PFD report

Lynn SILCOCK · Prevention of Future Deaths report

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Issued 23 Oct 2025•Shropshire, Telford and Wrekin

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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

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 of document exchange and communication between gastroenterology and cardiology teams
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable communication with cardiology teams about patient care
  2. Failure to obtain cardiology review of discharge appropriateness
    Part of recurring concern: Unreliable cardiology pathways for specialist reviewPart of recurring concern: Unreliable clinical review and authorisation of discharge decisionsPart of recurring concern: Unreliable hospital discharge processes
  3. Failure to arrange cardiology follow-up after discharge
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Unreliable arrangement and communication of patient appointments and follow-upPart of recurring concern: Unreliable tracking and follow-up of outpatient appointments
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.5

  1. Action

    Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
  2. Action

    Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
  3. Action

    Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.

    Stated by the Shrewsbury and Telford Hospital NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 of document exchange and communication between gastroenterology and cardiology teams

Wider context from the report

“(3) There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication of patient-care information between clinical staff; Unreliable communication with cardiology teams about patient care.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to obtain cardiology review of discharge appropriateness

Wider context from the report

“(1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate. ”

Is this part of a recurring concern?

Yes — Unreliable cardiology pathways for specialist review; Unreliable clinical review and authorisation of discharge decisions; Unreliable hospital discharge processes.

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 arrange cardiology follow-up after discharge

Wider context from the report

“(2) Discharged without a cardiology clinic appointment or plan to be later referred. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Unreliable arrangement and communication of patient appointments and follow-up; Unreliable tracking and follow-up of outpatient appointments.

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 investigate what went wrong and why between treating and administration teams

Wider context from the report

“(4) No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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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

Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.

Verbatim wording from the response

“A project feasibility request has already been raised to assess the need for a digital solution to support referral management. This is the route whereby needs are reviewed and scoped to develop proposals and business cases to place the need on the Trusts ‘digital roadmap’ (the overall programme of work to mature the Trusts digital systems).”

Source location

Response from Shrewsbury and Telford Hospital
Page 4 · response
Published 19 December 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

Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.

Verbatim wording from the response

“The case of Mrs Silcock has been raised as a Patient Safety Investigation (PSII) under the Patient Safety Incident Response framework and some of the initial work of that investigation has been used to inform the response outlined in this letter.”

Source location

Response from Shrewsbury and Telford Hospital
Page 2 · response
Published 19 December 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

Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.

Verbatim wording from the response

“In the short to medium term the Trust’s Medical Director and Deputy Medical Director are tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a clear standard operating procedure (SOP) for inpatient to outpatient referrals. This will be documented and shared across the team with clear direction on process, roles, and responsibilities in ensuring referrals are made and a system of safety netting is in place to ensure decisions to refer to other specialties are followed through and actioned.”

Source location

Response from Shrewsbury and Telford Hospital
Page 3 · response
Published 19 December 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

Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.

Verbatim wording from the response

“There will be a single referral email for each specialty for referral for outpatient follow-up, the referrals within the team will then be managed in the standard way all referrals are with appropriate triage. This process will be developed over the next 3 months with SOPs developed and appropriate communications cascaded.”

Source location

Response from Shrewsbury and Telford Hospital
Page 3 · response
Published 19 December 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

Develop and roll out the national Frontline Digitisation Programme, including electronic-record deployment guidance and support for safe implementation.

Verbatim wording from the response

“NHS England has long recognised that omissions in information-sharing within or between healthcare organisations can contribute to poor continuity of care and lead to poor health outcomes. In 2021, NHS England developed and rolled out a national ‘Frontline Digitisation’ (FD) Programme, which aimed to support NHS Trusts in England with the procurement and deployment of Electronic Patient Record (EPR) systems. The aim of this was to support increased digital maturity of organisations and improve information sharing within and between organisations. Beyond facilitating the procurement of EPR systems, the FD Programme also provided guidance and support to ensure safe and effective deployments.”

Source location

Response from NHS England
Page 1 · response
Published 19 December 2025

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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

Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.

Verbatim wording from the response

“The possibility of bleeding or malignancy led to the endoscopy investigations being prioritised with cardiology advising these should be completed first then cardiology would continue the process to investigate the aortic stenosis. On review it is clear there was no expectation that the gastroenterology team would be responsible for following up the referral to cardiology once Ms Silcock’s endoscopy investigations were completed.”

Source location

Response from Shrewsbury and Telford Hospital
Page 3 · response
Published 19 December 2025

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 concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.

Verbatim wording from the response

“The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

Source location

Response from NHS England
Page 1 · response
Published 19 December 2025

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

Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.

Verbatim wording from the response

“The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

Source location

Response from NHS England
Page 1 · response
Published 19 December 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.4

  1. 1

    Discuss all received Regulation 28 reports through the national Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
  2. 2

    Monitor emerging trends identified through Regulation 28 reports for potential need for further review and action.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
  3. 3

    Review SATH’s response to the concerns and determine whether further NHS England action is necessary.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
  4. 4

    Share key learnings and insights from received reports across the NHS at national and regional levels.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 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

Discuss all received Regulation 28 reports through the national Regulation 28 Working Group.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lynn, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 19 December 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

Monitor emerging trends identified through Regulation 28 reports for potential need for further review and action.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lynn, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 19 December 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

Review SATH’s response to the concerns and determine whether further NHS England action is necessary.

Verbatim wording from the response

“NHS England has requested to be included in SATH’s response to the concerns raised in your Report, and will review it to determine whether any further action is necessary.”

Source location

Response from NHS England
Page 2 · response
Published 19 December 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

Share key learnings and insights from received reports across the NHS at national and regional levels.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lynn, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 19 December 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