“West Suffolk Hospital NHS Foundation Trust During the course of the Inquest evidence was…”
Dated 4 Feb 2026, 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
Deadline passedReplies were due by 1 Apr 2026. A reply may have been sent and not yet published.
Organisations 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.
- Report dated4 Feb 2026
- Deadline1 Apr 2026
- Published on judiciary.uk10 Feb 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Suffolk NHS Foundation Trust | 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
West Suffolk Hospital NHS Foundation Trust During the course of the Inquest evidence was heard that neither the treating consultant, nor specialist doctors working in the team that treated Mrs. Moret-Dell on the 23rd December 2023 were proficient in the process to make referrals to the Transient Ischaemic Attack (TIA) Clinic. Evidence was also heard as to the importance of timely referrals to the TIA clinic in line with National Institute of Clinical Excellence (NICE) Guidance. Although the failure to refer Mrs. Moret-Dell to the TIA Clinic in a timely manner was not causative of her death, I am concerned that in another case the failure to correctly understand and implement TIA Clinic referrals in a timely manner gives rise to a risk of death. Suffolk and North East Essex Integrated Care Board Evidence was heard at the Inquest that the out of hour provision for stroke care did not include West Suffolk Hospital based stroke consultant input, this being obtained either through an approach to Addenbrookes Hospital, Cambridge, or other specialist hospitals in London. Due to the distances and time involved to Regulation 28 – After Inquest Document Template Updated 30/07/2021 subsequently transport patients to specialist centres, the lack of access to stroke consultant input adversely impacts on the treatment of stroke patients during out of hours. I am concerned that the lack of commissioned stroke consultant input during out of periods at west Suffolk Hospital gives rise to a risk of death.
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, 2026-0059
- Added to Minute Book
- 8 Oct 2026
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- 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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