- Clinicians caring for transplant patients in non-specialist hospitals lack reliably up-to-date blood test results, jeopardising timely appropriate treatment and patient survival.
- The arrangements for taking, processing and returning laboratory sample results may need improvement at Colchester General Hospital and across other UK hospitals.
- ESNEFT, Addenbrooke's Hospital and NHS England must respond within 56 days with details of action and timetables to prevent future deaths.
Date of report: 12/06/2026
Ref: 2026-0331
Deceased name: Suzanne Fredericks
Coroner name: Stephen Simblett
Coroner Area: Essex
This report is being sent to: East Suffolk and North Essex NHS Foundation Trust | Addenbrooke’s Hospital | NHS England
| REGULATION 28: REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| 1 |  CORONER I am Stephen Simblett, HMC Assistant Coroner, for the coroner area of Essex. |
| 2 | DATE OF REPORT 12th June 2026 |
| 3 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 4 | THIS REPORT IS BEING SENT TO 1. ESNEFT – East Suffolk and North Essex NHS Foundation Trust 2. Addenbrooke’s Hospital 3. PFD Regulation 28 NHS You are under a duty to respond to this report within 56 days of the date of this report, namely by August 07, 2026. I, the coroner, may extend the period if an appropriate application is made. |
| 5 | YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. I will pass any representations received to the Chief Coroner for a decision. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary. |
| 6 | SUMMARY OF CORONER’S CONCERN There is a concern as to how clinicians caring for transplant patients in non- specialist hospitals can obtain sufficiently up- to- date blood test results. Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. |
| 7 | ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. |
| 8 | INVESTIGATION AND INQUEST On 07 November 2024 I commenced an investigation into the death of Suzanne FREDERICKS aged 41. The investigation concluded at the end of the inquest on 04 June 2026. The conclusion of the inquest was that: The deceased, who had previously had a liver transplant, suffered liver and kidney problems. She was admitted into Colchester General Hospital for treatment. That treatment was unsuccessful and the deceased died in that hospital on 4th November 2024. |
| 9 | CIRCUMSTANCES OF DEATH The deceased, who had previously had a liver transplant, suffered liver and kidney problems. She was admitted into Colchester General Hospital for treatment. That treatment was unsuccessful and the deceased died in that hospital on 4th November 2024. The conclusion of the inquest was death by natural causes. The inquest heard that the complexity of this patient and the immuno- suppressant drugs that she was being treated with following her transplant |
| 10 | CORONER’S CONCERNS During the course of the inquest I heard evidence 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: |
| 11 | COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: I also have a duty to send a copy of the report to the Chief Coroner. |
| 12 | Stephen Simblett HMC Assistant Coroner Essex |
The post Suzanne Fredericks: Prevention of future deaths report appeared first on Courts and Tribunals Judiciary.
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