West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
Action Taken
• The Stroke team at WSFT immediately contacted the responsible medical team to clarify the correct TIA referral process with them. • The Trust has updated the TIA referral guideline to improve clarity around the process. (AI summary)
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Dear Mr Stewart
Response relating to Regulation 28 Report into the death of Mrs Lauren Moret-Dell
We write further to the report dated 4 February 2026, issued following your inquest into the death of Mrs Moret-Dell. This is a joint response prepared on behalf of both West Suffolk NHS Foundation Trust (WSFT) and the Suffolk and North East Essex Integrated Care Board (ICB). Both organisations acknowledge HM Coroner’s concerns and are grateful for the opportunity to outline the actions taken to address them.
In advance of responding to the specific concerns raised in your report, we would like to express our deep condolences to Mrs Moret-Dell’s family. We are keen to assure Mrs Moret-Dell’s family that the concerns you have raised have been listened to, reviewed and reflected upon.
Please find below details of the ongoing work to address your concerns, which we hope is of some small comfort to Mrs Moret-Dell’s family and friends.
WSFT Response
Matter of Concern: TIA referral HM Coroner expressed concern that clinicians involved in Mrs Moret‑Dell’s care on 23 December 2023 were not proficient in the process to make referrals to the Transient Ischaemic Attack (TIA) Clinic, leading to an incorrect referral route being used.
The following 6 actions have been taken by the Stroke team at WSFT in respect of this matter to address your concern: -
1 Immediate reinforcement of correct TIA referral pathway
Following the identification of the incorrect referral route, Sister Joana Proenca (Lead Nurse, ESOT) immediately contacted the responsible medical team to clarify the correct TIA referral process with them. Through those discussions she has directed them to the appropriate resources on the Trust’s intranet and the learning has been shared widely throughout the medical team on the Acute Assessment Unit (AAU).
2 Updated guideline including flow diagrams
The Trust has updated the TIA referral guideline to improve clarity around the process. It has also introduced new flow diagrams and streamlined the actual referral process. These have been circulated across Medical, Surgical and Emergency Medicine teams.
3 Education, training, and induction improvements
The guideline referred to above has been added to the induction programme for all incoming Medical Registrars so that each new cohort of resident doctors will be taught the correct referral process for when a TIA is suspected.
In addition to the above we have undertaken the following: -
• The Stroke referral processes are reinforced within the Emergency Department mandatory training.
• An e‑learning video and presentation has been created to support early identification of stroke/TIA.
4 Communication reminders Trust‑wide The Stroke team have conducted targeted internal communications to other areas including ED and medical teams, to remind them about the referral pathway.
5 24/7 access to ESOT for referral guidance Medical teams have been reminded that the Emergency Stroke Outreach Team (ESOT) is contactable 24/7 for support with referrals and can assist with form completion and pathway guidance at any time of the day. A review of how effective the TIA referral process is after this event has confirmed that this was an isolated incident.
6 Public awareness and professional reinforcement activities On World Stroke Day, additional internal communications are delivered Trust‑wide, reinforcing the #ActFAST message. This also now includes emphasising timely TIA referrals. The next initiative is planned for May 2026 with the support from the Stroke Association, where the issue will be raised again.
Matter of Concern: Out of Hours Stroke Consultant Access
Although this specific concern is addressed to the ICB, who have responded below, we hope the following information is of assistance to HM Coroner. We hope this information provides additional assurance and supplements the detail below.
The Emergency Stroke Outreach Team, including a stroke specialist nurse, are present 24 hours a day, 7 days a week in hospital. In addition to this, WSFT has access to a telemedicine service, whereby a telemedicine consultant is available remotely between 17:00–08:00 hours on weekdays, and 24 hours on weekends and bank holidays. This is primarily to support thrombolysis decision‑making. The consultant can remotely review scans, check a patient’s history, examination findings, and speak with the patient in real‑time if required.
Since Mrs Moret-Dell’s case, decisions regarding both thrombolysis decisions and mechanical thrombectomy referrals are made by the telemedicine stroke consultant. This service is not universally available and is provided only to patients who meet the eligibility criteria for one or both treatments.
As with most district general hospitals, WSFT does not have a local stroke consultant available to discuss all stroke referrals 24/7. However, since this case, the team have incorporated in their stroke specialists’ handover, the process of mentioning any atypical cases that were reviewed
overnight. Those cases are discussed at 09:00 hours when the stroke specialist doctor starts the shift. In addition to this, the WSFT stroke consultants have agreed to be contactable during night hours for advice where a patient shows atypical or complex symptoms—even outside eligibility windows. We hope this provides assurance that stroke nurses and medical teams have rapid access to senior support.
Matter of Concern: Introduction of CT Perfusion imaging CT perfusion scanning is now available 24/7, enabling an extended treatment window for thrombectomies in patients who have experienced symptoms up to 9 hours from the onset time.
I hope it is clear from the above that WSFT recognises the importance of timely diagnosis and escalation in suspected TIA and stroke cases. We are committed to strengthening staff awareness, improving out‑of‑hours senior support, and enhancing diagnostic capability wherever possible.
ICB Response
The ICB fully acknowledges HM Area Coroner’s concerns in respect of lack of commissioned stroke consultant input for out of hours stroke services at West Suffolk NHS Foundation Trust.
The West Suffolk Hospital has specialist 24/7 consultant cover for all patients presenting with a new or possible stroke. This is provided through the regional telemedicine service to assess whether patients are candidates for thrombolysis or thrombectomy. However, in line with most district general hospitals, this provision is not on site.
The ICB is currently reviewing the stroke specification for WSFT in order to understand what should be in place in line with current NHS standards. We will be working with the Trust to gain assurance the service provision is strengthened to reduce risk and delays in transferring patients to specialist neurological centres.
In addition, the ICB has responsibility to review and monitor all responses and improvements taken following Regulation 28 reports in respect of the services we commission. This will include the actions taken for improvement as identified in this response.
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.
Yours sincerely,
Response relating to Regulation 28 Report into the death of Mrs Lauren Moret-Dell
We write further to the report dated 4 February 2026, issued following your inquest into the death of Mrs Moret-Dell. This is a joint response prepared on behalf of both West Suffolk NHS Foundation Trust (WSFT) and the Suffolk and North East Essex Integrated Care Board (ICB). Both organisations acknowledge HM Coroner’s concerns and are grateful for the opportunity to outline the actions taken to address them.
In advance of responding to the specific concerns raised in your report, we would like to express our deep condolences to Mrs Moret-Dell’s family. We are keen to assure Mrs Moret-Dell’s family that the concerns you have raised have been listened to, reviewed and reflected upon.
Please find below details of the ongoing work to address your concerns, which we hope is of some small comfort to Mrs Moret-Dell’s family and friends.
WSFT Response
Matter of Concern: TIA referral HM Coroner expressed concern that clinicians involved in Mrs Moret‑Dell’s care on 23 December 2023 were not proficient in the process to make referrals to the Transient Ischaemic Attack (TIA) Clinic, leading to an incorrect referral route being used.
The following 6 actions have been taken by the Stroke team at WSFT in respect of this matter to address your concern: -
1 Immediate reinforcement of correct TIA referral pathway
Following the identification of the incorrect referral route, Sister Joana Proenca (Lead Nurse, ESOT) immediately contacted the responsible medical team to clarify the correct TIA referral process with them. Through those discussions she has directed them to the appropriate resources on the Trust’s intranet and the learning has been shared widely throughout the medical team on the Acute Assessment Unit (AAU).
2 Updated guideline including flow diagrams
The Trust has updated the TIA referral guideline to improve clarity around the process. It has also introduced new flow diagrams and streamlined the actual referral process. These have been circulated across Medical, Surgical and Emergency Medicine teams.
3 Education, training, and induction improvements
The guideline referred to above has been added to the induction programme for all incoming Medical Registrars so that each new cohort of resident doctors will be taught the correct referral process for when a TIA is suspected.
In addition to the above we have undertaken the following: -
• The Stroke referral processes are reinforced within the Emergency Department mandatory training.
• An e‑learning video and presentation has been created to support early identification of stroke/TIA.
4 Communication reminders Trust‑wide The Stroke team have conducted targeted internal communications to other areas including ED and medical teams, to remind them about the referral pathway.
5 24/7 access to ESOT for referral guidance Medical teams have been reminded that the Emergency Stroke Outreach Team (ESOT) is contactable 24/7 for support with referrals and can assist with form completion and pathway guidance at any time of the day. A review of how effective the TIA referral process is after this event has confirmed that this was an isolated incident.
6 Public awareness and professional reinforcement activities On World Stroke Day, additional internal communications are delivered Trust‑wide, reinforcing the #ActFAST message. This also now includes emphasising timely TIA referrals. The next initiative is planned for May 2026 with the support from the Stroke Association, where the issue will be raised again.
Matter of Concern: Out of Hours Stroke Consultant Access
Although this specific concern is addressed to the ICB, who have responded below, we hope the following information is of assistance to HM Coroner. We hope this information provides additional assurance and supplements the detail below.
The Emergency Stroke Outreach Team, including a stroke specialist nurse, are present 24 hours a day, 7 days a week in hospital. In addition to this, WSFT has access to a telemedicine service, whereby a telemedicine consultant is available remotely between 17:00–08:00 hours on weekdays, and 24 hours on weekends and bank holidays. This is primarily to support thrombolysis decision‑making. The consultant can remotely review scans, check a patient’s history, examination findings, and speak with the patient in real‑time if required.
Since Mrs Moret-Dell’s case, decisions regarding both thrombolysis decisions and mechanical thrombectomy referrals are made by the telemedicine stroke consultant. This service is not universally available and is provided only to patients who meet the eligibility criteria for one or both treatments.
As with most district general hospitals, WSFT does not have a local stroke consultant available to discuss all stroke referrals 24/7. However, since this case, the team have incorporated in their stroke specialists’ handover, the process of mentioning any atypical cases that were reviewed
overnight. Those cases are discussed at 09:00 hours when the stroke specialist doctor starts the shift. In addition to this, the WSFT stroke consultants have agreed to be contactable during night hours for advice where a patient shows atypical or complex symptoms—even outside eligibility windows. We hope this provides assurance that stroke nurses and medical teams have rapid access to senior support.
Matter of Concern: Introduction of CT Perfusion imaging CT perfusion scanning is now available 24/7, enabling an extended treatment window for thrombectomies in patients who have experienced symptoms up to 9 hours from the onset time.
I hope it is clear from the above that WSFT recognises the importance of timely diagnosis and escalation in suspected TIA and stroke cases. We are committed to strengthening staff awareness, improving out‑of‑hours senior support, and enhancing diagnostic capability wherever possible.
ICB Response
The ICB fully acknowledges HM Area Coroner’s concerns in respect of lack of commissioned stroke consultant input for out of hours stroke services at West Suffolk NHS Foundation Trust.
The West Suffolk Hospital has specialist 24/7 consultant cover for all patients presenting with a new or possible stroke. This is provided through the regional telemedicine service to assess whether patients are candidates for thrombolysis or thrombectomy. However, in line with most district general hospitals, this provision is not on site.
The ICB is currently reviewing the stroke specification for WSFT in order to understand what should be in place in line with current NHS standards. We will be working with the Trust to gain assurance the service provision is strengthened to reduce risk and delays in transferring patients to specialist neurological centres.
In addition, the ICB has responsibility to review and monitor all responses and improvements taken following Regulation 28 reports in respect of the services we commission. This will include the actions taken for improvement as identified in this response.
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.
Yours sincerely,