Woman died years after 'getting lost in the system' following discharge from Shrewsbury hospital - coroner

That is the conclusion of a coroner who has sent a “prevention of future deaths” report to the Shrewsbury and Telford Hospital (SaTH) NHS Trust.

Lynn Silcock was admitted to Royal Shrewsbury Hospital on September 12, 2022 with a history of lethargy, breathlessness, fatigue, and loss of appetite over the preceding six weeks.

The following day, a different diagnosis was made of congestive cardiac failure, aortic stenosis, severe anaemia and angiodysplasia.

Ms Silcock was referred to the cardiology team.

On September 14 the decision was made to treat the anaemia first and then transfer Ms Silcock to the cardiology ward for management of her aortic stenosis.

Later that day, an endoscopy and CT virtual colonoscopy was discussed and she was kept on ward 11. Ms Silcock was discharged on September 16 to the care of her GP with a view to be seen as an outpatient in the endoscopy clinic. She would then be referred to the cardiology team for treatment of the aortic stenosis.

A gastroscopy report was received on September 30 but no referral to cardiology was made, and consequently Ms Silcock “was lost in the system”.

She died at her home address on July 10, 2025, aged 65. A post-mortem examination conducted six days later gave a cause of death as:

• Aortic stenosis (on a background of bicuspid aortic value)

• Myocardial fibrosis.

Assistant coroner Heath Westerman said that, had Ms Silcock been referred in an appropriate and timely manner, “more likely than not her death would have been prevented”.

An inquest into Ms Silcock’s death was opened on August 28 this year and adjourned to October 21. However, it was further adjourned for more investigations to be carried out, and for the prevention of future deaths report to be published.

Now Mr Westerman has said that, during the course of the inquest, the evidence revealed matters giving rise to concern. Therefore, it is his opinion there is a risk that future deaths will occur unless action is taken.

Concerns highlighted

• Ms Silcock was discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate

• She was discharged without a cardiology clinic appointment or plan to be later referred

• There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about

• There was no investigation by SaTH into what went wrong and why between the treating teams and their respective administration teams.

Mr Westerman asked SaTH to respond to the report by December 18, detailing action taken or proposed to be taken, setting out the necessary timetable.

What action SaTH is taking

Dr John Jones, medical director at SaTH, said that, before the point Ms Silcock died and had a post-mortem investigation, there was no indication that an incident had occurred. This, he said, was because the cardiology referral had not been received, and there was no tracking on the intended ‘pathway’.

“A detailed review of the circumstances around the lack of referral to cardiology has been unable to determine the exact mechanism whereby the intended referral from the medical team to cardiology failed to occur,” said Dr Jones.

“On this basis, a patient safety investigation has been commissioned to further understand the current risks in inpatient to outpatient referrals across SaTH clinical specialties.”

Dr Jones added that it has not been possible, despite an in-depth review, to explain exactly where the issue that meant the referral was lost occurred.

He went on to explain what short- to medium-term, and long-term, actions the trust will take.

“In the short to medium term, the trust’s medical director and deputy medical director are tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a clear standard operating procedure (SOP) for inpatient to outpatient referrals,” said Dr Jones.

“This will be documented and shared across the team with clear direction on process, roles, and responsibilities in ensuring referrals are made and a system of safety netting is in place to ensure decisions to refer to other specialties are followed through and actioned.

“There will be a single referral email for each speciality for referral for outpatient follow-up, the referrals within the team will then be managed in the standard way all referrals are with appropriate triage. This process will be developed over the next three months with SOPs developed and appropriate communications cascaded.

“The trust has an ongoing programme of digital development to implement digital systems to support clinical teams to work effectively and safely.

“A project feasibility request has already been raised to assess the need for a digital solution to support referral management.

“It is difficult at this stage to give an indication of the timescale for development of any digital solution given the need to scope the process and available systems as well as the prioritisation of funding and scheduling such work.”

An NHS England spokesperson said it will not take any action because the issues fall outside its remit.

“NHS England has long recognised that omissions in information-sharing within or between healthcare organisations can contribute to poor continuity of care and lead to poor health outcomes,” said the spokesperson.

“In 2021, NHS England developed and rolled out a national frontline digitisation programme which aimed to support NHS trusts in England with the procurement and deployment of Electronic Patient Record (EPR) systems.

“As part of this initiative, SATH secured a multi-year funding to implement a replacement Patient Administration System (PAS) and emergency department solution.

“Subsequently, in April 2024, SATH deployed the ‘System C CareFlow EPR’.

“EPR systems typically include locally configurable functionality to ensure that NHS trusts can adapt them to meet their service needs. These systems can include capabilities for creating discharge summaries, patient search functions and the creation of referrals.

“However, despite EPR systems being able to enhance information sharing and referrals, these processes continue to rely on the user taking the correct action and there remains a risk of oversight, which may result in incomplete discharge summaries and/or referrals not being created or sent.

“To mitigate this risk, NHS trusts should ensure that discharge and referral processes are streamlined and aligned with clinical workflows, and that these are formalised within local SOPs.”