East Suffolk North Essex NHS Trust
NHS / Health Body
Action Taken
• The Trust implemented a new electronic patient record system in October 2025. • This system allows internal users to send secure messages to each other on patient records, creating a new line of communication internally. • This has reduced the pressure for response from the medical team for the Medical Assessment Unit by providing an alternative means of communication for internal users. (AI summary)
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Dear Mr Parsley
REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF TERRENCE PERCY FROST WHICH CONCLUDED ON 5 MARCH 2026
I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 9 March 2026 (“the Report”).
The Report highlighted concerns relating to the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department, which may lead to future deaths in cases where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Mr Frost’s had at the time of his arrival.
The information presented below is intended to describe the actions which have been taken by the Trust to mitigate the risk of future deaths and address the concerns you have raised.
COMMUNICATIONS WITH MEDICAL ASSESSMENT UNIT/EMERGENCY DEPARTMENT PRIOR TO OCTOBER 2025
At the time of Mr Frost’s attendance, the Registrars on shift in the Medical Assessment Unit would hold a bleep. This bleep was used to receive calls from both internal and external users seeking guidance regarding the management of patients deemed to require possible management in the
Medical Assessment Unit. This resulted in a significant demand and often led to long wait times for call connections, when the medical team were already responding to another call.
COMMUNICATIONS WITH MEDICAL ASSESSMENT UNIT/EMERGENCY DEPARTMENT SINCE OCTOBER 2025
In October 2025, the Trust implemented a new electronic patient record system, Epic. This new electronic patient record system allows internal users to send secure messages to each other on patient records within the system. This has created a new line of communication internally and has reduced the pressure for response from the medical team for the Medical Assessment Unit providing an alternative means of communication for internal users.
The bleep in the Medical Assessment Unit is now only used for external calls into the departments, increasing the capacity to answer calls in a timely manner and resulting in shorter call waiting queues.
GUIDANCE GIVEN TO BLEEP HOLDERS
During the Medicine Divisional staff meetings, the Divisional Director has reiterated the importance of answering the bleep calls in a timely manner, to those members of staff who hold the bleep.
ACCESSING AMBULANCE SERVICE FOR CONVEYING TO HOSPITAL
In circumstances where a patient is deemed to have suspected sepsis or be in a life-threatening condition presenting to a primary care provider, the expected course of action would be for the primary care provider to seek ambulance attendance to convey the patient to hospital. This would result in the ambulance service pre-alerting the Emergency Department of the patient’s attendance, through a designated hot line for ambulance pre-alerts.
This enables the Emergency Department to obtain relevant information about patients, their reason for attendance, any risks, initial treatment and vital signs ahead of their arrival.
The Trust hopes that the above information demonstrates the actions that have been implemented by the Trust and adequately responds to your concerns
I would like to personally extend our sincerest condolences to Mr Frost’s family for their loss.
If I can be of further assistance, please do not hesitate to contact me.
REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF TERRENCE PERCY FROST WHICH CONCLUDED ON 5 MARCH 2026
I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 9 March 2026 (“the Report”).
The Report highlighted concerns relating to the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department, which may lead to future deaths in cases where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Mr Frost’s had at the time of his arrival.
The information presented below is intended to describe the actions which have been taken by the Trust to mitigate the risk of future deaths and address the concerns you have raised.
COMMUNICATIONS WITH MEDICAL ASSESSMENT UNIT/EMERGENCY DEPARTMENT PRIOR TO OCTOBER 2025
At the time of Mr Frost’s attendance, the Registrars on shift in the Medical Assessment Unit would hold a bleep. This bleep was used to receive calls from both internal and external users seeking guidance regarding the management of patients deemed to require possible management in the
Medical Assessment Unit. This resulted in a significant demand and often led to long wait times for call connections, when the medical team were already responding to another call.
COMMUNICATIONS WITH MEDICAL ASSESSMENT UNIT/EMERGENCY DEPARTMENT SINCE OCTOBER 2025
In October 2025, the Trust implemented a new electronic patient record system, Epic. This new electronic patient record system allows internal users to send secure messages to each other on patient records within the system. This has created a new line of communication internally and has reduced the pressure for response from the medical team for the Medical Assessment Unit providing an alternative means of communication for internal users.
The bleep in the Medical Assessment Unit is now only used for external calls into the departments, increasing the capacity to answer calls in a timely manner and resulting in shorter call waiting queues.
GUIDANCE GIVEN TO BLEEP HOLDERS
During the Medicine Divisional staff meetings, the Divisional Director has reiterated the importance of answering the bleep calls in a timely manner, to those members of staff who hold the bleep.
ACCESSING AMBULANCE SERVICE FOR CONVEYING TO HOSPITAL
In circumstances where a patient is deemed to have suspected sepsis or be in a life-threatening condition presenting to a primary care provider, the expected course of action would be for the primary care provider to seek ambulance attendance to convey the patient to hospital. This would result in the ambulance service pre-alerting the Emergency Department of the patient’s attendance, through a designated hot line for ambulance pre-alerts.
This enables the Emergency Department to obtain relevant information about patients, their reason for attendance, any risks, initial treatment and vital signs ahead of their arrival.
The Trust hopes that the above information demonstrates the actions that have been implemented by the Trust and adequately responds to your concerns
I would like to personally extend our sincerest condolences to Mr Frost’s family for their loss.
If I can be of further assistance, please do not hesitate to contact me.