Suzanne Edwards

Milton Keynes University Hospital

Luton and Dunstable Hospital

Stoke Mandeville Hospital

I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes

On 26 April 2025 I commenced an investigation into the death of Suzanne EDWARDS aged 71. The investigation concluded at the end of the inquest on 24 July 2025. The conclusion of the inquest was that: Narrative conclusion The deceased died at Bedford General Hospital on 1st December 2024 from sepsis arising from an infected and obstructed kidney. in the 48 hours before her death, she consulted her GP and was later assessed at Milton Keynes University Hospital.  While appropriate individual steps were taken at each contact, there was a failure to recognise signs of a urinary tract obstruction resulting in a lost opportunity to treat the condition before the sepsis developed.

The deceased became very unwell on the 29th November 2024, she was seen by her GP and assessed at Milton Keynes Hospital, she was admitted to Bedford Hospital and underwent surgery to insert a stent in her kidney, she became increasingly unwell and died of sepsis at Bedford Hospital on 1st December 2024.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Emergency Departments at hospitals in this and surrounding jurisdictions do not have reliable access to patients’ primary care records, including recent GP consultations, investigations or concerns.  This means that clinicians are frequently treating acutely unwell patients without full access to their recent medical history, which can delay or misdirect diagnosis and undermine patient safety and continuity of care and lead to avoidable deaths. Without access to a patients full records further lives may be put at risk.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.