West Suffolk Hospital

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First report 20 Jun 2014•Latest report 2 Dec 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
6

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from West Suffolk Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Suffolk

    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.

    Read the report on judiciary.uk

    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 West Suffolk Hospital; 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 West Suffolk Hospital; 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 West Suffolk Hospital; 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

  2. Suffolk

    AI-generated summary

    Pamela Christine BRAND · 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

    Pamela Christine BRAND suffered a fall at her residence on 19 March 2024, sustaining a left hip fracture that was surgically treated. She suffered a cardiac arrest and died in hospital on 2 April 2024; the medical cause of death was pulmonary embolism due to deep vein thrombosis following the recent fall and hip fracture. The report raised concern that hospital records lacked key detail about observations and the rationale for clinical decision-making, potentially affecting future patient care.

    Read the report on judiciary.uk

    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record key detail about observations and the rationale for clinical decision making

    Wider context from the report

    “During the course of the Inquest evidence received by the Court indicated that the hospital records for Mrs. BRAND lacked key detail relating to observations undertaken and the rationale for clinical decision making. This impacted on the Inquest’s ability to build a complete picture concerning Mrs. BRAND’s presentation, care and treatment during her last admission to hospital. Although not identified as having made a contribution to Mrs. BRAND’s death, I am concerned that such poor record keeping may adversely impact on the care and treatment provided to other patients in the future if not addressed. ”
    Open source report

  3. Suffolk

    AI-generated summary

    Andrew Gibbins · 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

    Andrew Gibbins, who had a long history of mental health admissions, ran into the path of a lorry on the A14 on 15 January 2020 and died from his injuries. Before this, he had reportedly expressed suicidal feelings to a security guard while unescorted, but this information and concerns about his presentation were not passed to clinical staff. The inquest concluded that he had taken his own life.

    Read the report on judiciary.uk

    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report concerning patient presentations to clinicians

    Wider context from the report

    “(1) The Hospital Security Guard guided Andrew Gibbins back to AAU looking lost and confused (following a cigarette break) when in general way saying that he was feeling suicidal and that that had been the reason why he was under the care of Wedgewood. There were no immediate concerns for him, but the Security Guard had been concerned enough to ask for the Wedgewood staff member escort when he returned to AAU. Andrew's presentation had not been reported to any clinician at either AAU or Wedgewood. ”
    Open source report

  4. Suffolk

    AI-generated summary

    Karen Jane Winn · 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

    Karen ‘Jane’ Winn died at West Suffolk Hospital after developing bilateral pulmonary emboli and deep venous thromboses in the context of haemolytic anaemia. Although prophylactic anticoagulation was identified as necessary, it was not administered during most of her admission, and the report states that this contributed to her death. Concerns included a lack of early haematology consultant involvement, repeated manual overriding of the automated VTE assessment warnings, and inadequate electronic flagging of the anticoagulation decision.

    Read the report on judiciary.uk

    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the automated VTE assessment system to limit overrides and escalate repeated overrides

    Wider context from the report

    “2. In addition, I am concerned that the automated VTE assessment system does not appear to be significantly robust. I am aware that the WSH have taken steps to address the problem and have now placed the VTE assessment on the electronic Smart Zone ‘to do list’ and introduced an automated 14-hour consultant review function. However, I am concerned that as yet there is still no limit to the amount of times the automated ‘pop-up’ can be manually overridden and no automatic escalation process when it has been overridden a certain number of times. ”
    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate serious or rare blood-condition diagnoses for Haematology Consultant input

    Wider context from the report

    “1. I am concerned that a differential diagnosis of a rare and serious blood condition (haemolytic anaemia), although identified soon after admission, was not escalated to a Haematology Consultant at the time this diagnosis was made. It was a rare condition, which by its very nature should be treated with the support of haematology specialists. I am concerned that those specialist were unaware that a differential diagnosis of serious blood disorder had been made without their specialist input. ”
    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to clearly flag decisions to administer prophylactic anticoagulation in the patient electronic record

    Wider context from the report

    “3. I am further concerned that if a consultant at an early review has decided that prophylactic anticoagulation medication needs to be administered (even in the situation when a INR test is still awaited) that this is not clearly flagged on the patient electronic record in the Smart Zone, to act as a prompt for clinicians taking over that patients care. ”
    Open source report

  5. Suffolk

    AI-generated summary

    DAPHNE JOAN PENN · 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

    Daphne Joan Penn was transferred to Newmarket Community Hospital for rehabilitation and later died after readmission to West Suffolk Hospital, following deterioration. The inquest recorded pneumonia as the cause of death and identified concerns about an inadvertently rapid reduction in her long-term steroid therapy, delays in communicating family concerns, and a prescribing error that caused an additional reduction in the steroid dose.

    Read the report on judiciary.uk

    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately transcribe intended steroid doses when rewriting drug charts

    Wider context from the report

    “The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further gastro-intestinal bleeding here; that there was a delay transmitting to relevant medical staff concerns about her condition expressed to healthcare staff by Mrs Penn’s very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart. ”
    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in transmitting patient-condition concerns to relevant medical staff

    Wider context from the report

    “The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further gastro-intestinal bleeding here; that there was a delay transmitting to relevant medical staff concerns about her condition expressed to healthcare staff by Mrs Penn’s very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart. ”
    Open source report

  6. Suffolk

    AI-generated summary

    Else Merete-Harvey Samuel · 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

    Else Merete-Harvey Samuel was admitted to hospital after a fall, with continuing groin pain and a possible hip or pelvic fracture. Although initial radiographs did not show a fracture, some repeat views, including the pelvis, were not taken; a pelvic fracture was found at post mortem, alongside significant natural disease. The principal concerns were incomplete clinical information on imaging requests, insufficient senior discussion when investigations were challenged, and weaknesses in the subsequent incident investigation.

    Read the report on judiciary.uk

    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to include sufficient clinical information in radiograph and other imaging requests

    Wider context from the report

    “(1) Doctors requesting radiographs or other imaging investigations (whether out of hours or not) must include sufficient clinical information to explain why the investigation is indicated to avoid the request being rejected, and also to inform the radiologist who reports on the subsequent images what the relevant clinical history was. ”
    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct and document senior clinician–senior radiologist discussions for further out-of-hours investigation justification

    Wider context from the report

    “(2) In the event of further need for justification of an out hours investigation, discussion between senior clinician and senior radiologist should take place and be documented. ”
    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficiently robust post-untoward-incident investigations

    Wider context from the report

    “(3) In any post untoward incident investigation, the system for determining the correct level of post event analysis, and the investigation itself, must be sufficiently robust to establish fully what occurred and to take any statements required as near to the time of the event as possible so as to identify any lessons that need to be learned. ”
    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 West Suffolk Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the system for determining the correct level of post-event analysis to be sufficiently robust

    Wider context from the report

    “(3) In any post untoward incident investigation, the system for determining the correct level of post event analysis, and the investigation itself, must be sufficiently robust to establish fully what occurred and to take any statements required as near to the time of the event as possible so as to identify any lessons that need to be learned. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026