Lynn Silcock
23 Oct 2025 · Coroner Heath Westerman · Shropshire, Telford & Wrekin
The coroner's concerns
1. discharge without cardiology referral
“Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate”
2. discharge without cardiology appointment
“Discharged without a cardiology clinic appointment or plan to be later rereferred”
3. lack of communication between teams
“There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms [name redacted] was then forgotten about”
4. lack of investigation into systemic failures
“No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams”
Responses
2025-0636-Response-from-NHS-England.pdf ↗· NHS England
2025-0636-Response-from-Shrewsbury-and-Telford-Hospital.pdf ↗· Shrewsbury and Telford Hospital NHS Trust
Stated action · February
“The Trust has an ongoing programme of digital development to implement digital systems to support clinical teams to work effectively and safely. A project feasibility request has already been raised to assess the need for a digital solution to support referral management. This is the route whereby needs are reviewed and scoped to develop proposals and business cases to place the need on the Trusts 'digital roadmap' (the overall programme of work to mature the Trusts digital systems). There are several”