Shaun Marriott

Dear Ms Andrews Regulation 28 Report - response by Surrey & Sussex Healthcare NHS Trust Inquest touching the death of Mr Shaun Marriott This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to paragraph 7 to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 9 July 2025, made subsequent to the inquest into the death of Mr Marriott, which was concluded on 3 July 2025. The Trust was given until 4 September 2025 to respond to the coroner, pursuant to Regulation 29(4) Coroners (Investigations) Regulations 2013. We would like to start this response by offering our sincere condolences to Mr Marriott’s family and partner. As a Trust we are committed to learning from the issues raised during the Inquest. The Prevention of Future Deaths report identifies that Mr Marriott was not asked directly about his family history of haematological conditions, specifically venous thromboemboli Putting people first Delivering excellent, accessible healthcare An Associated University Hospital of Brighton and Sussex Medical School

NHS Surrey and Sussex Healthcare NHS Trust (blood clots), as this was not required by the computer system when taking a clinical history. We describe the details of the actions that we have undertaken in this regard. The patient questionnaire did not have a place for the patient to enter this important family history. The pre-operative assessment form did not have prompts for the question to be reviewed or asked. The Trust has now added an extra question on the pre-operative assessment ‘power’ form on the Family History Page. The Trust has also included other potential family history that may need further investigation (for example, cardiac, musculoskeletal). The Trust has not yet added this question to the patient questionnaire, but this will be completed with a future update of the questionnaire service itself making the whole process easier for patients. This action will be completed by January 2026. The Trust modified the way the pre-operative assessment form worked because we realised during this investigation that sometimes, patient responses may not have been visible at the time the pre-operative assessment form was completed - this has now been completed. This was not specifically related to this issue at hand. If a response to this question is added then it will add a "problem" to the record of "Significant Family History" and add the detail of what the issues were. This problem and the comments will pull through to the anaesthetic assessment stage and also show in the venous thromboembolism (VTE) form. It will highlight this issue to the anaesthetist on the day of surgery. The Trust may anticipate that this sort of extra information may in fact lead to further investigation(s) and the clock stops for elective surgery - which would have been material in Mr Marriott’s case - if the GP record makes no reference to further investigations. We have also added the VTE form and an asterisk indicating that it has not been completed on the Anaesthetist Workflow page for the day of surgery. The anaesthetists have discussed this issue and it is also being discussed at the next clinical governance day. In addition to these urgent clinical and administrative changes, the Trust has also undertaken an After-Action Review to ascertain how this gap was not identified earlier, and to seek recommendations and actions to ensure any learning from the death of a patient is established promptly and action taken. We hope the above provides you with sufficient information and assurance but if you require more details, please do not hesitate to contact me. 2

NHS Surrey and Sussex Healthcare NHS Trust