Janet Daniels

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

On 14th October 2024 I commenced an investigation into the death of Janet  Sylvia Daniels, aged 74 years. The investigation concluded at the end of the  inquest on the 30th January 2026.  Janet Sylvia Daniels died on 6th of October  2024 at Colchester General Hospital, Turner Road, Colchester, Essex from  Pulmonary Thromboembolism caused by Sepsis arising from Hickman Line  infection on a background of chronic kidney disease 3A and congestive cardiac failure.  The conclusion of the inquest was a Narrative Conclusion reflecting the  (admitted) shortcomings in the Trust’s communication with Mrs Daniels and her  family that preceded – and followed – the transition to end of life care and the  timing of, and clinical basis for, the withdrawal of active treatment which, in turn, probably impacted the timing of her death.

Mrs Daniels died from a recognised complication of a necessary medical  procedure in the context of significant clinical frailty contributed to by multiple co- morbidities and previous surgical interventions.  Her death occurred 6 days after  the withdrawal of treatment including intravenous fluids and antibiotics. On Friday 27th September 2024 Mrs Daniels confirmed to her Responsible  Clinician – in terms – that, notwithstanding very significant pain levels and  concerns about continuing to live with her reduced quality of life, she wished to  continue treatment, specifically including an anticipated further six weeks of  antibiotic treatment. It was acknowledged by the Trust that she had capacity to make these decisions about her immediate future care, management and treatment. On the morning of Saturday 28th September a decision was made by a  Specialist Palliative Care Nurse and a Senior Registrar to move Mrs Daniels to  end of life care and they initiated an Individualised Care Plan for Last Days of  Life (ICPLDL) but did so without clearly relaying or discussing the decision, or  explaining (or documenting) the clinical reasons for the decision, to either the  (capacitous) patient or her family, including those who held Lasting Power of  Attorney for Health and Well-being.  (A copy of the LPA had been provided to  the Trust on Mrs Daniels’ admission). The Trust accepted that there was a  failure to communicate appropriately with the family to ensure that they, and Mrs Daniels, fully understood that a transition to ‘last days of life’ care was deemed  clinically appropriate and/or the basis for that decision. The decision appeared to have been made by reference to the patient’s  presentation over a two-hour period on the morning of the 28th (although the  evidence indicated that Mrs Daniels had been sat up in bed that morning,  drinking tea, eating cereal and conversing with her family).  Neither the patient  or her family were informed of potentially relevant clinical features, including Mrs Daniel’s significantly improved CRP levels, only very moderately raised white  cell count (indicating, according to her Responsible Clinician Consultant, that  her Sepsis had stabilised and was controlled) and, for her, her stable kidney  function. In this context, the agreement of the family members on Sunday 29th September to discontinuation of intravenous antibiotic treatment was made on the basis of  partial and incomplete information.  In evidence the family confirmed that such  agreement would not have been forthcoming had the fuller clinical picture been  explained to them.  Her Responsible Clinician Consultant confirmed in evidence that Mrs Daniels would probably not have died on 6th October 2024 had   intravenous antibiotics and fluid continued to be administered as she had clearly indicated she wished to happen – and the family would have wished to have  happened, had the clinical position been discussed with them as, the Trust  accepted, in should have been .

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. – The Trust accepts that there was a significant failure on the part of clinical and nursing staff to communicate effectively with Mrs Daniels and her family in  respect to critical clinical decision making, and the basis for such clinical  decision making, relating to her transition to end of life care, directly impacting their involvement in decision making regarding the withdrawal of treatment, as required by Trust Policy and Guidance. Evidence from Trust witnesses, including the Langham Ward Manager/Nursing  Sister and two Langham Ward Consultant Gastroenterologists indicated that  clinical and nursing staff were insufficiently familiar with the principles set out in  the Trusts relevant policies and guidance, including the Trust Palliative Care  Guidance issued in April 2025, regarding the relevant considerations involved in the transition from palliative care to end of life care. Taken together, these two features give rise to a risk that patients and family  members may not be appropriately consulted with respect to the basis for and timing of end-of-life care and, accordingly, that withdrawal of active treatment  may be prematurely undertaken.

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.