Prevention of Future Deaths Report: Lorraine Parker (24 April 2025)

Summary

Lorraine Parker’s death was the third within three months at Royal Berkshire Foundation Trust following surgery by the same consultant colorectal surgeon.  

With the permission of both families, the coroner referred to two previous inquests – Mr MR (date of death 4 March 2024), and Mr ME (date of death 28 December 2023) – to focus on the trust’s death investigation processes, and how efficient they have been in terms of picking up issues following each of these deaths.

Content

The coroner instructed independent colorectal surgery experts to comment on the management, using two different experts for the three cases. The coroner made the following findings:

• In the case of Mr ME, a significant surgical error was made when a healthy part of the bowel was removed instead of the area with the cancer, resulting in a much more extensive operation and Mr ME dying around 5 weeks later. This was discussed in a morbidity and mortality meeting, which ends with the simple phrase “await coroner’s report”. A structured judgment review was carried out by a consultant colorectal colleague on 4 May 2024, over four months after the death. According to this review, all of the care given to Mr ME was either “good” or “excellent”.
• A further structured judgement review took place. It would appear that none of the colorectal surgeons was willing to carry this out, resulting in the need for a gastroenterologist to conduct a second review in July 2024, by which time the surgeon had already been suspended from major operative work.
• It is important to note that in a clinical governance meeting in February 2024 (ie before either of these structured judgement reviews) it was noted that there were “no learning points identified” in relation to Mr ME’s case.
• In the case of Mr MR, a structured judgement review took place conducted by a consultant surgical colleague. This report was poor and the coroner wrote to the Chief Medical Officer about it after the inquest. It has the look of the briefest of reviews and tick box exercises. Again, all of the management is referred to as “good”.
• Mr MR’s case was not discussed during the March 2024 morbidity and mortality meeting, despite the fact that a later death (Lorraine Parker’s, on 30 March 2024) was discussed then. Mr MR’s case did not go to a morbidity and mortality meeting discussion until May 2024. The reasons for this remain unclear.
• In Lorraine’s case, there was a morbidity and mortality meeting discussion in March 2024 (or perhaps shortly thereafter). The April clinical governance meeting minutes refer to Lorraine’s case and again state “no learning points”.
• None of these three cases has been the subject of a detailed PSIRF report.

Matters of concern

1. On the evidence from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well.
2. Evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously.
3. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings.
4. There is delayed escalation of concerns.
5. Structured judgement reviews are at best, poor, and at worst, defensive.
6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost.
7. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable.
8. The coroner is concerned about whether the trust has done enough to deal with the concerns about this particular surgeon, not just in the Berkshire area, but more widely.