Suzanne Pemberton

I am Sean Horstead, area coroner, for the coroner area of Essex

On  16 th September  2024  I  commenced  an  investigation  into  the  death  of Suzanne Pemberton, aged 61 years’. The investigation concluded at the end of the inquest on the 16 th December 2025. Suzanne Pemberton died on the 16 th September 2024 at Colchester General Hospital  (CGH),  Turner  Road,  Colchester,  Essex  from  a  cause  of  death confirmed  as: (1a)  pneumonia  and  sepsis  (joint  causes), arising  from (1b) exacerbation of long-standing bronchiectasis ; on a contributory background of (2): severe depressive disorder, malnutrition and chronic frailty. The Conclusion of the inquest was a Narrative Conclusion focussed on those aspects of the inadequate care, management and treatment provided by Essex Partnership NHS Foundation Trust (EPUT) that probably more than minimally contributed to the death.

Over the course of a two-year period preceding her death, there were a number of opportunities for (EPUT) staff and clinicians to escalate concerns regarding Suzanne’s  mental  health,  as  raised  by  those  treating  her  in  primary  and secondary care for her complex physical medical needs arsing, principally, from her chronic Bronchiectasis. Suzanne’s lack of concordance with her mental and physical health medication informed a pattern of repeated and extended periods of admission as an in- patient to treat her lung infections which, over time and following each hospital discharge,   led   –   in   that   non-concordance   –   to   chronic   and   sustained deconditioning consequent upon depleted nutritional and physiological reserves This,  in  turn,  directly  contributed  to  the  exacerbation  of  her  chronic  lung condition, leading to repeated infections and, ultimately, the fatal pneumonia and sepsis. The evidence confirmed that by the time of her final admission to CGH on Thursday 12 th September 2024, such was the extent of the depletion of her physical   and   nutritional   reserves   and   consequent   extreme   frailty   and deconditioning, that Suzanne’s death on Monday 16th September was unlikely to be avoidable. It was apparent, however, that from her admission through until the day of her death on 16 th September Suzanne had not been fully assessed in person by the CGH Dietetic team, notwithstanding that she had been referred to dietitians on Friday 13 th at 09:01 hours and then re-referred, the same day, at 10:09 hours and had been deemed, when later triaged, as a Category 2 priority to be seen within 24 hours.

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. Although, in the specific circumstances of this case, the delay in the provision of an  in-person  dietetic  assessment  was  not  a  probable  causative  factor  in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated: “At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding  starter  regimes  where  appropriate  whilst  awaiting  dietetic  input.” (Emphasis added). The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank  Holidays). The  Professional  Lead  further  reconfirmed,  in  terms,  that outside of those hours there is simply no specialist dietetic service or cover of any kind at all for patients at CGH. In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic  Team for  a new business case for funding having not  been taken forward). The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team). She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths.

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