Mid and South Essex NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust is undertaking a quality improvement program to improve processes for learning from deaths and will allow sharing of learning between teams and across hospital sites. The Rheumatology team will invite Cardiology colleagues to their meetings and present Miss Muir’s case at the Essex Rheumatology meeting to raise awareness. (AI summary)
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Dear Mr Simblet KC
Regulation 28 Report to Prevent Future Deaths – Miss Evie Gladys Muir
I write further to your Regulation 28 Report to Prevent Future Deaths dated 26 November 2025, relating to the Inquest of Miss Evie Muir.
We have considered your concerns and now set out our formal response to each matter using your numbering as follows.
Matters of Concern
1. That hospital reviews into unusual cardiac deaths such as this one are not more widely shared with other clinicians involved with a patient’s care, and other disciplines, such as, in this case, rheumatology specialists. This means that the full clinical picture of how a patient died may not be sufficiently widely understood.
Many medical specialist societies and national bodies have produced guidance on how to conduct morbidity and mortality (M&M) meetings, and these can be a valuable source of learning for the clinical teams and the wider organisation. At Mid and South Essex NHS Foundation Trust, the Cardiothoracic Centre (CTC) M&M meeting is conducted broadly in line with available guidance including an assessment of whether the death was potentially avoidable. Learning points are shared widely with the CTC team but are currently not included in the Trust-wide mortality review meetings which would allow dissemination to a much wider group of clinicians.
We are currently undertaking a quality improvement programme to improve our processes for learning from deaths in line with our new operating model and clinical governance structure. The new process will allow sharing of learning between teams and across hospital sites.
We do consider that it would have been beneficial for a joint review of Miss Muir’s care by both the Cardiology and Rheumatology teams.
The Rheumatology team have confirmed that they will in future invite Cardiology colleagues to their departmental meetings to improve education of coronary vasculitis and myopericarditis. I understand that the Rheumatology team are working hard to improve awareness and management of cases such as Miss Muir’s.
2. Patients with cardiac problems known to be HLA B27 positive or otherwise known to present rheumatological conditions being adequately assessed for the risks which those rheumatological problems might present, include vasculitis.
My clinical colleagues advise me that the coexistence of Ankylosing spondylitis with systemic vasculitis that specifically targets the coronary arteries is exceptionally rare and primarily documented in isolated case reports.
We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue to increase awareness among allied rheumatology health care professionals. We plan to complete a full review of our Learning From Death’s process this year with the aim of ensuring that it is robust and effective. As part of this work, we will be looking at the effectiveness of M&M meetings and identifying opportunities to elevate their use, with a focus on opportunities for cross-speciality learning. If I can assist further with these matters, please do not hesitate to contact me.
Regulation 28 Report to Prevent Future Deaths – Miss Evie Gladys Muir
I write further to your Regulation 28 Report to Prevent Future Deaths dated 26 November 2025, relating to the Inquest of Miss Evie Muir.
We have considered your concerns and now set out our formal response to each matter using your numbering as follows.
Matters of Concern
1. That hospital reviews into unusual cardiac deaths such as this one are not more widely shared with other clinicians involved with a patient’s care, and other disciplines, such as, in this case, rheumatology specialists. This means that the full clinical picture of how a patient died may not be sufficiently widely understood.
Many medical specialist societies and national bodies have produced guidance on how to conduct morbidity and mortality (M&M) meetings, and these can be a valuable source of learning for the clinical teams and the wider organisation. At Mid and South Essex NHS Foundation Trust, the Cardiothoracic Centre (CTC) M&M meeting is conducted broadly in line with available guidance including an assessment of whether the death was potentially avoidable. Learning points are shared widely with the CTC team but are currently not included in the Trust-wide mortality review meetings which would allow dissemination to a much wider group of clinicians.
We are currently undertaking a quality improvement programme to improve our processes for learning from deaths in line with our new operating model and clinical governance structure. The new process will allow sharing of learning between teams and across hospital sites.
We do consider that it would have been beneficial for a joint review of Miss Muir’s care by both the Cardiology and Rheumatology teams.
The Rheumatology team have confirmed that they will in future invite Cardiology colleagues to their departmental meetings to improve education of coronary vasculitis and myopericarditis. I understand that the Rheumatology team are working hard to improve awareness and management of cases such as Miss Muir’s.
2. Patients with cardiac problems known to be HLA B27 positive or otherwise known to present rheumatological conditions being adequately assessed for the risks which those rheumatological problems might present, include vasculitis.
My clinical colleagues advise me that the coexistence of Ankylosing spondylitis with systemic vasculitis that specifically targets the coronary arteries is exceptionally rare and primarily documented in isolated case reports.
We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue to increase awareness among allied rheumatology health care professionals. We plan to complete a full review of our Learning From Death’s process this year with the aim of ensuring that it is robust and effective. As part of this work, we will be looking at the effectiveness of M&M meetings and identifying opportunities to elevate their use, with a focus on opportunities for cross-speciality learning. If I can assist further with these matters, please do not hesitate to contact me.