NHS England
NHS / Health Body
Noted
NHS England acknowledges concerns about guidance for surgeons regarding CT scanning after abdominal surgery but notes that clinical guidelines are primarily the responsibility of NICE and Royal Colleges. They note that Clinical Quality colleagues have been asked to engage with the relevant ICB/Trust to ensure learnings have been taken. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Lorraine Sandra Parker who died on 30 March 2024
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 April 2025 concerning the death of Lorraine Sandra Parker on 30 March 2024. Whilst NHS England is not specifically named as a respondent in your Report, the Report was addressed to my colleague the National Director of Patient Safety for NHS England, (and a Deputy Chief Medical Officer at the Department of Health and Social Care (DHSC)).
I am therefore responding to you in my capacity as Co-National Medical Director (Secondary Care) for NHS England, with responsibility for all Regulation 28 Reports addressed to the organisation, and would like to assure you that Dr Fowler has been sighted on your Report and has provided input into this response. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Lorraine’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Lorraine’s care have been listened to and reflected upon.
Your Report raises the concern that there is a lack of guidance for surgeons regarding CT scanning for patients who have undergone major abdominal surgery and where they have a raised C-reactive protein (CRP), which is either continuing to rise or is not decreasing. You raise that clinical judgement alone is not always sufficient in this scenario.
While NHS England notes your concerns, clinical guidelines are primarily the responsibility of the National Institute for Health and Care Excellence (NICE) and the appropriate Royal Colleges. NHS Trusts are expected to have due regard to any clinical guidelines and to implement the appropriate local processes and/or guidance. I note that you have also addressed your Report to the Association of Coloproctology of Great Britain (ACPGBI) and the Royal College of Surgeons, who are the more appropriate organisations to respond to your concerns.
NHS England has however discussed your Report with the ACPGBI, and it is agreed that there is not a requirement for further guidance to be written. CRP levels are National Medical Director for Secondary Care NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
13 June 2025
commonly used as a marker to indicate or exclude evidence of leaks, including anastomotic leaks following abdominal surgery.
The following articles and guidance are relevant and may assist the Coroner further:
• ACPGBI Guidance on Prevention, Diagnosis and Management of Colorectal Anastomotic Leakage – March 2016.
• National Library of Medicine article: ‘Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery’ dated 3 February 2020.
• ‘Early warning model to detect anastomotic leakage following colon surgery: a clinical observational study’ dated 8 October 2024.
NHS England notes the local delays in reporting experienced by Lorraine, who was sent home on 31 January 2024 without a post-operative scan despite an elevated CRP, together with the misreporting of the CT scan in February 2024. Clinical Quality colleagues in the South East region have been made aware of your Report and asked to engage with the relevant Integrated Care Board / Trust on the details of Lorraine’s case and to seek assurance that learnings have been taken.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lorraine, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 April 2025 concerning the death of Lorraine Sandra Parker on 30 March 2024. Whilst NHS England is not specifically named as a respondent in your Report, the Report was addressed to my colleague the National Director of Patient Safety for NHS England, (and a Deputy Chief Medical Officer at the Department of Health and Social Care (DHSC)).
I am therefore responding to you in my capacity as Co-National Medical Director (Secondary Care) for NHS England, with responsibility for all Regulation 28 Reports addressed to the organisation, and would like to assure you that Dr Fowler has been sighted on your Report and has provided input into this response. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Lorraine’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Lorraine’s care have been listened to and reflected upon.
Your Report raises the concern that there is a lack of guidance for surgeons regarding CT scanning for patients who have undergone major abdominal surgery and where they have a raised C-reactive protein (CRP), which is either continuing to rise or is not decreasing. You raise that clinical judgement alone is not always sufficient in this scenario.
While NHS England notes your concerns, clinical guidelines are primarily the responsibility of the National Institute for Health and Care Excellence (NICE) and the appropriate Royal Colleges. NHS Trusts are expected to have due regard to any clinical guidelines and to implement the appropriate local processes and/or guidance. I note that you have also addressed your Report to the Association of Coloproctology of Great Britain (ACPGBI) and the Royal College of Surgeons, who are the more appropriate organisations to respond to your concerns.
NHS England has however discussed your Report with the ACPGBI, and it is agreed that there is not a requirement for further guidance to be written. CRP levels are National Medical Director for Secondary Care NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
13 June 2025
commonly used as a marker to indicate or exclude evidence of leaks, including anastomotic leaks following abdominal surgery.
The following articles and guidance are relevant and may assist the Coroner further:
• ACPGBI Guidance on Prevention, Diagnosis and Management of Colorectal Anastomotic Leakage – March 2016.
• National Library of Medicine article: ‘Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery’ dated 3 February 2020.
• ‘Early warning model to detect anastomotic leakage following colon surgery: a clinical observational study’ dated 8 October 2024.
NHS England notes the local delays in reporting experienced by Lorraine, who was sent home on 31 January 2024 without a post-operative scan despite an elevated CRP, together with the misreporting of the CT scan in February 2024. Clinical Quality colleagues in the South East region have been made aware of your Report and asked to engage with the relevant Integrated Care Board / Trust on the details of Lorraine’s case and to seek assurance that learnings have been taken.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Lorraine, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.