Lynn Silcock

I am Heath Westerman, H.M. Assistant Coroner, for the coroner area of Shropshire, Telford & Wrekin.

On 14 July 2025 I commenced an investigation into the death of Lynn SILCOCK The inquest was opened on 28 August 2025 and adjourned to the 21 October 2025. On 21 October 2025 the inquest was adjourned for further investigations and the issue of this Prevention of Future Deaths Report

Ms Silcock was admitted to The Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury,   Shropshire on 12 September 2022 with a history of lethargy, breathlessness, fatigue and loss of  appetite over the preceding 6 weeks. She was 62 years old. On 13 September 2022 on ward 11 a  differential diagnosis was made of congestive cardiac failure, aortic stenosis, severe anaemia and  angiodysplasia and she was referred to the cardiology team. On 14 September 2022 it was decided to  treat the anaemia first and then transfer to cardiology ward for management of her aortic stenosis. Later that day an endoscopy and CT virtual colonoscopy was discussed and she was kept on ward 11. She was discharged on 16 September 2022 to the care f her GP with a view to then be seen as an  outpatient in the endoscopy clinic on the 2 week rule pathway and then be referred to the cardiology  team for treatment of the aortic stenosis. A gastroscopy report was received on 30 September 2022 but no referral to cardiology was made and consequently she was lost in the system. She died at her home address on 10 July 2025. A postmortem examination conducted on 16 July 2025 gave a cause of death as: 1a. Aortic stenosis (on a background of bicuspid aortic value).

1. Myocardial fibrosis.

Had Ms Silcock have been referred in an appropriate and timely matter, more likely than not her death would have been prevented.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the  discharge was appropriate. (2) Discharged without a cardiology clinic appointment or plan to be later rereferred. (3) There was no document exchange or communication between the gastroenterology team and the  cardiology team meaning that Ms Silcock was then forgotten about. (4) No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between  the treating teams and their respective administration teams.

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.