Judith Hughes: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
Skip to related content
Date of report: 06/11/2025
Ref: 2025-0563
Deceased name: Judith Hughes
Coroner name: Simon Milburn
Coroner Area: Cambridgeshire and Peterborough
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Chief Medical Officer for North West Anglia Foundation Trust
(Peterborough City Hospital)
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Chief Medical Officer for North West Anglia Foundation Trust (Peterborough City Hospital) | |
| 1 | CORONER I am Simon MILBURN, Area Coroner for the coroner area of Cambridgeshire and Peterborough. |
| 2 | 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. |
| 3 | INVESTIGATION and INQUEST On 16 October 2020 I commenced an investigation into the death of Judith Claire HUGHES aged 86. The investigation concluded at the end of the inquest on 05 November 2025. The conclusion of the inquest was that: Judith died from natural causes. |
| 4 | CIRCUMSTANCES OF THE DEATH Judith Hughes had a past medical history of significant heart disease. She was admitted to Peterborough City Hospital on 30 July 2020 following a tonic clonic seizure, where it was also identified that she was suffering from fast ventricular atrial fibrillation and a high heart rate. These issues were treated and Judith was discharged home on 30 July 2020 at which point there was no evidence that she was in cardiac failure. Judith’s cardiac function declined from this point and she was further admitted to Peterborough City Hospital on 10 August 2020 when there was clear evidence of worsening heart failure. Sadly despite ongoing monitoring and care both in hospital and in the community Judith died at home, 129 Park Road in Peterborough, at 0030 hours on 07 October 2020. |
| 5 | CORONER’S CONCERNS 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: (brief summary of matters of concern) The Inquest heard evidence about the Trust’s use of the ‘Close Observation Risk Assessment’ (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including ‘inpatient falls during this admission’ and ‘previous falls’. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death. |
| 6 | ACTION SHOULD BE TAKEN 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 |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 01, 2026. I, the Coroner, may extend the period. 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family NWAFT Legal Governance I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. |
| 9 | Dated: 06/11/2025 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough |