Gemma Robins

[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner, Penelope Schofield for the Coroner Area West Sussex, Brighton and Hove, in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of [Gemma Louise Robins that concluded on 06 July 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, , Chief Executive of University Hospitals Sussex NHS Foundation Trust provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE: 28 August 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: Whilst it is appreciated that communication is difficult when so many different specialist clinicians are involved in a patient’s care particularly when on the Intensive Care Unit. At the time of Gemma’s death clinicians communicated via text, email and telephone to discuss patient care. I heard that these modes of communication can be extremely challenging and prone to miscommunication when multiple teams were involved with a patient. Although some improvements have been made the Court’s Expert witness indicated that these issues will continue to occur unless there is one centralised system/platform which clinicians across both NHS Trusts have access to and facilitates the use real time recording of communications.
3. DETAILS OF ACTION TAKEN University Hospitals Sussex NHS Foundation Trust confirm: In January 2026 the Critical Care Department of the Royal Sussex County set up a generic email address to use for communication with specialist teams both within and outside of our hospital. All of the Critical Care Consultants have access to this mailbox meaning that any communications will always be

[Page 2] visible to the duty Critical Care Consultant. The Critical Care Consultants at the Royal Sussex County Hospital have agreed that when surgeons or radiologists from other hospitals are offering advice to surgeons or radiologists in the Royal Sussex County Hospital, the Critical Care team will not relay messages between the two due to the risk of miscommunication. Instead, the Critical Care team will facilitate direct communication between the specialists involved as it is safer when the treating clinician and the advising clinician speak directly to one another.
4. DETAILS OF FURTHER ACTION PROPOSED University Hospitals Sussex NHS Foundation Trust confirm: Tertiary Specialties within the Royal Sussex County Hospital, and in other hospitals use the "referapatient" (https://www.referapatient.org/refer-a-patient) referral management system to ensure reliable and accountable communication between clinical teams. We support the use of this or a similar system between clinicians at the Royal Sussex County Hospital and the Hepato-pancreato-biliary service at the Royal Surrey Hospital. This would need to be commissioned by the Royal Surrey Hospital. SIGNATURE Chief Executive

[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Chief Executive, University Hospitals Sussex NHS Foundation Trust The Chief Executive Royal Surrey NHS Foundation Trust The Senior Coroner, Penelope SCHOFIELD, for the Coroner Area of West Sussex, Brighton and Hove in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Gemma Robins that concluded on 6 July 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Medical Director – Royal Surrey NHS Foundation Trust provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 24.08.2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: Whilst it is appreciated that communication is difficult when so many different specialist clinicians are involved in a patient’s care particularly when on the Intensive Care Unit. At the time of Gemma’s death clinicians communicated via text, email and telephone to discuss patient care. I heard that these modes of communication can be extremely challenging and prone to miscommunication when multiple teams were involved with a patient. Although some improvements have been made the Court’s Expert witness indicated that these issues will continue to occur unless there is one centralised system/platform which clinicians across both NHS Trusts have access to and

[Page 2] facilitates the use real time recording of communications.
3. DETAILS OF ACTION TAKEN The Royal Surrey is the tertiary unit for Hepato-Pancreato-Biliary (HPB) and provides advice to hospitals across the Surrey and Sussex region. The service provides a 24/7 on-call HPB Consultant who can be contacted by local hospitals for advice via the switchboard. Outcomes of the HPB MDT are communicated from one centralised pancreatitis team email address. To improve communication, the Trust’s HPB Lead Clinical Nurse Specialist suggested to the Royal Sussex NHS Foundation Trust that other centres in the region are using a generic inbox for receipt of emails from the pancreatic service. The ICU Consultants at the Royal Sussex are now using a generic inbox providing a centralised communication platform that all consultants have access to.
4. DETAILS OF FURTHER ACTION PROPOSED To further improve communication, the Royal Surrey are working towards implementing the Refer a Patient System. This is an on-line referral portal, which enables anyone at the referring and receiving Trust with login details the ability to access the communication about the patient. The Refer a Patient system has been demonstrated by the supplier to the Chief of Service for Surgery and has subsequently been demonstrated to all General Surgery doctors using the test platform. The Refer a Patient portal will greatly improve communication for general surgery as it allows quick access, accurate

[Page 3] information transfer and provides a full record of all referrals received into the HPB service and the communication around them. The Chief of Service is currently finalising the business case for the Refer a Patient System which is fully supported by the Executive Team. The introduction of this system will also support other tertiary services in their communication with their referring organisations. SIGNATURE

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Senior Coroner, Penelope Schofield for the Coroner Area West Sussex, Brighton and Hove in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Gemma Louise ROBINS, and an inquest that concluded on 06 July 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Chief Executive of University Hospitals Sussex NHS Foundation Trust provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 28 August 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: There was a failure to identify at an antenatal appointment that a blood pressure reading for a pregnant woman, in her third trimester (36 weeks) was showing signs of mild hypertension. Therefore no further checks were carried out and the patient left without urine analysis having been undertaken which I understand to be basic routine steps required to check for possible preeclampsia. There was no evidence of any adequate safeguard in place to ensure that these basic checks are carried out at these antenatal appointments.
4. DETAILS OF ACTION TAKEN, University Hospitals Sussex NHS Foundation Trust confirm: Communication regarding the importance of urinalysis and actions to be taken when a raised blood pressure is found has been shared with the maternity staff via the Maternity Message of the Week. This has been reinforced with the ‘Every Urine Sample Matters’ poster, displayed in the antenatal clinics, DAU (Day Assessment Unit), MAU (Maternity Assessment Unit), and Community team facilities. The Antenatal Care guideline has been updated to reflect the importance of

[Page 2] urinalysis.
5. DETAILS OF FURTHER ACTION PROPOSED An anonymised summary of Gemma’s case will be used in multidisciplinary mandatory training within the next annual programme, which is attended by all maternity staff, to highlight the importance of basic observations, including urinalysis, at every appointment. A Documentation Audit is within the Maternity targeted audit programme for financial year 26/27. The proforma for the audit is still under review before the audit is launched but is being planned to include whether the correct observations have been completed and the correct escalation has taken place if abnormal findings are made.
6. SIGNATURE Chief Executive