Assistant Coroner Rebecca Mundy has raised serious concerns about the Mid and South Essex NHS Foundation Trust's clinical record keeping after the July 2025 death of 82-year-old Margaret Templeman at Southend Hospital. Mundy said missing or incomplete notes on hydration, nutrition and medication meant she could not determine whether essential care was given, and she flagged a lack of family communication records. The trust says it will introduce a new digital patient record system across its sites and has pledged strengthened senior oversight and further improvements.
Coroner Warns Mid & South Essex Trust Over 'Inadequate' Clinical Records After Patient Death
Southend Hospital is run by the Mid and South Essex NHS Foundation Trust [Stuart Woodward/BBC]
Assistant Coroner Rebecca Mundy has criticised the Mid and South Essex NHS Foundation Trust for what she described as "inadequate" clinical record keeping following the July 2025 death of 82-year-old Margaret Templeman at Southend Hospital.
Templeman was admitted to Southend Hospital on 16 July 2025 after a fall at home and suffered a leg fracture. Her condition deteriorated and she died eight days after admission.
In a prevention of future deaths report submitted after the inquest at Essex Coroner's Court in Chelmsford, Mundy said there were "significant deficiencies" in Templeman's clinical records. She highlighted shortcomings in documentation of hydration, nutrition and medication management, and said the records were so incomplete that she could not determine whether essential elements of care had been provided.
"The deficiencies were such that I was unable to determine whether important elements of care had been provided appropriately, or at all," Mundy wrote, adding that these failings were not isolated to one ward or site.
Mundy warned that poor record keeping risks staff missing deterioration in patients' health and making clinical decisions without full information. She also noted there was "little or no documentation" of communication with Templeman's family while she was in hospital.
The Mid and South Essex NHS Foundation Trust, which runs Southend, Basildon and Broomfield hospitals, said it accepts the concerns and is taking action. Dr Christine Blanshard, the trust's chief medical officer, expressed condolences to Mrs Templeman's family and said the trust is developing a new digital patient record system to be used across its sites.
Dr Blanshard added: "We recognise that accurate record keeping is essential to delivering safe, high-quality care. We're committed to learning and making further improvements, supported by enhanced senior oversight at ward level."
What Happens Next
Under the prevention of future deaths process, the trust is expected to respond to the coroner's concerns with an action plan detailing improvements. The coroner's report also noted similar documentation failures in other inquests involving different wards and hospital sites within the trust, a matter that may prompt wider reviews of record-keeping practices.
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