West Suffolk NHS Foundation Trust
NHS / Health Body
Action Taken
• The Digital and Medicine teams reviewed the electronic patient record system to explore creating a digital solution for flagging critical medication information. • The Trust determined that the current electronic patient record system cannot create an automated digital alert for contraindications at scale. (AI summary)
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Dear Mr Stewart
WSFT information relating to Regulation 28 Report into the death of Roger Smith
I write further to the report dated 6 February 2026, issued following your inquest into the death of Roger Smith. West Suffolk NHS Foundation Trust (WSFT) acknowledges HM Coroner’s concerns and is grateful for the opportunity to outline the actions taken.
In advance of responding to the specific concerns raised in your Report, we would like to express our deep condolences to Mr Smith’s family. WSFT are keen to assure Mr Smith’s family that the concerns raised have been listened to, reviewed and reflected upon.
Please find below details of the ongoing work to address your three concerns, which we hope is of some small comfort to Mr Smith’s family and friends.
Coroner’s Concern 1 - I am concerned that the West Suffolk Hospital patient records management system is ineffective in accurately highlighting important information which should inform patient care and treatment.
This concern has been reviewed by the Digital and Medicine teams to explore if it is possible to create a digital solution for this issue and to consider the process of adding alerts to the electronic patient record system, known locally as eCare. Unfortunately, based on current system capabilities, it is not possible to create an automated digital alert within eCare to warn prescribers against anticoagulating patients with cerebral amyloid angiopathy (CAA).
The Digital and Medicines teams confirm that eCare does not support a universal contraindication‑based alerting function (a digital pop up). Instead, alerts must be built in manually for every individual drug. This would require bespoke configuration for each anticoagulant (of which there are many). It is also not possible to group drugs together by class to raise a generic alert either. As a result, it is not possible to manage a digital alert system at scale.
Furthermore, CAA is not listed as a contraindication for tinzaparin in the BNF (British National Formulary
– which is a comprehensive resource for healthcare professionals, featuring recommended guidance on prescribing, dispensing, and administering medications), meaning there is no nationally recognised evidence base on which to construct a “hard‑stop” alert. Implementing such an alert for CAA alone would set a false expectation that the system can flag all clinical contraindications across all medicines, which is neither possible nor safe, as prescribing decisions require a clinician’s judgement and a patient‑specific risk–benefit assessment. When exploring what was possible the Digital team found that
deciding to prescribe anticoagulants involves a complex decision model requiring the weighing up of a number of factors to balance the risk and benefit specifically relevant in CAA. These considerations cannot be reliably reduced to automated rules without generating significant alert fatigue or inappropriate overrides. For these reasons, any adjustment of practice needs to occur through clinical pathways (e.g., updating VTE assessment guidance) rather than through an electronic prescribing alert.
After exploring the Digital option and ruling this out for the reasons above, in order to address your concern, WSFT intends to take the following action: -
• WSFT will take forward a clinically‑led change to strengthen the visibility of risk factors within the existing VTE assessment processes.
As the current eCare system cannot technically support contraindication‑based alerting across all medications without creating new patient‑safety risks, the Trust will instead work through the Thrombosis Committee to consider adding an explicit reference within the VTE assessment tool to prompt clinicians to review “chronic conditions that may increase the bleeding risk (e.g., CAA).” This ensures CAA is considered during VTE prophylaxis decision‑making while remaining consistent with national guidance and system constraints. This clinical‑governance route will allow any agreed change to be embedded into Trust guidelines.
• The Trust will also strengthen the clarity of nursing roles and responsibilities in recognising and escalating risks associated with patients who repeatedly refuse medication. Whilst refusals of medication are documented by nursing staff within the electronic drug chart, this information does not always reach the prescribing team. To address this gap, the Trust will work with senior nursing leadership to reinforce expectations around proactive escalation, particularly where medication is repeatedly refused, or where a patient or family expresses concerns about treatment risk. This will include reviewing existing nursing handover processes, ensuring nurses understand when and how to raise medication‑related concerns directly with the medical team, and identifying opportunities to embed this into local nursing practice guidance. These steps will complement the technical and clinical governance actions already underway and ensure that the nursing contribution to safe VTE‑prophylaxis decision‑making is clearly defined and consistently applied.
• There is also a Quality Improvement Project (QIP) on ‘safer handovers’ currently underway. Although this project is looking to improve the reported safety and effectiveness of nurse-to- nurse transfers between adult inpatient wards, part of this involves looking at how essential information is highlighted. It is hoped this project will improve the quality of records which is accessible to all healthcare teams and drive-up standards.
We will continue to monitor the effect of these changes outlined above and whether any further steps are necessary to promote the safe prescribing of medication.
Coroner’s Concern 2 - I am concerned that communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
Since Mr Smith’s death on 12 September 2023, the Trust has adopted the national Call 4 Concern / Martha’s Rule programme. As part of this initiative, it introduces a daily structured patient‑wellness question, enabling both doctors and nurses to engage proactively with patients regarding their condition and any emerging concerns.
The programme provides a standardised response matrix that supports staff to escalate concerns consistently and ensures patients and families are afforded regular opportunities to contribute to decisions about their care. After a successful pilot on wards F7 and G4, demonstrating measurable improvement in patient–staff communication and early identification of deterioration, Martha’s Rule/Call
for Concern, was implemented at West Suffolk Hospital on 1 May 2024 across all inpatient areas. This initiative provides patients, relatives, carers and staff with a direct route to request an independent clinical review if they are worried about a patient’s clinical deterioration and feel their concerns have not been adequately addressed by the ward team. Between May 2024 and February 2026, the team received 255 calls. 73 calls were related to clinical deterioration (29%).
The Critical Care Outreach Team (CCOT) is responsible for delivering this service. Their responsibilities include:
• Receiving all calls.
• Conducting an initial triage to assess the nature and urgency of the concern.
• Attending the relevant ward/inpatient area to speak with the individuals raising the concern.
• Liaising with the ward team to review the situation collaboratively and ensure appropriate clinical action is taken.
• Referrals to different specialities, including intensive care if deemed necessary.
• If required, organising/facilitating multidisciplinary teams (MDT) meetings.
This process aims to strengthen patient safety, support open communication and provides an additional safeguard for patients experiencing clinical deterioration. I am sorry that it was not in place at the time of Mr Smith’s care.
Coroner’s Concern 3 - I am concerned that effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA).
Another quality improvement project the Trust has focused on is working to standardise board rounds and huddles to ensure: consistent MDT (multi-disciplinary team) presence; structured information sharing; and, constructive challenge across medical ward areas. Through the PDSA (Plan, Do, Study, Act) cycles, the Trust has now implemented a standardised process across general medical wards, recognising the importance of consistent MDT engagement in supporting safe and effective patient care.
Further review work is underway with the project team to continually assess whether the project is achieving its aim and to refine the approach further where needed. Ongoing monitoring will continue to support improvement and help ensure that any improvements made are sustained.
In addition, medical teams have been reminded that the Early Stroke Outreach Team service is available 24/7 to provide support with referrals, including guidance on pathway requirements and assistance with completing the necessary documentation with targeted internal communications.
To provide some additional assurance about the Trust’s ability to deliver timely specialist stroke team input, the Trust has been awarded an A rating by the Sentinel Stroke National Audit Programme (SSNAP) for the past six years. In our last audit, WSFT scored 94 out of 100. SSNAP audit spans the whole journey and measures how well stroke care is being delivered.
Thank you for bringing this important patient safety issue to our attention. We hope this information assists to address your concerns and please do not hesitate to contact us should you need any further information.
WSFT information relating to Regulation 28 Report into the death of Roger Smith
I write further to the report dated 6 February 2026, issued following your inquest into the death of Roger Smith. West Suffolk NHS Foundation Trust (WSFT) acknowledges HM Coroner’s concerns and is grateful for the opportunity to outline the actions taken.
In advance of responding to the specific concerns raised in your Report, we would like to express our deep condolences to Mr Smith’s family. WSFT are keen to assure Mr Smith’s family that the concerns raised have been listened to, reviewed and reflected upon.
Please find below details of the ongoing work to address your three concerns, which we hope is of some small comfort to Mr Smith’s family and friends.
Coroner’s Concern 1 - I am concerned that the West Suffolk Hospital patient records management system is ineffective in accurately highlighting important information which should inform patient care and treatment.
This concern has been reviewed by the Digital and Medicine teams to explore if it is possible to create a digital solution for this issue and to consider the process of adding alerts to the electronic patient record system, known locally as eCare. Unfortunately, based on current system capabilities, it is not possible to create an automated digital alert within eCare to warn prescribers against anticoagulating patients with cerebral amyloid angiopathy (CAA).
The Digital and Medicines teams confirm that eCare does not support a universal contraindication‑based alerting function (a digital pop up). Instead, alerts must be built in manually for every individual drug. This would require bespoke configuration for each anticoagulant (of which there are many). It is also not possible to group drugs together by class to raise a generic alert either. As a result, it is not possible to manage a digital alert system at scale.
Furthermore, CAA is not listed as a contraindication for tinzaparin in the BNF (British National Formulary
– which is a comprehensive resource for healthcare professionals, featuring recommended guidance on prescribing, dispensing, and administering medications), meaning there is no nationally recognised evidence base on which to construct a “hard‑stop” alert. Implementing such an alert for CAA alone would set a false expectation that the system can flag all clinical contraindications across all medicines, which is neither possible nor safe, as prescribing decisions require a clinician’s judgement and a patient‑specific risk–benefit assessment. When exploring what was possible the Digital team found that
deciding to prescribe anticoagulants involves a complex decision model requiring the weighing up of a number of factors to balance the risk and benefit specifically relevant in CAA. These considerations cannot be reliably reduced to automated rules without generating significant alert fatigue or inappropriate overrides. For these reasons, any adjustment of practice needs to occur through clinical pathways (e.g., updating VTE assessment guidance) rather than through an electronic prescribing alert.
After exploring the Digital option and ruling this out for the reasons above, in order to address your concern, WSFT intends to take the following action: -
• WSFT will take forward a clinically‑led change to strengthen the visibility of risk factors within the existing VTE assessment processes.
As the current eCare system cannot technically support contraindication‑based alerting across all medications without creating new patient‑safety risks, the Trust will instead work through the Thrombosis Committee to consider adding an explicit reference within the VTE assessment tool to prompt clinicians to review “chronic conditions that may increase the bleeding risk (e.g., CAA).” This ensures CAA is considered during VTE prophylaxis decision‑making while remaining consistent with national guidance and system constraints. This clinical‑governance route will allow any agreed change to be embedded into Trust guidelines.
• The Trust will also strengthen the clarity of nursing roles and responsibilities in recognising and escalating risks associated with patients who repeatedly refuse medication. Whilst refusals of medication are documented by nursing staff within the electronic drug chart, this information does not always reach the prescribing team. To address this gap, the Trust will work with senior nursing leadership to reinforce expectations around proactive escalation, particularly where medication is repeatedly refused, or where a patient or family expresses concerns about treatment risk. This will include reviewing existing nursing handover processes, ensuring nurses understand when and how to raise medication‑related concerns directly with the medical team, and identifying opportunities to embed this into local nursing practice guidance. These steps will complement the technical and clinical governance actions already underway and ensure that the nursing contribution to safe VTE‑prophylaxis decision‑making is clearly defined and consistently applied.
• There is also a Quality Improvement Project (QIP) on ‘safer handovers’ currently underway. Although this project is looking to improve the reported safety and effectiveness of nurse-to- nurse transfers between adult inpatient wards, part of this involves looking at how essential information is highlighted. It is hoped this project will improve the quality of records which is accessible to all healthcare teams and drive-up standards.
We will continue to monitor the effect of these changes outlined above and whether any further steps are necessary to promote the safe prescribing of medication.
Coroner’s Concern 2 - I am concerned that communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
Since Mr Smith’s death on 12 September 2023, the Trust has adopted the national Call 4 Concern / Martha’s Rule programme. As part of this initiative, it introduces a daily structured patient‑wellness question, enabling both doctors and nurses to engage proactively with patients regarding their condition and any emerging concerns.
The programme provides a standardised response matrix that supports staff to escalate concerns consistently and ensures patients and families are afforded regular opportunities to contribute to decisions about their care. After a successful pilot on wards F7 and G4, demonstrating measurable improvement in patient–staff communication and early identification of deterioration, Martha’s Rule/Call
for Concern, was implemented at West Suffolk Hospital on 1 May 2024 across all inpatient areas. This initiative provides patients, relatives, carers and staff with a direct route to request an independent clinical review if they are worried about a patient’s clinical deterioration and feel their concerns have not been adequately addressed by the ward team. Between May 2024 and February 2026, the team received 255 calls. 73 calls were related to clinical deterioration (29%).
The Critical Care Outreach Team (CCOT) is responsible for delivering this service. Their responsibilities include:
• Receiving all calls.
• Conducting an initial triage to assess the nature and urgency of the concern.
• Attending the relevant ward/inpatient area to speak with the individuals raising the concern.
• Liaising with the ward team to review the situation collaboratively and ensure appropriate clinical action is taken.
• Referrals to different specialities, including intensive care if deemed necessary.
• If required, organising/facilitating multidisciplinary teams (MDT) meetings.
This process aims to strengthen patient safety, support open communication and provides an additional safeguard for patients experiencing clinical deterioration. I am sorry that it was not in place at the time of Mr Smith’s care.
Coroner’s Concern 3 - I am concerned that effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA).
Another quality improvement project the Trust has focused on is working to standardise board rounds and huddles to ensure: consistent MDT (multi-disciplinary team) presence; structured information sharing; and, constructive challenge across medical ward areas. Through the PDSA (Plan, Do, Study, Act) cycles, the Trust has now implemented a standardised process across general medical wards, recognising the importance of consistent MDT engagement in supporting safe and effective patient care.
Further review work is underway with the project team to continually assess whether the project is achieving its aim and to refine the approach further where needed. Ongoing monitoring will continue to support improvement and help ensure that any improvements made are sustained.
In addition, medical teams have been reminded that the Early Stroke Outreach Team service is available 24/7 to provide support with referrals, including guidance on pathway requirements and assistance with completing the necessary documentation with targeted internal communications.
To provide some additional assurance about the Trust’s ability to deliver timely specialist stroke team input, the Trust has been awarded an A rating by the Sentinel Stroke National Audit Programme (SSNAP) for the past six years. In our last audit, WSFT scored 94 out of 100. SSNAP audit spans the whole journey and measures how well stroke care is being delivered.
Thank you for bringing this important patient safety issue to our attention. We hope this information assists to address your concerns and please do not hesitate to contact us should you need any further information.