Roger Smith
6 Feb 2026 · Coroner Darren Stewart · Suffolk
The coroner's concerns
1. missed critical medical information in electronic records
“Important information relating to advice concerning the prescription of anti-coagulation therapy (low weight molecular heparin - LWMH) for venous thromboembolism (VTE) prophylaxis and which was contained in Mr. [name redacted] medical records, was not flagged for clinican attention as part of the electronic records management system in use at West Suffolk Hospital”
2. ineffective patient‑family communication
“communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment”
3. lack of timely specialist stroke team input
“effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA)”