“The Inquest heard evidence that at the time of Ms”
Dated 12 Feb 2025, from the coroner for Suffolk. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 23 Dec 2025, after the 56 days for replies had ended (9 Apr 2025). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated12 Feb 2025
- Deadline9 Apr 2025
- Published on judiciary.uk23 Dec 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Suffolk Hospital | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| NHS Suffolk and North East Essex Integrated Care BoardNamed in the report as “Suffolk and North East Essex Integrated Care Board” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
The Inquest heard evidence that at the time of Ms. FAVRE’s discharge on the 25th January 2025, no oncology input was available on weekends or out of hours to inform discharge decision making. Criteria had been set by the treating Consultant Oncologist, however the evidence received at Inquest suggested that this was neither known nor followed in relation to Ms. FAVRE’s discharge. I found as a fact that the discharge of Ms FAVRE on the 25th January 2025 was a failed discharge although it was not possible to establish whether the failed discharge made a contribution to Ms. FAVRE’s death. Upon readmission to West Suffolk Hospital on 26th January 2025, poor records management meant that emergency department staff at West Suffolk Hospital did not identify that Ms. FAVRE had recently recieved chemotherapy treatment and as a result chemotherapy support medication Regulation 28 – After Inquest Document Template Updated 30/07/2021 was not administered. Although this made no contribution to Ms. FAVRE’s death, I am concerned that in the case of other patients such a failure may have a different adverse outcome. I therefore have two concerns: 1. The provision of on-call oncology support over weekends and out of hours to inform discharge planning and assist in reducing the incidence of failed discharge amongst cancer patients. 2. The record management in the emergency department, including the ability of emergency department staff to interrogate West Suffolk Hospital records in a timely and consistent manner in order to inform clinical decision making concerning patients who have either recently been discharged or are receiving ongoing outpatient care.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0639
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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