“(brief summary of matters of concern) On the 28th January 2025: 1) Signs of sepsis where…”
Dated 27 Feb 2026, from the coroner for Essex. 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 24 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 dated27 Feb 2026
- Deadline24 Apr 2026
- Published on judiciary.uk18 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Colchester General Hospital | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| East Suffolk and North Essex NHS Foundation Trust | Response publishedPublished on judiciary.uk in March 2026. |
The coroner’s concerns
(brief summary of matters of concern) On the 28th January 2025: 1) Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed. 2) An early Consultant Review was not sought. 3) The later attempt to seek the Consultant's views was hampered by the use of a mobile phone which had poor signal in the operating theatre and crucial information was not fully imparted/understood. 4) The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information. 5) An alternative Consultant's opinion was not sought. 6) The Multi Disciplinary Team meeting the following morning did not discuss Mr Fenn's case when it should have.
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, 2026-0145
- 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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