Dear Ms Hayes

REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF MR DAVID HEFFER WHICH CONLUDED ON 23 APRIL 2025

I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 4 June 2025 (“the Report”).

The Report highlighted concerns relating to Colchester Hospital, those concerns were expressed as follows:

1. The treating doctor was not informed when Mr Heffer was readmitted with a complication of the Endoscopic Retrograde Cholangiopancreatography (ERCP), and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office.

2. The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation.

The information presented below is intended to describe the actions which have been taken/are being taken by East Suffolk and North Essex NHS Foundation Trust (“the Trust”) to mitigate the risk of future deaths and address the concerns you have raised.

The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office.

The Trust acknowledges that the treating endoscopist was not informed of Mr Heffer’s readmission with a complication. The treating endoscopist was only made aware of the readmission following contact from the coroner’s service. The Trust acknowledges this represents a missed opportunity for early clinical input from the treating endoscopist, for reflective learning regarding the case and equipment used (specifically, the stent size) and to have open discussions with Mr Heffer and his family.

The Trust acknowledges the need for better communication between clinicians. Reminders will be provided to all general surgical teams, who remain the primary team managing ERCP-related complications, as agreed unanimously at the regional ERCP Clinical Delivery Group—that where feasible, the procedural endoscopist should be informed of any complication arising from an ERCP they performed. The expectation is that a phone call should be made to inform the procedural endoscopist of the readmission. Informing procedural endoscopists of any complication arising from an ERCP they performed will be included in departmental handover guidance and reinforced through clinical education sessions.

The Trust is committed to learning from deaths. The Division has agreed to conduct a Bi-monthly Endoscopy Governance meeting at the Colchester site to align with the Governance meetings that currently take place at Ipswich Hospital and promote a consistent approach to Governance at a local level. The Bi-monthly Endoscopy Governance meeting will include a standing agenda item to review all Colchester Hospital ERCP-related complications and deaths. Minutes will be taken at these meetings and shared with all endoscopy colleagues to ensure that those who are not able to attend are informed of the discussions that have taken place and any actions required. The Division are arranging the date for the first meeting to take place at Colchester Hospital which is planned for 1st September 2025.

The Division has also implemented a cross-site ERCP Governance review meeting which takes place every three months. This meeting is attended by all ERCP clinicians at both Colchester and Ipswich Hospital and provides a forum for case studies to be reviewed, from both sites, to look at outcomes and to share any learning.

In addition to the Governance meetings outlined above, the Trust will be conducting a yearly site specific ERCP audit. This audit will be presented locally and regionally to ensure patterns are identified and lessons disseminated.

The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation.

The Trust acknowledges the concerns regarding the quality and completeness of Mr Heffer’s medical records, including legibility and availability of key clinical information. The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 2025, all ESNEFT patient record keeping will be done electronically. This will have the benefit of being more user friendly and provide greater compliance with completing documents, as the system is able to be programmed to ensure areas of information are documented before being able to proceed through the system. It is also possible to set alerts that are triggered by timeframes to ensure staff are notified of any immediate actions that need to be carried out. EPIC will allow for real time, centralised access to clinical documentation, investigations and procedure details across sites. Records within EPIC will be input electronically, they will be time stamped and legible. This will help to improve continuity and clarity of information contained within medical records.

An electronic medical records system will improve auditability and traceability of patient pathways. This will allow for prompt case review and early identification of learning. Specifically in relation to the endoscopy unit there will be structured templates and mandatory fields which include stent type and sizing. This will reduce any omissions.

The Trust hopes that the above information demonstrates the learning and training that has been implemented 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.