PFD report

DAVID HEFFER · Prevention of Future Deaths report

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Issued 4 Jun 2025•Essex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to maintain legible medical records
  2. Failure to inform the treating doctor of readmission with a procedure complication
    Part of recurring concern: Unreliable communication with original treating teams after post-procedure readmission
  3. Lack of complete medical records containing pertinent and relevant information
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Reinforce informing procedural endoscopists about ERCP complications through team reminders, handover guidance and clinical education.

    Stated by East Suffolk and North Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
  2. Action

    Implement the EPIC electronic patient record system with centralised, legible records, mandatory clinical fields, structured endoscopy templates and alerts for required actions.

    Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain legible medical records

Wider context from the report

“(2) The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to inform the treating doctor of readmission with a procedure complication

Wider context from the report

“(1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. ”

Is this part of a recurring concern?

Yes — Unreliable communication with original treating teams after post-procedure readmission.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of complete medical records containing pertinent and relevant information

Wider context from the report

“(2) The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to seek treating-doctor advice about potential causes of complications

Wider context from the report

“(1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. ”

Is this part of a recurring concern?

Yes — Unreliable communication with original treating teams after post-procedure readmission.

Open source report

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 informing procedural endoscopists about ERCP complications through team reminders, handover guidance and clinical education.

Verbatim wording from the response

“The Trust acknowledges the need for better communication between clinicians. Reminders will be provided to all general surgical teams, who remain the primary team managing ERCP-related complications, as agreed unanimously at the regional ERCP Clinical Delivery Group—that where feasible, the procedural endoscopist should be informed of any complication arising from an ERCP they performed. The expectation is that a phone call should be made to inform the procedural endoscopist of the readmission. Informing procedural endoscopists of any complication arising from an ERCP they performed will be included in departmental handover guidance and reinforced through clinical education sessions.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 11 June 2025

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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 EPIC electronic patient record system with centralised, legible records, mandatory clinical fields, structured endoscopy templates and alerts for required actions.

Verbatim wording from the response

“The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 2025, all ESNEFT patient record keeping will be done electronically.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 3 · response
Published 11 June 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Conduct and present a yearly site-specific ERCP audit locally and regionally to identify patterns and disseminate lessons.

    Stated by East Suffolk and North Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
  2. 2

    Continue cross-site quarterly ERCP Governance review meetings for clinicians to examine cases, outcomes and shared learning.

    Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
  3. 3

    Establish bi-monthly Colchester Endoscopy Governance meetings to review ERCP-related complications and deaths, record minutes and share required actions with colleagues.

    Stated by East Suffolk and North Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.

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

Conduct and present a yearly site-specific ERCP audit locally and regionally to identify patterns and disseminate lessons.

Verbatim wording from the response

“In addition to the Governance meetings outlined above, the Trust will be conducting a yearly site specific ERCP audit. This audit will be presented locally and regionally to ensure patterns are identified and lessons disseminated.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 11 June 2025

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

Continue cross-site quarterly ERCP Governance review meetings for clinicians to examine cases, outcomes and shared learning.

Verbatim wording from the response

“The Division has also implemented a cross-site ERCP Governance review meeting which takes place every three months. This meeting is attended by all ERCP clinicians at both Colchester and Ipswich Hospital and provides a forum for case studies to be reviewed, from both sites, to look at outcomes and to share any learning.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 11 June 2025

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

Establish bi-monthly Colchester Endoscopy Governance meetings to review ERCP-related complications and deaths, record minutes and share required actions with colleagues.

Verbatim wording from the response

“The Trust is committed to learning from deaths. The Division has agreed to conduct a Bi-monthly Endoscopy Governance meeting at the Colchester site to align with the Governance meetings that currently take place at Ipswich Hospital and promote a consistent approach to Governance at a local level. The Bi-monthly Endoscopy Governance meeting will include a standing agenda item to review all Colchester Hospital ERCP-related complications and deaths. Minutes will be taken at these meetings and shared with all endoscopy colleagues to ensure that those who are not able to attend are informed of the discussions that have taken place and any actions required. The Division are arranging the date for the first meeting to take place at Colchester Hospital which is planned for 1st September 2025.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 11 June 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026