David Heffer
4 Jun 2025 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. lack of communication to treating doctor
“The treating doctor was not informed when Mr [name redacted] was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner's office.”
2. incomplete or illegible medical records
“The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation.”
Responses
2025-0274-Response-from-East-Suffolk-and-North-Essex-NHS-Foundation-Trust-.pdf ↗· East Suffolk and North Essex NHS Foundation Trust
Stated action · 1st September 2025
“The Trust acknowledges that the treating endoscopist was not informed of Mr [name redacted] readmission with a complication. The treating endoscopist was only made aware of the readmission following contact from the coroner's service. The Trust acknowledges this represents a missed opportunity for early clinical input from the treating endoscopist, for reflective learning regarding the case and equipment used (specifically, the stent size) and to have open discussions with Mr [name redacted] and his family.”
Stated action · October 2025
“The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 2025, all ESNEFT patient record keeping will be done electronically.”