Recurance · prevention of future deaths reports
Pre-inquest brief
Junior staff reluctance to challenge senior clinicians
The earlier warning
June Parlour · 28 Sept 2020 · Lincoln Brookes, Essex
“The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.”
judiciary.uk/prevention-of-future-death-reports/june-parlour
What was promised
Stated action 1 · response to June Parlour (28 Sept 2020) · stated timescale: none stated
“We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF).”
judiciary.uk/…/2020-0186-Response-from-East-Suffolk-and-North-E…
What recurred
- 27 Feb 2026 · David Fenn · Lincoln Brookes · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · June Parlour · 28 Sept 2020
“The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.”
Later · David Fenn · 27 Feb 2026
“The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.”
What happened next
No web check of the stated actions has been published for this chain.