UK Inquiry Tracker

Suzanne Pemberton

PFD Report All Responded Ref: 2026-0003

Date of Report 5 January 2026

Coroner Sean Horstead

Coroner Area Essex

Response Deadline est. 2 March 2026

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 2 Mar 2026

Coroner's Concerns (AI summary)

The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.

View full coroner's concerns

Although, in the specific circumstances of this case, the delay in the provision of an in-person dietetic assessment was not a probable causative factor in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated: “At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.” (Emphasis added). The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The Professional Lead further reconfirmed, in terms, that outside of those hours there is simply no specialist dietetic service or cover of any kind at all for patients at CGH. In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic Team for a new business case for funding having not been taken forward). The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team). She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths.

Responses

East Suffolk and North Essex NHS Foundation Trust NHS / Health Body

3 Mar 2026

Action Planned
The Trust has undertaken a project to ensure all relevant ward areas receive consistent and compliant training related to dietetic care planning, will monitor adherence with dietetic care planning in real time, is carrying out a therapeutic review of processes, and is seeking to develop an escalation process for out of hours periods. (AI summary)

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Dear Mr Horstead REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF SUZANNE PEMBERTON WHICH CONCLUDED ON 16 DECEMBER 2025 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 5 January 2026 (“the Report”). The Report highlighted concerns relating to the specialist dietetic service or cover of any kind at all for patients at Colchester General Hospital outside of weekday working hours, i.e. between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). 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. RESOURCE ALLOCATION As an Acute Medical Trust, East Suffolk and North Essex NHS Foundation Trust (“ESNEFT”) provide a wide range of services to patients, some of which necessitate 7-day coverage, while others do not mandate a permanent presence within a 7-day period. ESNEFT must manage these competing service needs within the constraints of finite funding availability across all its services. In relation to the specialist dietetic service provision, the Trust has reviewed its position and maintain that the provision of dietetic support in the acute setting is best administered through clinical service

during the weekday working hours, and robust care plans and enteral feeding starter regimes which are available for all staff to follow outside of weekday working hours. ACTIONS BEING TAKEN BY THE TRUST To ensure that patients who may need dietetic input outside of the weekday working hours receive the right care, the Trust has undertaken a project to ensure all relevant ward areas receive consistent and compliant training related to dietetic care planning. The Trust has, through the implementation of a new electronic patient record system, the capability to monitor adherence and compliance with dietetic care planning in real time. This will now make up part of the Trust’s audit programme. This audit has been registered formally within the 2026/27 Audit Programme, which will enable regular audit cycle to give assurance on compliance and learning opportunities and feedback to the Division/Trust on areas of concern. A therapeutic review of processes is being carried out across both sites to ensure policies, procedures and practices are in line with current guidance and are implemented in a consistent approach throughout the Trust. The dietetics team are also seeking to develop an escalation process for out of hours periods, which will be compliance audited regularly. 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 Suzanne’s family for their loss. If I can be of further assistance, please do not hesitate to contact me.

Sent To

East Suffolk and North Essex NHS Foundation Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 2 Mar 2026

All responses received

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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 16th September 2024 I commenced an investigation into the death of Suzanne Pemberton, aged 61 years’. The investigation concluded at the end of the inquest on the 16th December 2025. Suzanne Pemberton died on the 16th September 2024 at Colchester General Hospital (CGH), Turner Road, Colchester, Essex from a cause of death confirmed as: (1a) pneumonia and sepsis (joint causes), arising from (1b) exacerbation of long-standing bronchiectasis; on a contributory background of (2): severe depressive disorder, malnutrition and chronic frailty. The Conclusion of the inquest was a Narrative Conclusion focussed on those aspects of the inadequate care, management and treatment provided by Essex Partnership NHS Foundation Trust (EPUT) that probably more than minimally contributed to the death.

Circumstances of the Death

Over the course of a two-year period preceding her death, there were a number of opportunities for (EPUT) staff and clinicians to escalate concerns regarding Suzanne’s mental health, as raised by those treating her in primary and secondary care for her complex physical medical needs arsing, principally, from her chronic Bronchiectasis. Suzanne’s lack of concordance with her mental and physical health medication informed a pattern of repeated and extended periods of admission as an in-patient to treat her lung infections which, over time and following each hospital discharge, led - in that non-concordance - to chronic and sustained deconditioning consequent upon depleted nutritional and physiological reserves This, in turn, directly contributed to the exacerbation of her chronic lung condition, leading to repeated infections and, ultimately, the fatal pneumonia and sepsis. The evidence confirmed that by the time of her final admission to CGH on Thursday 12th September 2024, such was the extent of the depletion of her physical and nutritional reserves and consequent extreme frailty and deconditioning, that Suzanne’s death on Monday 16th September was unlikely to be avoidable. It was apparent, however, that from her admission through until the day of her death on 16th September Suzanne had not been fully assessed in person by the CGH Dietetic team, notwithstanding that she had been referred to dietitians on Friday 13th at 09:01 hours and then re-referred, the same day, at 10:09 hours and had been deemed, when later triaged, as a Category 2 priority to be seen within 24 hours.