Michael Chadwick

Dear Mr Hartley

Inquest: Michael Chadwick - Prevention of Future Death Report [PFDR] Response

I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Death Report issued on 27th April 2026 following the Inquest into the sad death of Mr Michael Chadwick. The enclosed commentary document responds to each of the concerns raised relating to Nottingham University Hospitals NHS Trust.

May I begin with offering my sincerest condolences to Mr Chadwick’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest.

The actions taken in response to the learning from the inquest are summarised in the attached document. Oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight and the Committees of our Board will receive a progress report.

I hope that this document provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.

Inquest touching the death of Michael Chadwick Response of Sherwood Forest Hospitals NHS Foundation Trust to Regulation 28 report to prevent future deaths This is the organisational response from Sherwood Forest Hospitals NHS Foundation Trust (SFH) to the Regulation 28: Report to Prevent Future Deaths issued by HM Assistant Coroner, following the conclusion of the inquest touching the death of Mr Michael Chadwick. We offer our condolences to Mr Chadwick’s family, and we hope our actions as a Trust provides reassurance of our commitment to ensuring that we learn from this and prevent future deaths. During the course of the inquest there was one matter of concern raised, as follows;
1. On multiple occasions that Mr Chadwick was assessed, and his cough syncope brought to the attention of the medical professionals, there was no advice given to him to stop driving and to notify the DVLA of his cough syncope, either orally or in writing. The HM Assistant Coroner is concerned that clinicians may fail to provide similar guidance to other patients, which may lead to episodes of syncope whilst driving, with potentially fatal consequences. An action plan has been formulated, and the Trust will continue to monitor the completion of these actions by attaching evidence of their completion that will be securely stored on the Trust’s datix incident system alongside the relevant action ID number to provide assurance of their completion. Patient Safety Alert – Fitness to Drive: Ask, Advise, Document A Trust wide patient safety alert has been developed, regarding Fitness to Drive: Ask, Advise, Document, this alert identifies that despite clinical contact, there was no documented evidence that the patient was advised not to drive, or to notify the DVLA of a relevant change in health status. The patient safety alert was signed off at Patient Safety Incident Response Group on 14/05/2026. Communication to all Heads of Service and Clinical Governance Leads Disseminate the DVLA guidance to colleagues via Clinical Governance meetings, reminding clinicians that considering fitness to drive is part of routine clinical assessment where conditions, symptoms or treatments may affect safe driving. As part of this communication clinicians are required to familiarise themselves with the DVLA Assessing fitness to drive guidance (2025). Added to all governance reports by 30th June 2026 and email sent to all Heads of Service and Clinical Governance Leads in Medicine Division. Add DVLA guidance to the Trust intranet. The guidance will be added to the intranet, this can be searched with keywords such as driving, drive, DVLA, or the full file name. This action is complete.

Add the DVLA guidance to be added to the learning area on EOLAS, as part of the extended learning and resources. The guidance will be added to the learning area.

The DVLA link regarding medical conditions to be added to Cardiology intranet page. The DVLA link to be added to the Cardiology intranet page regarding medical conditions.

Actions added to Datix

Action ID Description Planned action Due date Action allocated ('To') 7154 Patient Safety Alert for Fitness to Drive A Trust wide patient safety alert has been developed, regarding Fitness to Drive: Ask, Advise, Document, this alert identifies that despite clinical contact, there was no documented evidence that the patient was advised not to drive, or to notify the DVLA of a relevant change in health status. This will be added to all governance reports. 18/05/2026 Completed 7155 DVLA guidance to be shared to all Heads of Service and Clinical Governance Leads Disseminate the DVLA guidance to colleagues via Clinical Governance meetings, reminding clinicians that considering fitness to drive is part of routine clinical assessment where conditions, symptoms or treatments may affect safe driving. As part of this communication clinicians are required to familiarise themselves with the DVLA Assessing fitness to drive guidance (2025). 30/06/2026 7156 DVLA guidance to be added to the Trust intranet The guidance will be added to the intranet, this can be searched with keywords such as driving, drive, DVLA, or the full file name. 18/05/2026 Completed 7157 Add the DVLA guidance to the learning area on EOLAS, as part of the extended learning and resources The guidance will be added to the learning area. 30/06/2026

7175 Available DVLA link on the Cardiology Specialist Intranet Page The DVLA link to medical conditions including syncope to be added to the Cardiology intranet page. 31/05/2026

Signed off at Patient Safety Incident Review Group (PSIRG) 21/05/2026.

Dear Mr Hartley Re: Michael Chadwick DOB 27.06.78 (deceased) Late of 13 Turner Lane, Boughton, Newark, Nottinghamshire, NG22 9HN Following on from your concerns outlined in your report for Mr Chadwick, we would like to take this opportunity on behalf of the Partnership at Middleton lodge Practice to offer our sincere condolences to the family of Mr Chadwick. We have continued to support his wife at this difficult time. We have performed a case review of his records and hospital correspondence specifically regarding potential missed opportunity of notification not to drive and the potential risk of future missed opportunity. Whilst I can see there has been mention on a number of occasions where Mr Chadwick had a sudden loss of consciousness collapse, later noting a diagnosis of cough syncope which is identified from your inquest, this would require advice to stop driving and DVLA notification, no mention of this advice is present in the GP records. I am unable to comment if this information was verbally given but not written, as both clinicians who saw Mr Chadwick during this time have since left our Practice, one emigrating. We have taken this opportunity to review and discuss Mr Chadwick's case at both senior and clinical level, where I presented a case presentation at a clinical meeting where it was felt that on balance the majority of clinicians present felt 1

that this was a complex case, had multiple speciality input but on balance would and should have resulted in advice regarding fitness to drive. As a Practice this has highlighted the need to refresh our knowledge of the DVLA standards and guidance for medical professionals. All clinicians were advised to keep this guidance as a bookmark for ease of access. We have also identified the importance of accurate documentation, if this advice is given verbally but not documented, even if fitness to drive has been consider but deemed safe, both relevant and need clear documentation. There is also the ability to quick code this advice via our clinical system, SystmOne. This also includes a quick guide and notification responsibilities of the patient and clinicians. One clinician reflected on a recent case of collapse where it was unclear if this advice was given, where they have since reviewed this case and contacted the patient for review, communicating the specialities involved that this advice has been given. Following from this I plan to run a system audit in 6months to audit the use of readcodes/identification. We continue to offer support to Mrs Chadwick and offer opportunity for further discussions.