Concerns raised 2 Lack of commissioned stroke consultant input during out-of-hours periods View source Failure to correctly understand and implement timely TIA Clinic referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lauren Rae MORET-DELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lauren Rae Moret-Dell developed neurological symptoms, later suffered bilateral embolic strokes, and died on 10 January 2024. Concerns were raised about failures to make timely referrals to the TIA Clinic and about the lack of commissioned stroke consultant input at West Suffolk Hospital out of hours, both of which were considered to give rise to a risk of death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Suffolk and North East Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned stroke consultant input during out-of-hours periods
Wider context from the report “Evidence was heard at the Inquest that the out of hour provision for stroke care did not include West Suffolk Hospital based stroke consultant input , this being obtained either through an approach to Addenbrookes Hospital, Cambridge, or other specialist hospitals in London. Due to the distances and time involved to subsequently transport patients to specialist centres, the lack of access to stroke consultant input adversely impacts on the treatment of stroke patients during out of hours .
I am concerned that the lack of commissioned stroke consultant input during out of periods at West Suffolk Hospital gives rise to a risk of death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Suffolk and North East Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly understand and implement timely TIA Clinic referrals
Wider context from the report “During the course of the Inquest evidence was heard that neither the treating consultant, nor specialist doctors working in the team that treated Mrs. Moret-Dell on the 23rd December 2023 were proficient in the process to make referrals to the Transient Ischaemic Attack (TIA) Clinic . Evidence was also heard as to the importance of timely referrals to the TIA clinic in line with National Institute of Clinical Excellence (NICE) Guidance.
Although the failure to refer Mrs. Moret-Dell to the TIA Clinic in a timely manner was not causative of her death, I am concerned that in another case the failure to correctly understand and implement TIA Clinic referrals in a timely manner gives rise to a risk of death .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the TIA referral guideline, introduce flow diagrams, streamline the referral process, and circulate the materials across relevant clinical teams.
Verbatim wording from the response “2 Updated guideline including flow diagrams” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver recurring Trust-wide stroke-awareness communications that reinforce timely TIA referrals, including the planned May 2026 initiative with the Stroke Association.
Verbatim wording from the response “6 Public awareness and professional reinforcement activities
On World Stroke Day, additional internal communications are delivered Trust-wide, reinforcing the #ActFAST message. This also now includes emphasising timely TIA referrals. The next initiative is planned for May 2026 with the support from the Stroke Association, where the issue will be raised again.” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Route thrombolysis and mechanical thrombectomy decisions for eligible patients to the telemedicine stroke consultant.
Verbatim wording from the response “The Emergency Stroke Outreach Team, including a stroke specialist nurse, are present 24 hours a day, 7 days a week in hospital. In addition to this, WSFT has access to a telemedicine service, whereby a telemedicine consultant is available remotely between 17:00–08:00 hours on weekdays, and 24 hours on weekends and bank holidays. This is primarily to support thrombolysis decision-making. The consultant can remotely review scans, check a patient’s history, examination findings, and speak with the patient in real-time if required.” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include atypical overnight cases in the morning stroke-specialist handover and enable consultants to provide night-time advice for atypical or complex symptoms.
Verbatim wording from the response “As with most district general hospitals, WSFT does not have a local stroke consultant available to discuss all stroke referrals 24/7. However, since this case, the team have incorporated in their stroke specialists’ handover, the process of mentioning any atypical cases that were reviewed” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce the correct TIA referral pathway with the responsible medical team and disseminate referral resources across the Acute Assessment Unit.
Verbatim wording from the response “1 Immediate reinforcement of correct TIA referral pathway” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed correct TIA referral education in registrar induction and emergency-department training, supported by a new stroke/TIA e-learning video and presentation.
Verbatim wording from the response “3 Education, training, and induction improvements” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the WSFT stroke specification against current NHS standards and work with the Trust to strengthen service provision and reduce transfer delays.
Verbatim wording from the response “The ICB is currently reviewing the stroke specification for WSFT in order to understand what should be in place in line with current NHS standards. We will be working with the Trust to gain assurance the service provision is strengthened to reduce risk and delays in transferring patients to specialist neurological centres.” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver targeted internal communications to emergency, medical, and other teams reinforcing the TIA referral pathway.
Verbatim wording from the response “4 Communication reminders Trust-wide
The Stroke team have conducted targeted internal communications to other areas including ED and medical teams, to remind them about the referral pathway.” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the out-of-hours stroke consultant access concern rests with the ICB, which has responded separately.
Verbatim wording from the response “Matter of Concern: Out of Hours Stroke Consultant Access” Source location 2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
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2 Dec 2025 Brigitte Dominique FAVRE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Failure of emergency department records management to enable timely and consistent interrogation of patient records View source Failure to ensure that oncology discharge criteria are known and followed View source Unavailability of on-call oncology support for cancer patient discharge planning during weekends and out of hours View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Brigitte Dominique FAVRE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brigitte Dominique FAVRE, who had small cell leukaemia and was receiving chemotherapy, was discharged on 25 January 2025, readmitted the following day after her condition deteriorated, and died on 30 January 2025 from neutropenic sepsis following chemotherapy. Concerns were raised about the lack of oncology input for weekend and out-of-hours discharge planning and about emergency department record management, which meant recent chemotherapy and the need for support medication were not identified promptly.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Suffolk and North East Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency department records management to enable timely and consistent interrogation of patient records
Wider context from the report “The Inquest heard evidence that at the time of Ms. FAVRE’s discharge on the 25th January 2025, no oncology input was available on weekends or out of hours to inform discharge decision making. Criteria had been set by the treating Consultant Oncologist, however the evidence received at Inquest suggested that this was neither known nor followed in relation to Ms. FAVRE’s discharge. I found as a fact that the discharge of Ms FAVRE on the 25th January 2025 was a failed discharge although it was not possible to establish whether the failed discharge made a contribution to Ms. FAVRE’s death.
Upon readmission to West Suffolk Hospital on 26th January 2025, poor records management meant that the emergency department staff at West Suffolk Hospital did not identify that Ms. FAVRE had recently received chemotherapy treatment and as a result chemotherapy support medication was not administered. Although this made no contribution to Ms. FAVRE’s death, I am concerned that in the case of other patients such a failure may have a different adverse outcome.
I therefore have two concerns:
1. The provision of on-call oncology support over weekends and out of hours to inform discharge planning and assist in reducing the incidence of failed discharge amongst cancer patients.
2. The record management in the emergency department, including the ability of emergency department staff to interrogate West Suffolk Hospital records in a timely and consistent manner in order to inform clinical decision making concerning patients who have either recently been discharged or are receiving ongoing outpatient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Suffolk and North East Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that oncology discharge criteria are known and followed
Wider context from the report “The Inquest heard evidence that at the time of Ms. FAVRE’s discharge on the 25th January 2025, no oncology input was available on weekends or out of hours to inform discharge decision making. Criteria had been set by the treating Consultant Oncologist, however the evidence received at Inquest suggested that this was neither known nor followed in relation to Ms. FAVRE’s discharge . I found as a fact that the discharge of Ms FAVRE on the 25th January 2025 was a failed discharge although it was not possible to establish whether the failed discharge made a contribution to Ms. FAVRE’s death.
Upon readmission to West Suffolk Hospital on 26th January 2025, poor records management meant that the emergency department staff at West Suffolk Hospital did not identify that Ms. FAVRE had recently received chemotherapy treatment and as a result chemotherapy support medication was not administered. Although this made no contribution to Ms. FAVRE’s death, I am concerned that in the case of other patients such a failure may have a different adverse outcome.
I therefore have two concerns:
1. The provision of on-call oncology support over weekends and out of hours to inform discharge planning and assist in reducing the incidence of failed discharge amongst cancer patients.
2. The record management in the emergency department, including the ability of emergency department staff to interrogate West Suffolk Hospital records in a timely and consistent manner in order to inform clinical decision making concerning patients who have either recently been discharged or are receiving ongoing outpatient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Suffolk and North East Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of on-call oncology support for cancer patient discharge planning during weekends and out of hours
Wider context from the report “The Inquest heard evidence that at the time of Ms. FAVRE’s discharge on the 25th January 2025, no oncology input was available on weekends or out of hours to inform discharge decision making . Criteria had been set by the treating Consultant Oncologist, however the evidence received at Inquest suggested that this was neither known nor followed in relation to Ms. FAVRE’s discharge. I found as a fact that the discharge of Ms FAVRE on the 25th January 2025 was a failed discharge although it was not possible to establish whether the failed discharge made a contribution to Ms. FAVRE’s death.
Upon readmission to West Suffolk Hospital on 26th January 2025, poor records management meant that the emergency department staff at West Suffolk Hospital did not identify that Ms. FAVRE had recently received chemotherapy treatment and as a result chemotherapy support medication was not administered. Although this made no contribution to Ms. FAVRE’s death, I am concerned that in the case of other patients such a failure may have a different adverse outcome.
I therefore have two concerns:
1. The provision of on-call oncology support over weekends and out of hours to inform discharge planning and assist in reducing the incidence of failed discharge amongst cancer patients.
2. The record management in the emergency department, including the ability of emergency department staff to interrogate West Suffolk Hospital records in a timely and consistent manner in order to inform clinical decision making concerning patients who have either recently been discharged or are receiving ongoing outpatient care.
” Open source report
Concerns raised 1 Failure to apply NICE self-harm guidance and the SNEE/SCC crisis-support policy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Erin Louise TILLSLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Erin Louise Tillsley, aged 14, died on 14 July 2023 after being found suspended by a ligature at home; emergency services were unable to resuscitate her. The inquest heard that, after she attended the emergency department following an overdose on 31 December 2022, the relevant NICE guidance and local policy on self-harm assessment and mental health support were not applied, resulting in a missed opportunity for early mental health engagement.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Suffolk and North East Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to apply NICE self-harm guidance and the SNEE/SCC crisis-support policy
Wider context from the report “This Policy document outlined the resources available in circumstances where Young People Present into an Emergency Department (ED) in Suffolk to facilitate NICE recommended urgent and emergency care, including NICE recommended treatment for self-harm. The available resources on a 24/7 basis for all age groups includes the Mental Health Liaison Service (MHLS) which offers specialist mental health care in a physical health setting by supporting the work of clinicians working in general health pathways, enabling EDs and wards in general hospitals to assess and support mental health needs as they present or arise among people being cared for in the general health pathway.
Evidence received during the course of the Inquest indicated that neither the NICE Guidance nor the SNEE/SCC Policy were applied in relation to the care and treatment extended to Erin in the West Suffolk Hospital Emergency Department during her attendance over the period 31ˢᵗ December 2022 to 1ˢᵗ January 2023.
The failure to apply this guidance/policy meant that there was a missed opportunity for mental health services to engage early with a vulnerable child who had presented to the Emergency Department having undertaken an act which she described as an overdose.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a Patient Safety Review of the incident and use its findings to coordinate related safety projects and workstreams.
Verbatim wording from the response “Patient Safety Review & Learning” Source location Response from West Suffolk NHS & Suffolk and North East Essex ICB
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Suffolk and North East Essex protocol for supporting children and young people in crisis.
Verbatim wording from the response “Response:
The ICB, in partnership with its provider services and system partners, regularly reviews the Suffolk and North East Essex Health and Social Care Protocol for the Support of Children and Young People in Crisis. This is to ensure it contains the latest guidance, evidence-based practice, configuration of local services, children and young people’s (CYP) mental health services, and support for our clinicians in delivering care for CYP in crisis. An update is currently underway, which the ICB will share widely on completion, seeking robust assurance of local implementation across its services.” Source location Response from West Suffolk NHS & Suffolk and North East Essex ICB
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update policy PP459 with emergency-admission requirements for triage, mental-health risk assessment, observation, ligature safety and safer waiting arrangements.
Verbatim wording from the response “3. To further support staff to make the right decisions in future, WSFT’s policy: Mental Health – supporting patients with their mental health (PP459) has been updated in August 2024. A new section 5.3 has specifically been added, focussing on how the policy applies to emergency admissions, an extract is below:” Source location Response from West Suffolk NHS & Suffolk and North East Essex ICB
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the updated children and young people in crisis protocol widely on completion and seek assurance of implementation across ICB services.
Verbatim wording from the response “Response:
The ICB, in partnership with its provider services and system partners, regularly reviews the Suffolk and North East Essex Health and Social Care Protocol for the Support of Children and Young People in Crisis. This is to ensure it contains the latest guidance, evidence-based practice, configuration of local services, children and young people’s (CYP) mental health services, and support for our clinicians in delivering care for CYP in crisis. An update is currently underway, which the ICB will share widely on completion, seeking robust assurance of local implementation across its services.” Source location Response from West Suffolk NHS & Suffolk and North East Essex ICB
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend electronic emergency-department triage and automatic Mental Health Liaison Team referral triggers to patients under 18, including overdose presentations.
Verbatim wording from the response “4. Further work following a review of Erin’s case by the ED team has resulted in the triage process discussed in point 3 being extended to patients under 18. The Manchester Triage system used for suspected mental health conditions was originally designed for adult patients and has been working successfully for some time. However, that has been adapted and extended for use in under 18’s care. Briefly there are 5 categories within the triage process that trigger automatically at the point of triage for MHLT review/referral. These include patient’s that present with an overdose. This leads to an additional assessment by the triage nurse at that time and, once completed, that sends an alert to the MHLT for them to complete part 2 of the referral. Examples of the new process and subsequent risk assessments are included in Appendix 1.” Source location Response from West Suffolk NHS & Suffolk and North East Essex ICB
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations