Suzanne Pemberton · Prevention of Future Deaths report

On 16th September 2024 I commenced an investigation into the death of Suzanne Pemberton, aged 61 years’. The investigation concluded at the end of the inquest on the 16th December 2025.

Suzanne Pemberton died on the 16th September 2024 at Colchester General Hospital (CGH), Turner Road, Colchester, Essex from a cause of death confirmed as: (1a) pneumonia and sepsis (joint causes), arising from (1b) exacerbation of long-standing bronchiectasis; on a contributory background of (2): severe depressive disorder, malnutrition and chronic frailty.

The Conclusion of the inquest was a Narrative Conclusion focussed on those aspects of the inadequate care, management and treatment provided by Essex Partnership NHS Foundation Trust (EPUT) that probably more than minimally contributed to the death.

Over the course of a two-year period preceding her death, there were a number of opportunities for (EPUT) staff and clinicians to escalate concerns regarding Suzanne’s mental health, as raised by those treating her in primary and secondary care for her complex physical medical needs arising, principally, from her chronic Bronchiectasis.

Suzanne’s lack of concordance with her mental and physical health medication informed a pattern of repeated and extended periods of admission as an in-patient to treat her lung infections which, over time and following each hospital discharge, led - in that non-concordance - to chronic and sustained deconditioning consequent upon depleted nutritional and physiological reserves This, in turn, directly contributed to the exacerbation of her chronic lung condition, leading to repeated infections and, ultimately, the fatal pneumonia and sepsis.

The evidence confirmed that by the time of her final admission to CGH on Thursday 12th September 2024, such was the extent of the depletion of her physical and nutritional reserves and consequent extreme frailty and deconditioning, that Suzanne’s death on Monday 16th September was unlikely to be avoidable.

It was apparent, however, that from her admission through until the day of her death on 16th September Suzanne had not been fully assessed in person by the CGH Dietetic team, notwithstanding that she had been referred to dietitians on Friday 13th at 09:01 hours and then re-referred, the same day, at 10:09 hours and had been deemed, when later triaged, as a Category 2 priority to be seen within 24 hours.

Although, in the specific circumstances of this case, the delay in the provision of an in-person dietetic assessment was not a probable causative factor in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated:

“At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.” (Emphasis added).

The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The Professional Lead further reconfirmed, in terms, that outside of those hours there is simply no specialist dietetic service or cover of any kind at all for patients at CGH.

In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic Team for a new business case for funding having not been taken forward).

The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team).

She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths.