Suzanne Fredericks

Dear Assistant Coroner Simblett,

Re: Regulation 28 Report dated 12 June 2026 Inquest touching upon the death of Suzanne Fredericks

Thank you for your Regulation 28 Report dated 12 June 2026.

| write on behalf of Cambridge University Hospitals NHS Foundation Trust ("CUH") and would like to take this opportunity to express my sincere condolences to Suzanne Fredericks’ family and partner following her death. CUH is grateful for the care with which the family's concerns were explored during the inquest and has reflected carefully on the evidence heard and the concern identified in the Regulation 28 Report.

The concern identified

CUH agrees with the concern identified by the Learned Coroner, namely the ability of clinicians in non-specialist hospitals to obtain sufficiently up to date blood results when managing transplant patients.

Timely tacrolimus monitoring can be an important part of the safe management of transplant patients, particularly where there is renal dysfunction, liver dysfunction, infection, suspected toxicity, or concern regarding graft function.

In providing its response, CUH wishes to ensure that transplant services and the tacrolimus testing pathway are clearly explained.

CUH's role as the tertiary transplant centre

CUH provides specialist transplant services through the Cambridge Transplant Centre. The Cambridge Biomedical Campus hosts the largest and only comprehensive adult solid organ transplant programme in the United Kingdom. Addenbrooke's Hospital is one of a limited number of liver transplant units in the United Kingdom and provides specialist assessment, treatment, advice and follow up for patients with complex transplant related needs.

[Page 2] Within a local hospital pathway, CUH's role is to provide, when required, tertiary transplant expertise, specialist advice regarding appropriate pre trough tacrolimus levels and, where clinically indicated, achievable and in accordance with the patient's w ishes, to work with the general hospital to facilitate transfer.

The Learned Coroner heard evidence of the extensive parallel care Ms Fredericks required from the General Hospital for her acute comorbidities relating to infection, acute kidney injury, dialysis and orthopaedic issues.

The identified concerns CUH is grateful for the Coroner's careful summary of the evidence at the conclusion of the inquest, noting the Coroner's recognition of the continuing involvement of CUH's transplant team during the relevant period, including the provision of specialist advice, discussions regarding transfer, and the efforts made to support Suzanne Fredericks' care despite clear barriers to engagement.

The concerns in this case relate to the ability of general hospitals to obtain up to date and timely pre trough tacrolimus results.

As the Coroner will be aware, Addenbrooke's Hospital is a tertiary centre and, despite this, it has been named as one of the recipients of the Prevention of Future Deaths Report. Accordingly, and in compliance with Regulation 29 of the Coroners (Investigat ions) Regulations 2013, CUH provides the following response based on the factual matrix available at the time of the inquest.

The Response Whilst CUH had the ability to test tacrolimus levels, the samples considered during this inquest were not those for which it was responsible for testing or reporting, save for a single request on 29 October 2024. The laboratory record shows that this request was processed by CUH in a timely manner.

The evidence before the inquest indicated that the General Hospital received tacrolimus results on more occasions than the single occasion on which CUH was involved. It therefore appears that the samples were being sent to another organisation for testing during the relevant period, which is ultimately a matter for the General Hospital and the testing laboratory to assure you accordingly.

Furthermore, CUH does not have the power to compel the General Hospital to send its samples to CUH laboratories to the exclusion of all others.

For these reasons, the identified concern regarding delayed and/or intermittent tacrolimus results is not within CUH's direct control. CUH is therefore not able to ameliorate the risk of death identified in this case. However, CUH recognises the importance of timely tacrolimus monitoring and remains willing to support any wider regional or national work to improve pathways for transplant patients receiving care outside specialist centres.

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[Page 3] Conclusion In CUH's submission, it is not the appropriate organisation to address the risk of death identified by this inquest. Nevertheless, CUH recognises the importance of the issues identified and will continue to engage constructively with the parties identified , NHS England and any relevant regional or national bodies in relation to wider pathway improvement work.

CUH is grateful for the opportunity to respond and remains committed to supporting safe, timely and effective care for transplant patients.

Dear Mr Simblett REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF SUZANNE FREDERICKS WHICH CONCLUDED ON 4 JUNE 2026 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 12 June 2026 (“the Report”). The Report highlighted concerns relating to how clinicians caring for transplant patients in non- specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results. Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved. The information presented below is intended to describe the processes and steps that can be taken by East Suffolk and North Essex NHS Foundation Trust (“ESNEFT”) to mitigate the risk of future deaths and address the concerns you have raised in respect of Colchester General Hospital. 8

[Page 2] TAKING, PROCESSING AND RETURNING SAMPLE RESULTS FOR TRANSPLANT PATIENTS AT COLCHESTER GENERAL HOSPITAL The Renal Unit at Colchester General Hospital are able to process most blood samples for transplant patients but at present are not able to process specialist tests, such as tacrolimus concentration. Colchester General Hospital therefore have to obtain blood samples for such tests and send them to a transplant centre to process and return results. Historically, this approach however is not standard as the blood results have often been sent to the relevant transplant centre where the transplant has taken place, with varying processes for each. The Trust has however taken the decision to standardise the practice and send all blood samples to a single point of contact that has a daily assay for tacrolimus and can prioritise a sample on request. The Trust hopes that the above information demonstrates the steps been implemented to address to the concern in respect of the taking of samples. The Trust are therefore changing the process for testing in Colchester General Hospital in order to reduce this operational risk in the future I would like to personally extend our sincerest condolences to Ms Fredericks’ family for their loss. If I can be of further assistance, please do not hesitate to contact me.