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Source · Prevention of Future Deaths

Suzanne Fredericks

Ref: 2026-0331 Date: 12 Jun 2026 Coroner: Stephen Simblett Area: Essex 2 responses identified · 3 indexed addressees View PDF

AI-generated concerns summaryConcerns were raised that non-specialist hospitals may not provide sufficiently up-to-date blood test results for transplant patients, impacting survival, and the processes for handling samples may need improvement.

Date 12 Jun 2026
56-day deadline 28 Oct 2026 est. estimated from the Judiciary.uk publication date
Responses identified 2 of 3

Coroner's concerns

AI summary
Concerns were raised that non-specialist hospitals may not provide sufficiently up-to-date blood test results for transplant patients, impacting survival, and the processes for handling samples may need improvement.
View full coroner's concerns
There is a concern as 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.

Responses

2 respondents

East Suffolk and North Essex NHS Foundation Trust

NHS Trust
PDF
AI-classified response stance Action Taken
AI-generated response summary

East Suffolk and North Essex NHS Foundation Trust has decided to standardise the process for specialist blood tests for transplant patients, such as tacrolimus concentration, by sending all samples to a single point of contact with a daily assay to ensure timely and prioritised results.

Cambridge University Hospitals NHS Foundation Trust

NHS Trust
PDF
AI-classified response stance Disputed
AI-generated response summary

The Trust states the concern regarding delayed tacrolimus results is not within its direct control and it is not the appropriate organization to address this risk. It remains willing to support wider regional or national work to improve transplant patient pathways.

Report sections

Investigation and inquest
On 07 November 2024 I commenced an investigation into the death of  Suzanne FREDERICKS aged 41. The investigation concluded at the end of the inquest on 04 June 2026. The conclusion of the inquest was that:  The deceased, who had previously had a liver transplant, suffered liver and kidney problems. She was admitted into Colchester General Hospital for  treatment. That treatment was unsuccessful and the deceased died in that  hospital on 4th November 2024.
Circumstances of the death
The deceased, who had previously had a liver transplant, suffered liver and  kidney problems. She was admitted into Colchester General Hospital for  treatment. That treatment was unsuccessful and the deceased died in that  hospital on 4th November 2024. The conclusion of the inquest was death by  natural causes.  

The inquest heard that the complexity of this patient and the immuno-  suppressant drugs that she was being treated with following her transplant  was particularly challenging. The nephrologists and other specialists involved  in her care needed extremely contemporaneous and informed medical  information about the effects of those drugs on the patients’ condition.  Some of the treating doctors felt that the time taken to process laboratory results was affecting their ability to advise the appropriate clinical treatment for the  deceased.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power  to take such action.

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Report details

Reference
2026-0331
Date of report
12 June 2026
Coroner
Stephen Simblett
Coroner area
Essex

Responses identified

Responses identified 2 of 3
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Oct 2026 (estimated from the Judiciary.uk publication date).

Sent to

Addenbrooke’s Hospital
East Suffolk and North Essex NHS Foundation Trust
NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.