Dear Mrs Johnson,

REGULATION 28 REPORT – ABSOLUM ADOLPHUS ABRAHAM ZEPHANIA DUFFY Thank you for your letter dated 16th August 2023 enclosing your Regulation 28 Report following the inquest investigating the death of the late Mr Duffy. As required under Section 7 of your report, we have now considered your points and respond accordingly. CIRCUMSTANCES OF THE DEATH: Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 2021 when he exited from Sand Lane, Saxilby onto Doddington Road and collided with another vehicle. Paramedics attended however he died as a result of his injuries. YOUR MATTERS OF CONCERN: Your concerns listed in the Report are:
• The B1190 Tom Otter’s Lane junction with the C267 Sand Lane, Saxilby, Lincolnshire provides for the road user approaching from either direction on Sand Lane to give way to traffic on the major B1190 road. There is a restricted view of the B1190 as a road user approaches the junction. To be certain the B1190 road is clear a road user would be required to stop, however the road signage only requires a road user to give way. Would the junction be safer for road users if it displayed a stop command rather than a give way warning?

RESPONSE: We have conducted a thorough investigation into this location, with your concerns in mind. Over the last 5 years, there has been one other collision at this location. This was on the South-West junction arm, the opposite side to this collision. This was a serious collision and involved a lorry travelling South-West to North-East, not giving way at Sand Lane junction

Head of Highways Asset and Local Management Services Lincolnshire County Council County Offices Newland Lincoln LN1 1YL

Marianne Johnson HM Assistant Coroner

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with Tom Otters Lane, colliding with a car driving South-East to North-West. The collision was during foggy and wet weather at 08:00 in the morning on 17 th December 2021.

Tom Otters/Sand Lane junction is within a 60mph speed limit on all approaches. The approaches along Tom Otters Lane have both map signs and crossroad warning signs on each approach.

The warning signs from the North-West arm of the junction also have “370 yds” plates below them. The ones from the South-East arm have “Reduce Speed Now” plates below them. The North-Eastern arm, where the collision occurred, has an advanced “Give Way 300yds” sign with countdown marker signs at every 100 yards to the junction. The junction mouth itself has a large yellow backed “Give Way” warning sign on each side. There are centre lines on the approach and the give way markings at the junction.

The visibility at the junction to the South-East is approximately 220m. The visibility to the North-West is approximately 200m. There is vegetation that could be cut back to improve this further.

The Traffic Signs Regulations and General Directions deals with STOP signs. It states:
• 2.2.1.  STOP signs, other than at junctions with tramways, should be provided only where visibility is so restricted that it is essential for drivers to stop before entering the major road. The sign will be well respected only if drivers can see the need for it.

• The possibility of making a visibility improvement at a junction should always be investigated before considering a STOP sign. Restriction of visibility caused, for example, by a hedge that can be reduced in height or removed will not normally justify a STOP sign, particularly as highway authorities have powers under section 79 of the Highways Act 1980 to remove such obstructions.

• 2.2.2.  Visibility distances which a STOP sign might be considered are specified in Table 2-1. Other factors which should be taken into account include traffic volumes on both the major and minor roads, gradient of the minor road, accident record, poor alignment or any other factors which cause unusual difficulty. It does not automatically follow that STOP signs should always be provided at sites where the criteria are met.

The visibility distance below which a STOP sign might be considered at this location is 90m (based on using 85th percentile speed of 60mph) as specified in Table 2.1 of Traffic Signs Manual Chapter 3. In conclusion, as outlined above the visibility at the junction to the South-East is approximately 220m. The visibility to the North-West is approximately 200m. As such, the visibility at this junction far exceeds that required to consider a STOP sign (and would do so for any 85th percentile speed) and so on consideration, we are not proposing to change the existing GIVE WAY signage at this time.

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ACTIONS TAKEN (TO BE TAKEN):

• Vegetation at approaches to this junction will be assessed regularly by the Local Highways team, with appropriate enforcement action taken to ensure that it gives maximum visibility and does not reduce the splays when exiting onto the B1190.

Dear Sirs, RE: RESPONSE TO THE REGULATION 28 REPORT Our Client: Regenesis Health Travel Ltd We represent Regenesis Health Travel Ltd (our client or the Company), and our client authorised us to send this letter in response to the Coroner's Regulation 28 Report dated 4 September 2023 (the Report). Our Authority to Act is enclosed to this letter. I – Death of Emma Louise Morrissey Emma Louise Morrissey (Emma) engaged with our client to undergo gastric sleeve surgery in the Termessos Hospital (the Hospital) in Antalya, Turkey, on 7 July 2022 and then died the next day, on 8 July 2022. II – The Report Our client is obliged to comply with the requirements addressed in the Report. Although our client continually looks for the best outcomes for its patients, since the death of Emma, the Company has been working on developing its business operations for the sole benefit of its future patients and to prevent further deaths. III – Response to Section 5 of the Report Our client provides a detailed response for each paragraph of section 5 of the Report to give as much information as possible and support the purpose of the Report. Our client's response to each paragraph of section 5 of the Report can be found below. Paragraph 1 of the Report: "The health tourism company Regenesis UK relied upon patient self declaration of health and made no independent enquiries to satisfy themselves that Emma was fit for the gastric sleeve procedure before making the arrangement for her to have surgery at the Termessos Hospital, Antalya in Turkey." Response to Paragraph 1, Section 5 of the Report: Our Client encourages its patients to undergo health checks in the UK before a medical treatment abroad is proposed. The

Company advises the patients to visit accredited clinics, laboratories and other healthcare providers in the UK. Our client took steps to ensure that the patients are fit for the proposed treatment and added the following wording to its formal documents: "We always encourage our patients to be seen by independent local and national medical practitioners and/or clinics in the UK to ensure their suitability for the proposed medical treatments in this document. If you wish to be seen by medical practitioners and/or clinics, please contact us, and we will assist you with your enquiry." Furthermore, our client added the following wording to its formal documents: "Important note! Please give detailed information about your general health condition and medication before the operations. You will be asked to refrain from some medication before the surgery, as they may increase the risk of bleeding or other complications." All these changes were completed until the date of this letter and implemented into the business operations effective immediately. Our client declined to offer medical treatments to approximately 12 people only in October 2023 for various health-related findings of those people. One person was refused treatment when the person was found unsuitable for the proposed medical treatment as a result of the medical checks carried out at the relevant hospital in Turkey. In addition to the above measures, the prospective patients undergo further checks at the hospital/medical clinic abroad to ensure that the patients are fit for the treatment. This is a standard and mandatory measure taken by the hospital/medical clinic abroad that is fully accredited to provide medical treatment services. Paragraph 2, Section 5 of the Report: "The series of health related pre-assessment questions asked before referral to the private hospital in Turkey were unclear, as there was no evidence of a standard form produced by a medically trained source for the referring staff to refer to. The questions did not include an enquiry about family history of medical conditions such as cardiac related relevant to Emma." Response to Paragraph 2, Section 5 of the Report: Our client revised the Patient Health Questionnaire for future patients. The Company increased the number of questions in the Questionnaire from 13 to 29. Our client revised this Questionnaire with the assistance of a surgeon of a hospital in Turkey. The improvements in this form clarified the meaning of the questions. Furthermore, in the same form, the Company requires a letter or email from the patient's General Practitioner or healthcare provider in the UK to state that they are happy for the patient to undergo gastric surgery. The patients are asked the following question in the Patient Health Questionnaire: "Have you ever applied to the NHS for weight loss surgery? Are you on a waiting list or have you been declined? (please state reason for decline)" This question reveals if the patient was declined to be treated in the UK and addresses the potential issues related to the patient's medical conditions.

The enhanced form also includes the following two questions about the medical history of the patient's family: "Do you have any genetic/hereditary diseases in your family such as arthritis, diabetes, heart disease?" "Do you have any known cardiovascular problems (abnormal ecg, previous heart attack etc:" Our client placed these questions into the Questionnaire to reach a higher standard in the form and clarify the meaning. All these changes mentioned in this response were completed until the date of this letter and implemented into the business operations effective immediately. Further improvements to the Company's business operations following Emma's death
1. Document Revision: Our client is focused on improving its service quality for the sole benefit of its patients. The Company amended all its 18 documents and upgraded them to a higher standard.
2. Personal Data Protection: The Company registered its business with the Information Commissioner's Office (ICO) and drafted a Data Protection Notice for Patients to inform the patients how they deal with sensitive personal data. The Company revised its Privacy Policy & Cookies Policy and Terms of Use published on its official website on 24 July 2023.
3. Professional Accreditation and Service Standards: The Company is in the process of obtaining ISO9001 Quality Management Systems accreditation to improve its management services for the benefit of its patients. Our client estimates that this will be completed by the end of 2023. Our client will then consider obtaining ISO27001 Information Security Certification to enhance its patients' personal data protection.
4. Organisation Memberships: The Company became a member of the Medical Tourism Association and is looking to attend their webinars and events in order to exchange more information, knowledge and expertise with other businesses in the same industry.
5. Official Communications: Our client is in contact with the Turkish authorities, such as the Commercial Counsellor's Office of the Turkish Embassy in London and the Medical Tourism Department of the Ministry of Health in Turkey, to receive the latest news in the medical tourism industry and implement the recent changes to its operations for the sole benefit of its patients. All of the above improvements have been implemented into the Company's business operations for the safety and security of its patients, effective immediately. Our client is continuously working to improve its service quality to offer safer and more reliable services to its clientele. Paragraph 3, Section 5 of the Report: "There has been no evidence of an investigation into the operating table death by the Ministry of Health in Turkey, the private Termessos Hospital or Regenesis UK despite Regenesis having been informed that the death had been caused by the surgeon during the operation." Response to Paragraph 3, Section 5 of the Report: Our client's employees in Turkey sent enquiries to the Directorate of Communications of the Presidency of Turkey (Cimer) after Emma's death. Cimer is the highest and most effective complaints handling and investigation unit of the Turkish Government that also accepts such enquiries from the relevant parties. Furthermore, Ms Kellie Cooper, the Company's Chief Human Resources Officer, sent a message to the Hospital on 4 July 2023 and requested further documentation about Emma's death. Despite the employees of our client's efforts, unfortunately, our client did not receive

any news from Cimer, and the Hospital did not take any further steps to investigate this sad incident. Paragraph 4, Section 5 of the Report: "The embalming process for repatriation from Turkey to the UK was inadequate due to there being no evidence of fluid perfused to the great vessels, leaving Emma's body at risk of infection during transit. This presented a risk of decomposition as well as a health risk to the professionals receiving her body in the UK." Response to Paragraph 4, Section 5 of the Report: Our client assisted Emma's family after her death as much as possible. Although the Company helped Emma's family to the best of its abilities, the Company has no power to organise the embalming process for repatriation from Turkey to the UK. This process is carried out by an independent funeral company in compliance with the laws of Turkey and inspected by the government authorities at the Turkish border, to the best of our client's knowledge. Paragraph 5, Section 5 of the Report: "The surgery note provided to Regenesis stated that the sleeve gastrectomy operation was not completed following the intra-abdominal bleed in the omentum. The UK post mortem confirms that the surgery had been completed and that the site of the bleed was the lieno-renal ligament and not the omentum. The lieno-regal ligament site had been packed to stem the bleed during the operation and was present at post mortem." Response to Paragraph 5, Section 5 of the Report: Our client understands that the findings between the UK authorities and the death report issued by the Hospital do not comply with each other. Therefore, our client is ready to assist Emma's family to the best of its abilities as the family has decided to start court proceedings against the Hospital and the doctor(s) responsible for Emma's death. After the Company's contractual agreement with the Hospital ended, the Company did not renew its contract with the Hospital. Regardless of Emma's family's potential action against the mentioned parties, our client instructed its lawyers in Turkey to pursue a claim against them. Paragraph 6, Section 5 of the Report: "The cause of death reported in Turkey was natural. It was recorded as la, Cardigenic Shock, due to lb. Disseminated Intravascular Coagulation. In the circumstances of a massive bleed in the abdomen following the introduction of the instrument known as the optical trocar, the death is regarded as unnatural. The evidence before the inquest was that three incisions had been made to the abdomen, two of which with a sharp instrument." Response to Paragraph 6, Section 5 of the Report: As stated in the above paragraph, our client is preparing its case against the Hospital and the doctor(s) regarding the cause of Emma's death. The Company plans to start the court proceedings in the next three to five months. We hope that the answers below will be found satisfactory to the Coroner. Our client is ready to cooperate with the Coroner's further requests. Please feel free to contact us should you wish to ask any questions about this letter.