“CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving…”

The coroner’s concerns

CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern and in my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Concern 1: Inadequate Clinical Record Keeping During the course of this investigation I heard evidence of significant deficiencies in the maintenance of clinical records relating to hydration, nutrition, communication, observations, medication management and aspects of clinical decision making. The deficiencies were such that I was unable to determine whether important elements of care had been provided appropriately, or at all. This is not an isolated concern. I have encountered similar failings in record keeping and documentation in other inquests involving different wards and hospital sites within the Trust, as have other Coroners within this jurisdiction. I am concerned that inadequate clinical records create a risk that deterioration in patients may not be identified promptly, that care may not be delivered consistently, that clinical decisions may not be appropriately informed, and that subsequent investigations into patient safety incidents are hindered. Concern 2: Failure to Document Communication and Escalation Evidence revealed little or no documentation of communication with family members, discussions regarding changes in treatment plans, surgical cancellations, concerns raised or information shared by relatives, or internal communication between healthcare professionals. Family members in this case provided supporting information about Margaret’s conditions and raised concerns regarding her deterioration which ultimately preceded the diagnosis of sepsis, yet there was limited documentation of their instructions or concerns or any action taken in response. I am concerned that failures to record and communicate information effectively between staff and with families create a risk that important clinical information may be lost, deterioration may not be recognised or acted upon, and opportunities to intervene may be missed. Concern 3: Reliability of Patient Safety Assurance Processes The Trust's own review identified learning regarding communication, documentation and the timing of treatment. However, evidence heard during the inquest revealed additional shortcomings that were either not identified or could not be fully explored because of inadequacies in the contemporaneous records. I am concerned that where record keeping is poor, the Trust may be unable to accurately assess the quality and safety of care delivered, identify learning, or assure itself that risks have been addressed. Concern 4: Trust-Wide Nature of the Issue I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site. Similar concerns have arisen in multiple inquests heard by this Court involving different areas of the Trust. In circumstances where recurring deficiencies are being identified across multiple services, there is a risk that systemic shortcomings exist in relation to record keeping, documentation standards, clinical communication and oversight. Unless effective action is taken, there remains a risk that future patients may suffer harm and that future deaths may occur. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]   – Daughter - Son I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Rebecca MUNDY HM Assistant Coroner for Essex

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, 2026-0382

Added to Minute Book

7 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0