PFD report

Suzanne FREDERICKS · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 12 Jun 2026•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
1

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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.1

  1. Action

    Standardise transplant blood-sample routing through a single contact offering daily tacrolimus assays and sample prioritisation on request.

    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 2 September 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Delayed or intermittent tacrolimus results are outside CUH’s direct control, so CUH is not the appropriate organisation to address the identified risk.

    Stated by Cambridge University Hospitals NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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 provide clinicians caring for transplant patients with reliably up-to-date blood test results

Wider context from the report

“There is a concern as to how clinicians caring for transplant patients in non-specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results. Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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

Standardise transplant blood-sample routing through a single contact offering daily tacrolimus assays and sample prioritisation on request.

Verbatim wording from the response

“The Trust has however taken the decision to standardise the practice and send all blood samples to a single point of contact that has a daily assay for tacrolimus and can prioritise a sample on request.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 2 September 2026

Open published response

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

Delayed or intermittent tacrolimus results are outside CUH’s direct control, so CUH is not the appropriate organisation to address the identified risk.

Verbatim wording from the response

“For these reasons, the identified concern regarding delayed and/or intermittent tacrolimus results is not within CUH's direct control. CUH is therefore not able to ameliorate the risk of death identified in this case. However, CUH recognises the importance of timely tacrolimus monitoring and remains willing to support any wider regional or national work to improve pathways for transplant patients receiving care outside specialist centres.”

Source location

Response from Cambridge University Hospitals NHS Foundation Trust
Page 2 · response
Published 2 September 2026

Open published response

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

CUH cannot require the General Hospital to send tacrolimus samples exclusively to CUH laboratories.

Verbatim wording from the response

“Furthermore, CUH does not have the power to compel the General Hospital to send its samples to CUH laboratories to the exclusion of all others.”

Source location

Response from Cambridge University Hospitals NHS Foundation Trust
Page 2 · response
Published 2 September 2026

Open published response

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 assuring tacrolimus sample testing and reporting rests with the General Hospital and testing laboratory.

Verbatim wording from the response

“The evidence before the inquest indicated that the General Hospital received tacrolimus results on more occasions than the single occasion on which CUH was involved. It therefore appears that the samples were being sent to another organisation for testing during the relevant period, which is ultimately a matter for the General Hospital and the testing laboratory to assure you accordingly.”

Source location

Response from Cambridge University Hospitals NHS Foundation Trust
Page 2 · response
Published 2 September 2026

Open published response

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

The renal unit cannot process specialist transplant tests, so samples must be sent elsewhere for processing and results.

Verbatim wording from the response

“The Renal Unit at Colchester General Hospital are able to process most blood samples for transplant patients but at present are not able to process specialist tests, such as tacrolimus concentration. Colchester General Hospital therefore have to obtain blood samples for such tests and send them to a transplant centre to process and return results.”

Source location

Response from East Suffolk and North Essex NHS Foundation Trust
Page 2 · response
Published 2 September 2026

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.1

  1. 1

    Continue constructive engagement with NHS England and relevant regional or national bodies on wider transplant pathway improvement.

    Stated by Cambridge University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2026.

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 constructive engagement with NHS England and relevant regional or national bodies on wider transplant pathway improvement.

Verbatim wording from the response

“Conclusion In CUH's submission, it is not the appropriate organisation to address the risk of death identified by this inquest. Nevertheless, CUH recognises the importance of the issues identified and will continue to engage constructively with the parties identified, NHS England and any relevant regional or national bodies in relation to wider pathway improvement work.”

Source location

Response from Cambridge University Hospitals NHS Foundation Trust
Page 3 · response
Published 2 September 2026

Open published response
Back to top

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