“The Trust accepts that there was a significant failure on the part of clinical and…”
Dated 2 Feb 2026, from the coroner for Essex. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedOrganisations 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.
- Report dated2 Feb 2026
- Deadline30 Mar 2026
- Published on judiciary.uk13 Apr 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Suffolk and North Essex NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2026. |
The coroner’s concerns
– The Trust accepts that there was a significant failure on the part of clinical and nursing staff to communicate effectively with Mrs Daniels and her family in respect to critical clinical decision making, and the basis for such clinical 2 decision making, relating to her transition to end of life care, directly impacting their involvement in decision making regarding the withdrawal of treatment, as required by Trust Policy and Guidance. Evidence from Trust witnesses, including the Langham Ward Manager/Nursing Sister and two Langham Ward Consultant Gastroenterologists indicated that clinical and nursing staff were insufficiently familiar with the principles set out in the Trusts relevant policies and guidance, including the Trust Palliative Care Guidance issued in April 2025, regarding the relevant considerations involved in the transition from palliative care to end of life care. Taken together, these two features give rise to a risk that patients and family members may not be appropriately consulted with respect to the basis for and timing of end-of-life care and, accordingly, that withdrawal of active treatment may be prematurely undertaken.
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, 2026-0202
- 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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