2 Apr 2026 David ABBOTT · Prevention of Future Deaths report Suffolk
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Concerns raised 4 Inadequate recording of important discharge advice View source Absence of an assurance mechanism to identify and remedy discharge advice errors View source Ineffective communication processes for patient and family engagement in clinical decisions View source Provision of wrong advice to patients on discharge View source See 1 more concern
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AI-generated summary
David ABBOTT · 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
David ABBOTT underwent surgery at West Suffolk Hospital on 25 October 2023 and was discharged the following day with advice that he interpreted as meaning he should not mobilise. He remained immobile for four days, subsequently developed deep vein thrombosis and pulmonary embolism, and died in cardiac arrest at home on 29 November 2023. Concerns included potentially incorrect discharge advice, inadequate recording of important advice, and ineffective communication between hospital staff, patients and families.
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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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of important discharge advice
Wider context from the report “West Suffolk Hospital NHS Foundation Trust
Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings.
At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible.
By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs.
I am concerned that one or both of the following has occurred:
a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or
b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge . If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error.
I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an assurance mechanism to identify and remedy discharge advice errors
Wider context from the report “West Suffolk Hospital NHS Foundation Trust
Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings.
At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible.
By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs.
I am concerned that one or both of the following has occurred:
a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or
b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge. If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error .
I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication processes for patient and family engagement in clinical decisions
Wider context from the report “West Suffolk Hospital NHS Foundation Trust
Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings.
At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible.
By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs.
I am concerned that one or both of the following has occurred:
a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk, and /or
b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge. If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error.
I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of wrong advice to patients on discharge
Wider context from the report “West Suffolk Hospital NHS Foundation Trust
Evidence received from Mr. ABBOTT’s Family at the Inquest was that advice provided to Mr. ABBOTT by a medical registrar at West Suffolk Hospital at the time of his discharge on the 26th October 2023 was not weight bear and not be mobile. This is corroborated in the medical records where the relevant entry reads: ‘avoid weight bearing’. In addition no advice was given in relation to the use of anti-embolism (TED) stockings.
At Inquest, the clear evidence was that unless a medical rationale existed to the contrary, this advice was wrong. No medical rationale for the advice was recorded in Mr. ABBOTT’s hospital notes, or in his discharge documentation. A possible explanation was offered that the registrar may have confused advice to ‘avoid heavy lifting’ with ‘avoid weight bearing’. These are two very different forms of advice, the latter leaving Mr. ABBOTT with the clear and not unreasonable impression that he was not to mobilise and avoid weight bearing following the procedure. He followed this advice until the 30th October 2023 when he attended a follow up outpatients clinic. Instead he should have mobilised and whilst not carrying heavy objects, otherwise carried on with his usual activity as far as possible.
By not mobilising and resting for this 4 day period, Mr. ABBOTT was more susceptible to contracting a DVT. This subsequently occurred and although it is not possible to establish precisely when the DVT/s formed, a period of 4 days of immobility immediately post operation will have likely contributed to him developing DVT in his lower legs.
I am concerned that one or both of the following has occurred:
a. The wrong advice has been provided to a patient on discharge which has exposed them to increased risk , and /or
b. Inadequate record keeping has resulted in inaccurate records being maintained in relation to important advice provided to patients on discharge. If this is the scenario, there would appear to be no assurance mechanism in place to identify and remedy any error.
I am further concerned that the communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
” 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 Train junior doctors during induction to use standardised discharge-summary #tags.
Verbatim wording from the response “Junior doctors receive training on the use of #tags during their induction, ensuring early awareness and consistent application in clinical practice.” Source location Response from West Suffolk NHS Foundation Trust
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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 Explore wider rollout of the “write to me rather than about me” approach across the Trust.
Verbatim wording from the response “Recently, as a continuation of this project, WSFT is exploring how best it can utilise the “write to me rather than about me” paradigm. This has been advocated by the Academy of Medical Royal Colleges since 2018 and has just been updated. A link to the further guidance can be found here: https://www.aomrc.org.uk/wp-content/uploads/2026/02/Please_write_to_me_0226.pdf” Source location Response from West Suffolk NHS Foundation Trust
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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 Rectify digital barriers and implement digital enablers for producing discharge letters.
Verbatim wording from the response “This incident has reinforced the importance of clear verbal and written communication at discharge. Improving the quality of discharge letters has been a project over the last 18 months led by the Associate Medical Director ████████. This has focused on initially identifying the barriers and the work to address them.” Source location Response from West Suffolk NHS Foundation Trust
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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 Assign consultants ownership of discharge processes and require checking and challenging draft discharge letters.
Verbatim wording from the response “To address this, consultants have been requested to take ownership of the discharge process and provide check and challenge where appropriate of draft discharge letters.” Source location Response from West Suffolk NHS Foundation Trust
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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 Use a standardised discharge-summary process with pre-approved #tag advice to reduce variation and inaccurate instructions.
Verbatim wording from the response “Since 2024, a standardised discharge summary process has been implemented within the Trust. This utilises #tag functionality, allowing clinicians to insert pre-approved, standardised advice directly into discharge documentation.” Source location Response from West Suffolk NHS Foundation Trust
Open published response
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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 Monitor discharge-letter compliance through Clinical Directors and Clinical Leads and discuss the data in governance meetings.
Verbatim wording from the response “The digital team have now rectified the digital barriers and have tried to implement the enablers. We have also put in place methods to ensure compliance can be monitored by Clinical Directors and Clinical Leads. It is advised that this data should be discussed at departmental and divisional governance meetings.” Source location Response from West Suffolk NHS Foundation Trust
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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 Operate the Call 4 Concern/Martha’s Rule programme across all inpatient areas, including structured wellness questions and escalation for independent clinical review.
Verbatim wording from the response “As reported previously, we would like to highlight the continued work introducing the national ‘call for concern’ and Martha’s rule programme. Since Mr Abbott’s death on 29 November 2023, the Trust has adopted the national Call 4 Concern / Martha’s Rule programme. As part of this initiative, it introduces a daily structured patient-wellness question, enabling both doctors and nurses to engage proactively with patients regarding their condition and any emerging concerns.” Source location Response from West Suffolk NHS Foundation Trust
Open published response
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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 hospital visiting hours to 8pm to improve relatives’ participation in ward-round communication.
Verbatim wording from the response “In addition to the above, since April 2026 WSFT has extended its visiting hours from 10am to 8pm. This will support improved communication with relatives and patients, as the next of kin can be present during ward rounds and thus increasing the opportunity for face-to-face communication with consultant teams.” Source location Response from West Suffolk NHS Foundation Trust
Open published response
6 Feb 2026 Roger Knight SMITH · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 8 Limited specialist stroke team input into care and treatment for patients at increased stroke risk View source Failure of the patient records management system to accurately highlight important information for patient care and treatment View source Failure of the patient records management system to accurately highlight important information for patient care and treatment View source Delays and non-concordant management in acute stroke diagnosis, stroke-unit transfer and blood-pressure management View source Ineffective communication processes for engaging patients and families in clinical decisions View source Ineffective communication processes for engaging patients and families in clinical decisions View source Limited specialist stroke team input into care and treatment for patients at increased stroke risk View source Failure to adequately consider and respond to patients’ medication refusals View source See 5 more concerns
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
Roger Knight SMITH · 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
Roger Knight SMITH, who had cerebral amyloid angiopathy and a history of strokes, was readmitted to West Suffolk Hospital in August 2023 and received tinzaparin for venous thromboembolism prophylaxis. He later suffered a cerebral haemorrhage and died on 12 September 2023; the inquest narrative attributed his death to the effects of a stroke brought about by tinzaparin administration. The principal concerns were failures in the electronic records system to flag relevant anticoagulation advice, inadequate communication with the patient and his family, and insufficient timely specialist stroke-team input.
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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 West Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited specialist stroke team input into care and treatment for patients at increased stroke risk
Wider context from the report “There was limited input from the West Suffolk Hospital stroke team into Mr. Smith’s care and treatment during the period following his admission on the 14th April 2023 until his stroke on the 1st May 2023. This was notwithstanding Mr. Smith and his Family raising on multiple occasions the increased risk of stroke to Mr. Smith due to his pre-existing CAA condition. Following his stroke on the 1st May 2023, measures taken to diagnose the stroke, move Mr. Smith to a stroke unit and correctly manage his blood pressure in accordance with NICE guidelines were slow, and with respect to blood pressure management, non-concordant with existing national stroke guidance.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient records management system to accurately highlight important information for patient care and treatment
Wider context from the report “I am concerned that the West Suffolk Hospital patient records management system is ineffective in accurately highlighting important information which should inform patient care and treatment .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient records management system to accurately highlight important information for patient care and treatment
Wider context from the report “Important information relating to advice concerning the prescription of anti-coagulation therapy (low weight molecular heparin - LWMH) for venous thromboembolism (VTE) prophylaxis and which was contained in Mr. Smith’s medical records, was not flagged for clinician attention as part of the electronic records management system in use at West Suffolk Hospital. This meant that when Mr. Smith was readmitted on the 25th August 2023, this information did not form part of the reviewing consultants considerations and would not be thought to precribe tinzaparin (LWMH) to Mr. Smith for VTE prophylaxis. He subsequently received 8 doses of tinzaparin which contributed to him suffering a catastrophic stroke that led to his 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 West Suffolk NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and non-concordant management in acute stroke diagnosis, stroke-unit transfer and blood-pressure management
Wider context from the report “There was limited input from the West Suffolk Hospital stroke team into Mr. Smith’s care and treatment during the period following his admission on the 14th April 2023 until his stroke on the 1st May 2023. This was notwithstanding Mr. Smith and his Family raising on multiple occasions the increased risk of stroke to Mr. Smith due to his pre-existing CAA condition. Following his stroke on the 1st May 2023, measures taken to diagnose the stroke, move Mr. Smith to a stroke unit and correctly manage his blood pressure in accordance with NICE guidelines were slow , and with respect to blood pressure management, non-concordant with existing national stroke guidance .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication processes for engaging patients and families in clinical decisions
Wider context from the report “I am concerned that communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication processes for engaging patients and families in clinical decisions
Wider context from the report “During both admissions to West Suffolk Hospital during the period April to August 2023, Mr. Smith and his Family fiercely advocated for considerations associated with his cerebral amyloid angiopathy (CAA) to be taken into account as part of his care and treatment. This occurred during Mr. Smith’s first admission between 14th April and 21st August 2023 with alternative management used to address the VTE risk. This did not occur during Mr. Smith’s second admission from 25th August 2023 and despite Mr. Smith declining tinzaparin on two occasions, the medication continued to be administered without adequate consideration as to why Mr. Smith had declined it or by engaging in consultation with either Mr. Smith or his Family.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited specialist stroke team input into care and treatment for patients at increased stroke risk
Wider context from the report “I am concerned that effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA).
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately consider and respond to patients’ medication refusals
Wider context from the report “During both admissions to West Suffolk Hospital during the period April to August 2023, Mr. Smith and his Family fiercely advocated for considerations associated with his cerebral amyloid angiopathy (CAA) to be taken into account as part of his care and treatment. This occurred during Mr. Smith’s first admission between 14th April and 21st August 2023 with alternative management used to address the VTE risk. This did not occur during Mr. Smith’s second admission from 25th August 2023 and despite Mr. Smith declining tinzaparin on two occasions, the medication continued to be administered without adequate consideration as to why Mr. Smith had declined it or by engaging in consultation with either Mr. Smith or his Family.
” 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 Consider adding an explicit CAA bleeding-risk prompt to the VTE assessment tool through the Thrombosis Committee and embed any agreed change in Trust guidelines.
Verbatim wording from the response “• WSFT will take forward a clinically-led change to strengthen the visibility of risk factors within the existing VTE assessment processes.” Source location 2026-0069 - Response from West Suffolk NHS Foundation Trust
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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 Strengthen nursing escalation of repeated medication refusals and treatment-risk concerns by reviewing handovers and embedding responsibilities in local nursing guidance.
Verbatim wording from the response “• The Trust will also strengthen the clarity of nursing roles and responsibilities in recognising and escalating risks associated with patients who repeatedly refuse medication. Whilst refusals of medication are documented by nursing staff within the electronic drug chart, this information does not always reach the prescribing team. To address this gap, the Trust will work with senior nursing leadership to reinforce expectations around proactive escalation, particularly where medication is repeatedly refused, or where a patient or family expresses concerns about treatment risk. This will include reviewing existing nursing handover processes, ensuring nurses understand when and how to raise medication-related concerns directly with the medical team, and identifying opportunities to embed this into local nursing practice guidance.” Source location 2026-0069 - Response from West Suffolk NHS Foundation Trust
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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 Develop the safer handovers quality-improvement project to improve highlighting of essential information during nurse-to-nurse transfers.
Verbatim wording from the response “• There is also a Quality Improvement Project (QIP) on ‘safer handovers’ currently underway. Although this project is looking to improve the reported safety and effectiveness of nurse-to-nurse transfers between adult inpatient wards, part of this involves looking at how essential information is highlighted. It is hoped this project will improve the quality of records which is accessible to all healthcare teams and drive-up standards.” Source location 2026-0069 - Response from West Suffolk NHS Foundation Trust
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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 Implement the Martha’s Rule/Call 4 Concern programme across inpatient areas, providing structured wellness questions and a route to independent clinical review.
Verbatim wording from the response “Since Mr Smith’s death on 12 September 2023, the Trust has adopted the national Call 4 Concern / Martha’s Rule programme. As part of this initiative, it introduces a daily structured patient-wellness question, enabling both doctors and nurses to engage proactively with patients regarding their condition and any emerging concerns.” Source location 2026-0069 - Response from West Suffolk NHS Foundation Trust
Open published response
×
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 Remind medical teams through targeted internal communications that the Early Stroke Outreach Team is available 24/7 for referrals and pathway support.
Verbatim wording from the response “In addition, medical teams have been reminded that the Early Stroke Outreach Team service is available 24/7 to provide support with referrals, including guidance on pathway requirements and assistance with completing the necessary documentation with targeted internal communications.” Source location 2026-0069 - Response from West Suffolk NHS Foundation Trust
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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 An automated CAA anticoagulation alert cannot be implemented because eCare lacks the necessary functionality and reliable evidence base.
Verbatim wording from the response “This concern has been reviewed by the Digital and Medicine teams to explore if it is possible to create a digital solution for this issue and to consider the process of adding alerts to the electronic patient record system, known locally as eCare. Unfortunately, based on current system capabilities, it is not possible to create an automated digital alert within eCare to warn prescribers against anticoagulating patients with cerebral amyloid angiopathy (CAA).” Source location 2026-0069 - Response from West Suffolk NHS Foundation Trust
Open published response
4 Feb 2026 Lauren Rae MORET-DELL · Prevention of Future Deaths report Suffolk
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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.
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
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 West Suffolk NHS Foundation Trust; 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 West Suffolk NHS Foundation Trust; 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
12 Nov 2024 Erin Louise TILLSLEY · Prevention of Future Deaths report Suffolk
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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.
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
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 West Suffolk NHS Foundation Trust; 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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations