Response to Regulation 28 Report – Inquest into the Death of Mrs. Ann Caldicott: Thank you for your letter and the Regulation 28 Report following the inquest into the death of Mrs Ann Caldicott. We acknowledge the serious concerns raised regarding her care, particularly the missed opportunities to address her frailty and nutritional needs. Following the inquest in January 2025, Mrs. Caldicott’s case was discussed in detail at our clinical meeting on 3rd February 2025 and again at our multidisciplinary meeting on 22nd July 2025. We have since conducted a thorough internal review and identified several key learning points and areas for improvement. Lessons Learned
1. Early Identification of Frailty and Malnutrition There was a delay in recognising Mrs. Caldicott’s declining nutritional status and frailty. Earlier intervention may have led to better outcomes and improved suitability for potential treatment options.
2. Inadequate Multidisciplinary Involvement Opportunities to involve the frailty team, dietitians, pharmacists, and mental health or safeguarding teams were not taken in a timely manner.
3. Chronic Condition Oversight Mrs. Caldicott had chronic kidney disease, and we recognise the need for more proactive management and earlier referral to nephrology in accordance with NICE guidelines. Actions Taken Since Mrs. Caldicott’s Death We have implemented several changes across our practice to prevent similar issues in the future:
1. Frailty and Malnutrition Identification
• Regular weight and height monitoring is now in place for all patients aged 31 Manor Road

Folkestone Kent, CT20 2SE

65 and over.
• Any unintentional weight loss is immediately flagged and followed up.
• The Primary Care Network’s Frailty First Contact Practitioner (FCP) Dietitian is now actively involved in early assessments.
• Referral criteria for the FCP Dietitian have been clarified, laminated, and placed in all clinical rooms. These were also reviewed during clinical meetings.
• Unintentional weight loss is proactively investigated, with dietary supplementation considered as appropriate.
2. Strengthening the Role of the Frailty and Dietetic Teams
• Clinicians are encouraged to refer frail patients early to the dietitian and frailty teams for proactive support.
• Discussions now routinely consider whether additional input is needed from our practice pharmacist (e.g., for nutritional supplements) or from mental health or safeguarding services.
3. Chronic Kidney Disease (CKD) Management
• CKD monitoring protocols have been re-emphasised to all clinicians and are now regularly discussed in clinical meetings.
• Referrals to renal specialists are made in line with NICE guidance.
4. Improved Monitoring in Care Homes
• Our home-visiting nurse now ensures that height and weight measurements are recorded for all new care home residents.
• Any observed weight loss is followed up with appropriate investigations and dietary interventions as needed.
5. Significant Event and Death Review
• Unexpected deaths are routinely included in our clinical meeting discussions.
• However, as Mrs. Caldicott passed away in hospital following a prolonged inpatient stay, her case was not initially flagged for review. We were unaware of the full circumstances surrounding her death until the Coroner contacted us.
• We can find no record that we were formally notified by the hospital of her death or the cause. It was only upon receiving the Coroner’s request for information that the practice became aware of the details. We have shared this feedback with the Trust to support improvements in their practice.
6. Support for Vulnerable and At-Risk Groups
• Our rough sleeping policy has been updated to include assessment of nutritional status.
• We ensure that patients experiencing rough sleeping are under the care of the Rainbow Centre, where they can receive appropriate nutritional support.
• Frailty and nutritional checks are now encouraged even in non-traditional settings or populations.

• Our self-neglect policy has also been updated to include frailty and nutritional status as key considerations.
7. Listening to Family and Public Concerns
• We take seriously any concerns raised by family members or members of the public regarding our patients.
• With appropriate regard for confidentiality, we always seek to contact the patient and respond to concerns raised in a sensitive and timely manner. Ongoing Commitment These changes have already been implemented and will be reviewed again in three months to ensure their continued effectiveness and integration into our routine clinical practice. We remain committed to a culture of learning and continuous improvement, and we acknowledge our responsibility to act on the findings from this case. We extend our sincere condolences once again to Mrs. Caldicott’s family and thank the Coroner for highlighting areas where we can enhance patient safety and quality of care. (Salaried GP) (Senior Partner)

Dear Ma’am,

Regulation 28 – Prevention of Future Deaths (PFD) Response regarding the inquest into the death of Mrs Ann Caldicott

On behalf of East Kent University Hospitals NHS Foundation Trust (the “Trust”), we would like to reiterate our apology to the family of Mrs Caldicott. We want to assure the coroner and the family that steps have been and will continue to be taken to ensure that this situation does not arise again.

The matters that gave rise to the PFD and the Trust’s response to each point is outlined below:

1. Mrs Caldicott’s malnutrition and declining frailty were not investigated despite continued requests by Mrs Caldicott and her family to primary and secondary care settings. Prior to the issuing of the PFD, and as part of our expected processes, a Nutrition Trust Wide Improvement Plan (“TWIP”) had been developed for 2025/26. This followed an internal review of quality indicators across the previous year which had demonstrated inconsistent standards of nutritional care being provided, including contributing factors of gaps in staff knowledge (for example around naso-gastric feeding), and nutrition and hydration not consistently being discussed as part of the Multi-Disciplinary Team (MDT) board rounds, which can hinder timely recognition and management of these patients’ nutritional needs.

Key priorities in the TWIP include:
• Identifying essential nutrition training requirements and delivering this training to all staff groups.
• Enhanced daily ward processes to identify at-risk patients early and ensure an appropriate nutritional care plan is developed and implemented.
• Improved communication across teams and with families.

HM Coroner Sarah Clarke North East Kent Coroners Oakwood House Oakwood Road Maidstone Kent ME16 8AE

Chief Executives Office Trust Offices Kent & Canterbury Hospital Ethelbert Road Canterbury Kent CT1 3NG

In light of the coroner’s findings, the TWIP has been re-reviewed and the MDT element further strengthened, to ensure clear clinical leadership, to drive lasting improvements.

Progress and outcomes, including updates from care groups on their actions, will be regularly measured and reported to the Nutrition Steering Group on a bi-monthly basis, and to the Fundamentals of Care Committee (FOC) quarterly. Any concerns, delays, or barriers will be escalated through these reporting frameworks to ensure senior support and leadership.

We are committed to embedding these changes to ensure that nutritional care is recognised and prioritised as a fundamental aspect of patient safety and quality across the Trust, with the goal of improving patient outcomes and preventing future harm.

The Trust is also committed to ensuring family concerns are listened to and a guideline for clinicians for the implementation of Martha’s Rule was approved in July 2025 and is now actively being used by families and clinicians. A copy of the Trust’s guideline can be provided on request.

Action: Complete and ongoing

2. Mrs Caldicott marked anaemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary.

Mrs Caldicott was identified to have been losing weight and anaemic during a hospital attendance in January 2023. Investigations were undertaken and she was referred to the outpatient gastroenterology team. She was also under the care of the diabetic and endocrine team. It is likely that Mrs Caldicott’s anaemia was as a result of her other chronic health conditions. No specific gastro-intestinal cause of anaemia or weight loss were identified. Also, no underlying cancer diagnosis was identified on CT, gastroscopy and sigmoidoscopy.

However, there was potentially a missed opportunity to consider Mrs Caldicott’s declining health more holistically. Weight loss and anaemia are likely to have been consequences of Mrs Calidcott’s chronic health conditions. Her general condition had declined significantly over the few months leading up to her death. Whilst nutritional state and anaemia were factors in decision making about treatment options for the perforated bladder, there were other serious co- morbidities and current acute kidney injury which also impacted.

A multi professional review of the 12 months care and treatment preceding her admission late 2023 will take place. This is described further later in this letter.

Action: Complete

3. No internal investigations were conducted by Mrs Caldicott’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Mrs Caldicott’s Death. The Trust has found several points at which an investigation could have been triggered into the care Mrs Caldicott received. Unfortunately, there were missed opportunities meaning that some of the issues only came to light during the Inquest itself and beyond. We apologise to Mrs Caldicott’s family in this regard.

We have highlighted this case to the Lead Medical Examiner as the first point at which it was felt a Structured Judgement Review could have taken place. If this had happened then it would have triggered many other actions and the Trust could have learned from this case earlier than it has now. Individual feedback has been provided and additional support will be provided to the Medical Examiner team to allow them to better identify cases for further investigation. Regrettably, the clinician who gave evidence at the Inquest did not raise a Datix and therefore, once again, the opportunity to investigate and learn was lost. We apologise that this wasn’t completed in a timely manner but the clinicians have been received feedback and they have reflected on the importance of raising incidents for learning and improvement. The Trust realises this is not reassuring but we believe this to be an isolated incident. However, as part of our commitment to improving governance and patient safety, the Trust will continue to review learning from incidents, complaints, claims and inquests. Action: Ongoing
4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Mrs Caldicott’s death. The Dr providing evidence was to raise a Datix in relation to Mrs Caldicott’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place.

See above.

Action: Ongoing

5. No consideration was given prior to Mrs Caldicott’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Mrs Caldicott’s nutritional status.

Mrs Caldicott was identified to have been losing weight and anaemic during a hospital admission in late 2022. Investigations are undertaken and she was referred to the outpatient gastroenterology team. She was also under the care of the diabetic and endocrine team. It is likely that Mrs Caldicott’s anaemia was as a result of her other chronic health conditions. No specific gastro intestinal cause of anaemia or weight loss were identified. No underlying cancer diagnosis was identified on CT, gastroscopy and sigmoidoscopy.

We believe that the Manor Clinic can also respond in this regard as her primary care provider.

6. If Mrs Caldicott had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation.

The Trust feels this is an opinion better suited for an expert to determine and not one that requires action per se. However, the William Harvey Clinical lead for Nutrition Dr Helen Mackie, consultant gastroenterologist has stated, that it is difficult to say with any certainty what the probability would have been.

On review of Mrs Caldicott’s hospital records from January 23 to the time of her death she was seen by several specialities. She had a number of chronic health conditions which may have been contributory to her cachexia and weight loss. Hyperthyroidism, Diabetes Mellitus, hypertension, generalised atherosclerotic disease, brain small vessel disease, and latterly, acute kidney injury.

Investigations did not identify a cancer diagnosis nor any other clear cause of her weight loss. She was also anaemic and this was a chronic anaemic most likely due to underlying chronic health conditions.

Even if her nutritional state had been optimised earlier, it is impossible to speculate if that optimisation would have improved her general health to the level of further live-saving treatment. It is likely that her other health conditions were the drivers of her poor nutritional state rather that a consequence of it.

We will be undertaking a full multi-professional case note review of Mrs Caldicott’s care and treatment in the months preceding her admission which will ascertain if her continuing decline in health could have been identified earlier in a more holistic manor. We anticipate that this will take 2 months and we will inform the family of the outcome of this review. Action: ongoing. We hope that we have assured you that whilst the Trust has not completed all of the actions that you have identified, we are learning and improving and sincerely hope that a case such as Mrs Caldicott’s does not happen again.