chronic Kidney Disease
The Court heard that Mr Fenn had in fact attended Colchester General Hospital a few days earlier with similar symptoms on 28th January 2025 but after several hours he was discharged home. It was accepted by the Hospital that with hindsight he should not have been discharged home and that instead the Sepsis 6 pathway should have been followed and that he should also have had urgent knee surgery to address the source of the sepsis. The Court ruled that whilst it could not be satisfied on the balance of probability that he would have survived had he not been discharged on the 28th January, it did observe that he could possibly have survived.
David Fenn, a 68 years old gentleman, was admitted into A&E Dept of Colchester General Hospital on 1st February 2025 with suspected sepsis / septic left knee arthritis. He had a history of previous Total Knee Replacement followed by multiple revision surgeries over many years. His past medical history included Liver Cirrhosis with Portal Hypertension, Advanced Kidney disease Stage, and Atrial Fibrillation (on Edoxaban). Following urgent surgery on 2nd Feb he was admitted to the ICU where he required multiorgan support and antibiotics for severe sepsis but he progressively deteriorated. After ongoing family discussions about his severe condition, he was palliated due to progressive multiorgan failure and failure to respond to treatment. Sadly he died on 12th February 2025 at 10.23 hrs. The Medical Cause of Death was found to be : 1 a) Multi-Organ Failure.. 1 b) Septicaemia 1 c) Septic Arthritis Left Knee
2) Liver Cirrhosis, Portal Hypertension, Advanced Chronic Kidney Disease
The Court heard that Mr Fenn had in fact attended Colchester General Hospital a few days earlier with similar symptoms on 28th January 2025 but after several hours he was discharged home. It was accepted by the Hospital that with hindsight he should not have been discharged home and that instead the Sepsis 6 pathway should have been followed and that he should also have had urgent knee surgery to address the source of the sepsis. The Court ruled that whilst it could not be satisfied on the balance of probability that he would have survived had he not been discharged on the 28th January, it did observe that he could possibly have survived.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.