Dear HM Coroner

Re: Response relating to Regulation 28 Report into the death of Brigitte Dominique Favre

West Suffolk NHS Foundation Trust acknowledges receipt of the Regulation 28 Report to Prevent Future Deaths issued following the inquest into the death of Mrs Brigitte Dominique Favre. This is a joint response prepared on behalf of both West Suffolk NHS Foundation Trust (WSFT) and the Integrated Care Board (ICB).

In advance of responding to the two specific concerns raised in your Report, we would like to express our deep condolences to Mrs Favre’s family and loved ones. Both the ICB and WSFT are keen to assure the family, and HM Coroner, that the concerns raised have been listened to and reflected upon.

On behalf of everyone involved in Mrs Favre’s care, we are sorry that she suffered a failed discharge so close to her death. This must have been incredibly distressing for her family to witness. Please be assured the WSFT team are doing all we can to make sure discharges are safe, timely and appropriate. No one wants any patient to suffer the discomfort of having to come back to hospital so soon after discharge, if at all possible.

Please find below details of the ongoing work date to address your two concerns, as well as some additional information which we hope is of some small comfort to Mrs Favre’s family and friends.

WSFT RESPONSE

Coroner’s Concern 1 - Provision of oncology input over weekends and out of hours to inform discharge decision-making and reduce failed discharges.

Clarification of Out-of-Hours Oncology Support The Trust would like to clarify that an out-of-hours oncology telephone advice service is available via a Service Level Agreement with Cambridge University Hospitals (CUH). This has been in existence for over 20 years and provides consultant-level oncology advice. The service is accessed through the Trust’s switchboard. The senior clinician requests to be connected to the doctor on-call for Oncology and the switchboard then make contact with CUH. WSFT is not able to offer a formal out of hours Consultant oncology service, as that would mean increasing the consultant body and resources are not available to achieve this. However, in addition to the formal arrangements, informally all WSFT Oncology consultants are happy to be contacted at any time should advice be required.

Despite the system being in place for many years, it is clear WSFT need to raise awareness of the process when dealing with complex discharges and seeking out of hours specialist advice. Therefore, the following action is being taken: -

Action o Targeted communication will be shared with ward teams, including nursing and medical staff, to highlight learning from this case and reinforce safe discharge principles for oncology patients. This will be shared through the Medical Director’s bulletin and Departmental Governance Meetings, emphasising:  The expectation that oncology advice should be sought prior to the discharge of complex oncology patients when discharge is occurring out of hours or over weekends.  A discharge criteria set by oncology consultants must be clearly documented, actively checked, and strictly adhered to prior to discharge and any areas of doubt should prompt engagement with the CUH OOH service.  Whilst not directly related, one of the Associate Medical Directors is leading a project to improve the completion of transfer of care summary letters (discharge letters). This work will help improve the discharge process and a side effect is that it should help to reduce failed discharges. This project specifically has implemented new digital solutions to make completion of discharge letters easier, as well as starting to change the way ward and board rounds work to help timely completion of documentation associated with discharge. This will be monitored through the governance processes.

Timetable To be completed by March 2026.

Coroner’s Concern 2 - Record management in the Emergency Department, including awareness of recent chemotherapy and access to hospital records.

The usual process for managing patients who have undergone chemotherapy is that all chemotherapy patients are given a contact card which they can use 24/7 to contact the nurses on G1 if they are concerned. When contacted, the nurses use the UKONS triage tool (national recognised and recommended) to assess patients. Each patient will be allocated a level of clinical priority from the symptoms that they present with and from this, advice can be given. If the patient needs to attend hospital, they are asked to go to the Emergency Department (ED). ED are contacted by the G1 staff to let them know that the patient will be attending. ED also has a dedicated area within the Medical Assessment Area that looks after patients with infections, or who require isolation from infection, since the cubicle has a positive pressure ventilation system.

Mrs Favre’s medical records do not confirm if she spoke to the Oncology team prior to her readmission on 26 January 2025. However, her medical records do confirm that she was brought in by ambulance and under the background section the following is specifically documented:

“small cell carcinoma- T4 N3 M1c

D/c [discharged] from hospital yesterday”.

The discharge letter was also available on the system and makes reference to Mrs Favre’s recent chemotherapy.

In order to answer this concern, when discussing with senior ED staff about the process of how they review medical records, we would like to share the following by way of clarification for Mrs Favre’s family about the process:

“It was known that Mrs Favre was a post-chemotherapy patient, it is noted in the clerking that that patient is a known cancer patient and because the discharge letter was available then it would be known that the patient had been on chemotherapy. I feel this is clearly visible in the ED records.

The process for treating a patient given the availability of the e-Care system is not simply to see the patient and treat as though they are a new patient, but to review the patient’s records. I am absolutely positive that this would have been done. Within about 25 minutes of arrival Mrs Favre was being given 2 antibiotics intravenously. The working diagnosis at that stage was a possible meningitis i.e. an infection. I think this is a reasonable first consideration given the clinical presentation and without any new blood results. She was thereafter investigated appropriately and was referred to the medical team for admission.”

With regards to the specific concern about the ED teams’ ability to access the wider hospital’s medical records, the ED team confirm:

“What you are asking is whether the doctor considered the records before starting treatment, my view would be that this was considered, the doctors deal with septic patients requiring urgent treatment several times per day, we are fortunate that the previous admission records are available on e-Care.

I think you can reassure the Coroner that we are aware of the issues of post-chemotherapy patients, Dr Patterson’s contribution to this has been invaluable and we are continuing to relay his message to future generations of doctors.”

Mrs Favre, was very unwell and was showing signs of a serious infection (sepsis) and antibiotics were prescribed promptly. In situations like this, the immediate clinical priority is to begin urgent treatment with antibiotics and investigate the source of the infection, as this is potentially life‑threatening. This urgent treatment would have taken priority over the administration of post chemotherapy medication. However, we are sorry that this was not expressly communicated to Mrs Favre’s family. This would have provided them with a greater understanding about the care being provided and the rationale for it. We apologise for the anxiety that was caused as a result. This was already a very distressing time and we regret this compounded those feelings.

With regards to actions and learning, the Trust’s Emergency Department Governance lead confirms that patients who are admitted via ED with sepsis or potential neutropenic sepsis are identified quickly by a well-established ED triage process and antibiotics are started rapidly, plus fluids and any relevant medications. This is a well-practiced procedure that ED staff are reminded of every few months and the new medical staff at their induction (which is delivered by the Governance Lead himself).

The ED Governance Lead goes on to confirm that discharge letters from previous admissions are available to ED clinicians and, as a matter of protocol, refer to these to guide their clinical decision making. We have referenced above in response to the first concern the work being undertaken to improve that aspect of our care which will only help the ED decision making in future.

Through our existing governance processes WSFT will continue to monitor this issue. We do this by triangulating data from various sources such as: incidents, complaints, and audit data. We use that to feed into future improvement work and priorities for the future. The team will remain vigilant for learning opportunities around this and similar issues as part of our continuous journey of improvement.

ICB RESPONSE

The ICB fully acknowledges HM Area Coroner’s concerns in respect of oncology support over weekends at West Suffolk NHS Foundation Trust, and also the patient record management in the

Emergency Department, including the ability of Emergency Department staff to interrogate records in a timely and consistent manner.

The ICB has responsibility to review and monitor all responses and improvements taken following Regulation 28 reports in respect of the services we commission. This will include the actions taken for improvement as identified in this response.

Thank you for bringing this important patient safety issue to our attention. We hope this information assists to address your concerns and please do not hesitate to contact us should you need any further information.