Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Lynn Silcock who died on 10th July 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23rd October 2025 concerning the death of Lynn Silcock on 10th July 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Lynn's family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Lynn’s care have been listened to and reflected upon.

You raised concerns that Lynn was discharged by the gastroenterology team at The Royal Shrewsbury Hospital in September 2022, without referral to the cardiology team or a plan to be referred later, and that no investigation had taken place by Shrewsbury and Telford Hospital NHS Trust (‘SATH’) as to why this had occurred and what had gone wrong.

The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed to, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.

NHS England has long recognised that omissions in information-sharing within or between healthcare organisations can contribute to poor continuity of care and lead to poor health outcomes. In 2021, NHS England developed and rolled out a national ‘Frontline Digitisation’ (FD) Programme, which aimed to support NHS Trusts in England with the procurement and deployment of Electronic Patient Record (EPR) systems. The aim of this was to support increased digital maturity of organisations and improve information sharing within and between organisations. Beyond facilitating the procurement of EPR systems, the FD Programme also provided guidance and support to ensure safe and effective deployments.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

12 December 2025

As part of this initiative, SATH secured a multi-year funding to implement a replacement Patient Administration System (PAS) and Emergency Department (ED) solution. Subsequently, in April 2024, SATH deployed the ‘System C CareFlow EPR’. EPR systems typically include locally configurable functionality to ensure that NHS Trusts can adapt them to meet their service needs. These systems can include capabilities for creating discharge summaries, patient search functions and the creation of referrals.

However, despite EPR systems being able to enhance information sharing and referrals, these processes continue to rely on the user taking the correct action and there remains a risk of oversight, which may result in incomplete discharge summaries and/or referrals not being created or sent.

To mitigate this risk, NHS Trusts should ensure that discharge and referral processes are streamlined and aligned with clinical workflows, and that these are formalised within local Standard Operating Protocols (SOPs). These workflows should be configured in a way that supports staff and should be rigorously tested, incorporated into training programmes and clearly communicated to clinical staff for them to facilitate workflows in the most efficient and effective way possible.

NHS England has requested to be included in SATH’s response to the concerns raised in your Report, and will review it to determine whether any further action is necessary.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lynn, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Westerman, Thank you for your letter dated 23rd of October 2025 issued under Regulation 28: Report to prevent future deaths, in relation to the risks you identified examining the death of the late Lynn Silcock. I write to provide details of the steps that we have taken and plan to address the issues highlighted in your letter. These issues were outlined as:
1. Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate.
2. Discharged without a cardiology clinic appointment or plan to be later rereferred.
3. There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about.
4. No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams. I have taken these points slightly out of order to provide appropriate context to then outline the actions we are taking to reduce the risk of a similar incident.

4. No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams. The case of Mrs Silcock has been raised as a Patient Safety Investigation (PSII) under the Patient Safety Incident Response framework and some of the initial work of that investigation has been used to inform the response outlined in this letter. The PSII was raised following communication between the coroner’s office and the Trust’s legal team following the issuing of Ms Silcock’s cause of death in July 2025. The legal team put in a Datix incident report which led to a review of the issues relating to Ms Silcock’s care. This led to the raising of the PSII via the Trust Executive chaired incident review group on the 4th of November 2025. Before the point in July when Ms Silcock sadly died and had a post-mortem investigation there was no indication for the Trust that an incident had occurred as the Cardiology referral had not been received and so there was no tracking on the intended pathway. A detailed review of the circumstances around the lack of referral to Cardiology has been unable to determine the exact mechanism whereby the intended referral from the medical team to Cardiology failed to occur. On this basis, the PSII has been commissioned to further understand the current risks in inpatient to outpatient referrals across SaTH clinical specialties. Further to this the PSII will also explore the likely optimum system to reduce risk of referrals being lost to help inform in the longer term the tools (likely to be digital) which can support a safe referral system which reduces risk to the lowest level reasonably practicable.
1. Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate.
2. Discharged without a cardiology clinic appointment or plan to be later rereferred.
3. There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about. Ms Silcock was admitted to SaTH in 2022 with shortness of breath. Initial blood test investigation indicated she had a low haemoglobin (ie she was anaemic). A cardiac echo investigation was undertaken which reported severe aortic stenosis. The investigation results outlined above led to discussions with gastroenterology and cardiology teams regarding ongoing investigations and care. This resulted in the decision based on the specialist’s advice to refer Ms Silcock for outpatient upper and lower gastrointestinal (GI) endoscopy to investigate potential bleeding or malignancy in the GI tract. The medical team would also refer to the outpatient service of the cardiology team for further follow up and investigation of Ms Silcock’s aortic stenosis.

The possibility of bleeding or malignancy led to the endoscopy investigations being prioritised with cardiology advising these should be completed first then cardiology would continue the process to investigate the aortic stenosis. On review it is clear there was no expectation that the gastroenterology team would be responsible for following up the referral to cardiology once Ms Silcock’s endoscopy investigations were completed. The decision to refer to the cardiology team as an outpatient is documented in the discharge letter and notes and should have occurred formally at the point of Ms Silcock’s discharge from the medical inpatient team in 2022. The process failed at the point of discharge and the referral to cardiology was lost in the system. It has not been possible despite in depth review to explain exactly where the issue arose that mean this referral was lost. It is possible to postulate a number of potential scenarios, but we do not know the precise issue that led to the missed opportunity to further investigate Ms Silcock’s stenosis. Based on the initial review of the issues around Ms Silcock’s care and the information gathered as part of the PSII we can say broadly:
• There is variation across the inpatient specialties in the Trust in terms of the process of referral to other specialties on an inpatient to outpatient basis.
• Not all specialties have a defined standard operating procedure (SOP) for these referrals which can lead to variation and potentially increase risk of referrals becoming lost.
• There is currently no standardised tool available to teams digitally which enables referrals to be made and tracked or audited to ensure follow up appointments are made. The current process of referral is largely paper based, which can increase risk. On the basis of these initial insights we have proposed two courses of action to address risk and reduce the likelihood of a similar incident occurring. One course of action is aimed at the short to medium term and the other looking for a longer term and sustainable solution to this challenge. Actions in the short to medium term: In the short to medium term the Trust’s Medical Director and Deputy Medical Director are tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a clear standard operating procedure (SOP) for inpatient to outpatient referrals. This will be documented and shared across the team with clear direction on process, roles, and responsibilities in ensuring referrals are made and a system of safety netting is in place to ensure decisions to refer to other specialties are followed through and actioned. There will be a single referral email for each speciality for referral for outpatient follow-up, the referrals within the team will then be managed in the standard way all referrals are with appropriate triage. This process will be developed over the next 3 months with SOPs developed and appropriate communications cascaded.

Actions in the long term: The Trust has an ongoing programme of digital development to implement digital systems to support clinical teams to work effectively and safely. A project feasibility request has already been raised to assess the need for a digital solution to support referral management. This is the route whereby needs are reviewed and scoped to develop proposals and business cases to place the need on the Trusts ‘digital roadmap’ (the overall programme of work to mature the Trusts digital systems). There are several potential existing systems available which may support referral processes and reduce the risk which has been highlighted by this incident. The ongoing PSII, which is likely to be completed by February, will engage clinical teams in outlining a robust and reliable referral process. This work will be used to evaluate what system is best suited to support management of referrals. It is difficult at this stage to give an indication of the timescale for development of any digital solution given the need to scope the process and available systems as well as the prioritisation of funding and scheduling such work. Thank you for bringing your concerns to my attention. I hope that you are assured that I have taken them seriously, we are investigating them appropriately and we are putting in place systems and processes to reduce future harm. If I can provide any further information, please do not hesitate to contact me at the above address.