Neil Carter

Care Quality Commission

Citygate
Gallowgate
Newcastle upon Tyne
Dr Sean Cummings NE1 4PA
HM Assistant Coroner London (Western District) Telephone: 03000 616161
Coroner's Office Fax: 03000 616171
25 Bagleys Lane
Fulham www.eqc.org.uk
SW6 2QA
8 May 2014

BY EMAIL and POST

Care Quality Commission
Re: Inquest into the death of Mr Neil James Carter

Dear Dr Cummings

Thank you for your report dated 5 March 2014 in which you wrote to us under the
provisions of Regulations 28 and 29 of the Coroners (Investigations) Regulations
2013 in relation to the inquest into the death of Mr Neil Carter.

We are extremely saddened to learn of the circumstances leading to Mr Carter’s
death on 20 November 2012. We are also very grateful for identifying particular
concerns and for requiring the Commission to review what actions should be taken to
prevent the occurrence or continuation of such circumstances in the future.

Please treat this letter as the formal response of the Care Quality Commission (‘the
Commission’) to your report of 5 March 2014.

In your report and pursuant to the requirements of Regulation 29 of the Regulations
you require the Commission to provide details of any action that has been taken or
which is proposed to be taken in response to the concerns highlighted in your report,
or an explanation as to why no action is proposed if appropriate.

In responding to your Report we endeavour to address the three specific concerns
raised in the order that you set them out. We will also outline proposed developments
in the Commission’s regulatory functions across Mental Health Services more
generally. Before doing so, however, we set out below an overview of the
Commission’s recent regulatory action in relation to The Priory Hospital Roehampton.
We do so with the aim of providing some context and overview for our actions and to
address some of the underlying concerns you raised in relation to The Priory Hospital
Roehampton as follows:

e An introduction to the role of the Commission in the context of The Priory
Hospital Roehampton;

e The Commission's recent regulatory involvement with The Priory Hospital
Roehampton;

e The Commission's response to the specific concerns set out in your report
arising from the death of Mr Neil James Carter; and

e The proposed future regulatory response across Mental Health Services.

The Commission: An introductory summary of our regulatory responsibilities

The Commission has the following fundamental statutory functions conferred on us
by the Health and Social Care Act 2008 (‘the Act’):

e Registration functions;

e Review and investigation functions;

e Monitoring, compliance and enforcement functions; and
e Functions under the Mental Health Act 1983.

Our main objective in performing our functions is to protect and promote the health,
safety and welfare of people who use health and social care services.

We perform our functions for the general purpose of encouraging the following:

¢ The improvement of health and social care services;

¢ The provision of health and social care services in a way that focuses on the
needs and experiences of people who use those services; and

¢ The efficient and effective use of resources in the provision of health and
social care services.

In performing our functions, we must have regard to the following:

e Views expressed by or on behalf of members of the public about health and
social care services;

e Experiences of people who use health and social care services and their
families and friends;

e Views expressed by Local Healthwatch organisations about the provision of
health and social care services;

e The need to protect and promote the rights of people who use health and
social care services. Those right inciude in particular the rights of children, of
persons detained under the Mental Health Act 1983, of persons who are
deprived of their liberty in accordance with the Mental Capacity Act 2005, and
of other vulnerable adults;

e The need to ensure that action by the Commission in relation to health and
social care services is proportionate to the risks against which it would afford
safeguards and is targeted only where it is needed;

e Any developments in approaches to regulatory action, and best practice
among persons performing functions comparable to those of the Commission

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(including the principles under which regulatory action should be transparent,
accountable and consistent); and
¢ Such aspects of government policy as the Secretary of State may direct.

The Act requires the Commission to publish guidance about compliance with the
requirements of the regulations. The Commission has published “Guidance about
compliance, Essential standards of Quality and Safety’ (‘the Guidance’) which
provides advice to providers about how and what they need to do to comply with the
Regulations in the form of outcomes and prompts.

The Guidance sets out what people who use services have a right to expect about
the quality and safety of care. There are 16 standards that compliance inspectors
inspect as part of their role. Those standards deal with aspects of care such as
treating people with dignity and respect, providing effective and appropriate care and
treatment that meets their needs and protects their rights, protecting people from
abuse, having clean environments and having enough qualified and supported staff
to provide the care needed.

In addition we are the body corporate delegated to monitor the exercise of duties and
powers of the Mental Health Act 1983 as set out in section 120 of the Mental Health
Act 1983 (‘the Mental Health Act’) as well as associated directions and regulations.
These state in particular that the Commission:

e Must keep under review and, where appropriate, investigate the exercise of
the powers and the discharge of the duties conferred or imposed by the
Mental Health Act so far as relating to the detention of patients or their
reception into guardianship or to relevant patients. Relevant patients are
patients liable to be detained under the Mental Health Act, community
patients, and patients subject to guardianship.

e Must make arrangements for persons authorised by the Commission to visit
and interview relevant patients in private.

e Must make arrangements for persons authorised by the Commission to
investigate any complaint as to the exercise of the powers or the discharge of
the duties conferred or imposed by the Mental Health Act in respect of a
patient who is or has been detained under the Mental Health Act or who is or
has been a relevant patient. These arrangements:

o may exclude matters from investigation in specified circumstances, and

© do not require any person exercising functions under the arrangements
to undertake or continue with any investigation where the person does
not consider it appropriate to do so.

For the purposes of a review or investigation, the Commission may at any
reasonable time:

e Visit and interview in private any patient in a hospital or regulated
establishment,

¢ lf the authorised person is a registered medical practitioner or approved
clinician, examine the patient in private there, and

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¢ Require the production of and inspect any records relating to the detention or
treatment of any person who is or has been detained under this Act or who is
or has been a community patient or a patient subject to guardianship.

In monitoring the operation of the Mental Health Act, the Commission must also
ensure that registered providers and wider statutory services work within the Mental
Health Act Code of Practice unless there are cogent reasons for departure.

In addition, since the UK ratified the United Nations Optional Protocol to the
Convention against Torture (OPCAT’) in 2009 we are required to prevent torture and
other forms of inhuman or degrading treatment through regular visits to places of
detention by bodies known as National Preventive Mechanisms (‘NPM’). As the
visiting body to places of psychiatric detention in England, the Commission is part of
the UK’s NPM and our work helps to fulfil the UK’s legal obligations under the
OPCAT.

The Commission’s response and regulatory functions encompass first health and
social care statutory functions under the Health and Social Care Act 2008, as well as
the associated Care Quality Commission (Registration) Regulations 2009 and the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2010; secondly,
they comprise the role as the body monitoring the exercise of duties and powers of
the Mental Health Act.

The Commission’s recent regulatory involvement with The Priory Hospital
Roehampton

As you are aware The Priory Hospital Roehampton is an independent hospital
specialising in the management and treatment of mental health problems including
addictions and eating disorders, and the treatment of people detained under the
Mental Health Act.

Since June 2013 the Commission have carried out the following compliance
inspections of The Priory Hospital Roehampton:

1. 25 June and 3 July 2013: On those dates the Commission carried out an
unannounced joint compliance inspection by a team that included compliance
inspectors, a pharmacy inspector and a Mental Health Act Commissioner. The
visit was carried out following concerns that the Commission had received
about the care being provided. This visit was also the first inspection visit
following the death of Mr Carter. The inspection focussed on 8 outcomes, and
the service was found to be non-compliant with four outcomes. We set out a
summary of the findings below:

(1) Outcome 1: Respecting and involving people who use services. This
corresponds with Regulation 17 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010.

The Priory Hospital Roehampton was found to be non-compliant with this
outcome and the provider was required to take appropriate action to achieve
compliance with the regulations.

5

(2) Outcome 2: Consent to care and treatment. The Priory Hospital Roehampton
was found to be meeting this standard.

(3) Outcome 4: Care and welfare of people using the service. The Priory Hospital
Roehampton was found to be meeting this standard.

(4) Outcome 7: Safeguarding of people who use the service from abuse. The
Priory Hospital Roehampton was found to be meeting this standard.

(5) Outcome 9: Management of medicines and corresponds. This corresponds to
Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010.

The Priory Hospital Roehampton was found to be non-compliant with this
outcome and the provider was required to take appropriate action to achieve
compliance with the regulations.

(6) Outcome 10: Safety and suitability of premises. This corresponds to
Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010.

The Priory Hospital Roehampton was found to be non-compliant with this
outcome and the provider was required to take appropriate action to achieve
compliance with the regulations.

(7) Outcome 13: Staffing. This corresponds to Regulation 22 of the Health and
Sociat Care Act 2008 (Regulated Activities) Regulations 2010.
The Priory Hospital Roehampton was found to be hon-compliant with this
outcome and the provider was required to take appropriate action to achieve
compliance with the regulations.

(8) Outcome 17: Complaints: The Priory Hospital Roehampton was found
compliant with this standard.

Where The Priory Hospital Roehampton was found non-compliant the
Commission required that compliance actions be taken. The provider sent a
report setting out the actions that were being taken, which were acceptable to the
Commission.

2. 24 October 2013: The Commission undertook a joint unannounced inspection
in direct response to information that was received following a death of a
patient at the hospital in September 2013. The inspection was conducted by
compliance inspectors and a Mental Health Act Commissioner. The inspection
focussed on outcome areas that related to some of the concerns raised
including emergency procedures, observation policies and staff training and
also assessed whether the actions required to achieve compliance with
Outcomes 14 and 10, following the inspection on 25 June and 3 July 2013, had
been completed. The Priory Hospital Roehampton was found to be compliant
with all outcomes that were assessed. We set out a summary of those findings
below:

(1) Outcome 1: Respecting and involving people who use services.
The Priory Hospital Roehampton was found to have become compliant with
this standard with compliance actions satisfactorily met.

(2) Outcome 4: Care and welfare of people using the service. The Priory Hospital
Roehampton was found to be meeting this standard.

(3) Outcome 7: Safeguarding of people who use the service from abuse. The
Priory Hospital Roehampton was found to be meeting this standard.

(4) Outcome 10: Safety and suitability of premises. The Priory Hospital
Roehampton was found to have become compliant with this standard with
compliance actions satisfactorily met.

(5) Outcome 14: Supporting workers. The Priory Hospital Roehampton was found
to have become compliant with this standard with compliance actions
satisfactorily met.

3. 12 March 2014: The Commission carried out a joint unannounced inspection
comprising a compliance inspector, a Mental Health Act Commissioner and a
pharmacy inspector. The inspection focussed on assessment against
outcomes 9 and 13 to consider whether the compliance actions that were
required following the inspections on 25 June and 3 July 2013 had been
satisfactory completed. We summarise the findings below:

(1) Outcome 9: Management of medicines. The Priory Hospital Roehampton was
found to be meeting this standard.

(2) Outcome 13: Staffing. The Priory Hospital Roehampton was found to be
meeting this standard.

The specific concerns set out in your report arising from the death of Mr Carter

Having provided the context in which the Commission currently operates we now set
out our considered response to the specific concerns arising from the death of Mr
Carter that were identified in your report of 5 March 2013.

1. There were repeated failures to perform basic nursing observations

One of the steps that the Commission has undertaken in response to this has
been to consider observation training as part of the follow-up inspection of staffing
standards on 12 March 2014. The inspection on 12 March comprised a joint
unannounced inspection comprising a compliance inspector, a Mental Health Act
Commissioner and a pharmacy inspector. The inspection of 12 March focussed
on assessment against outcomes 9 (Medicines Management) and 13 (Staffing) to
consider whether the compliance actions that were required following the
inspections on 25 June and 3 July 2013 had been satisfactory completed. During
the inspection of 14 March the Commission found training on how to carry out

7

observations formed a specific component of improved training that had been
introduced by The Priory Hospital Roehampton for agency staff.

Observation training was also a specific component of improved training for new
permanent staff. All new staff underwent an ‘assessment of competence to carry
out observation’ when they began employment. This included assessment of their
understanding of the observation policy, recording observations and
responsibilities when carrying out observations. These competencies were signed
off by the ward manager once completed before staff could work on the wards. In
addition, all staff were given quick reference ‘flash cards’ which they were able to
refer to if they needed reminding of certain procedures including the one on
observations.

The provider’s observation policy and the implementation of that policy were
considered in detail at the inspection of October 2013, which was carried out by
compliance inspectors and a Mental Health Act Commissioner. The policy and its
implementation met appropriate standards and the provider was found to be
compliant with the regulations in this respect. However, we will continue to
monitor information we receive from and about the provider in this respect and will
use the information highlighted in the Report to plan and focus the Commission’s
next inspection of The Priory Hospital Roehampton.

2. Inadequate numbers of staff with an inappropriate skill mix and with an
inappropriate layout over two floors.

In relation to the concern about the inadequacy of staff numbers and skill mix at
The Priory Hospital Roehampton, the Commission incorporated that concern into
the inspection of The Priory Hospital Roehampton on 14 March 2014. The
Commission found that there had been improvements in staffing at the location
since the death of Mr Carter. In particular:

e Ward managers confirmed that there had been a recruitment drive since the
death of Mr Carter.

° The Priory Hospital Roehampton’s Human Resources (HR) department
detailed the changes that had introduced since our previous inspection in
October 2013. In particular, whereas all staff recruitment had previously been
carried out centrally, away from the site which was having an impact on the
amount of time it took to recruit staff, all assessment days and interviews are
now taking place on site. They reported that this had reduced the average
time that it took to recruit permanent staff and carry out all the necessary
Disclosure and Barring Service (DBS formerly known as Criminal Records
Bureau or CRB) checks and occupational health checks was approximately 20
working days, a reduction of 15 days. All staff interviews included a three point
competency assessment which tested candidates on drug calculation, care
planning and verbal reasoning. Successful candidates were interviewed by a
panel which consisted of a clinical services manager, HR staff and a ward
manager.

¢ The provider had carried out a needs analysis to calculate how many more
staff were needed. We saw that although there were still some vacancies
open at the hospital, the provider had taken steps to try and recruit into these
positions. Since June 2013, 56 clinical staff had been recruited. We were
shown evidence that since our previous inspection in October 2013 the use of
agency staff across the whole hospital had reduced from 18% to 8%.

e A Mental Health Act Commissioner made a further visit to the ward, where Mr
Carter was a patient, on 19 March 2014. They found safe staffing levels were
in place on that occasion. However, the Commission intends that ward staffing
levels and, in particular, the skill-mix of staff be incorporated within our
monitoring of the provider, as well as in the planning and focus of our next
inspection of The Priory Hospital Roehampton.

e The appropriateness of the ward layout over two floors and its impact on
patient care has not been specifically looked at by the Commission to date in
its inspections since the death of Mr Carter. Within the Commission’s
regulatory methodology this concern relates to outcome 10 dealing with the
safety and suitability of premises. Outcome 10 corresponds to regulation 15 of
the Heaith and Social Care Act 2008 (Regulated Activities) Regulations 2010.
We are grateful that this concern has been brought to our attention and we
intend to incorporate the outcome specifically into the planning and execution
of our next inspection of the hospital.

3. There was deliberate falsification of a nursing record

The Commission has seen no evidence of deliberate falsification during the
course of our inspections. It is extremely worrying that such evidence was
presented. It is also a very difficult thing for the Commission to identify either in
regular monitoring or at an inspection visit unless it had been brought to our
attention by staff, patients or relatives. Nevertheless, this information will
inform the planning and delivery of the next inspection visit of The Priory
Hospital Roehampton.

The Commission would also respectfully suggest that if it has not been done
so already this may be a matter which would require referral to the relevant
professional regulatory body, whether NMC, GMC or otherwise.

The Commission plans to undertake the next inspection visit of The Priory Hospital
Roehampton within the next four months. The precise date of the inspection has not
been set and it is to be unannounced. It is also intended that that visit would consider
not only the specific areas of concern highlighted in this report but also those
highlighted in a separate Regulation 28 report that was addressed to the Commission
following the inquest into the death of another service user at The Priory Hospital
Roehampton. That visit would also take account of any further intelligence that is
gathered or brought to the Commission's attention before that inspection. The
planning of that inspection is also being coordinated with the Mental Health Act
Commissioners’ monitoring of the provider for the same purposes.

The Commission’s proposed future regulatory response across Mental Heaith
Services

In more general terms the Commission has published its intentions for a more
specialised approach to the inspection of mental health services in both the NHS and
independent sector. The changes are set out in a fresh start for the regulation and
inspection of mental health services. An overview of the main changes proposed
include as follows:

e Full integration of regulation and Mental Health Act (MHA) monitoring;

¢ Including Mental Health Act specialists on all inspections of mental! health
services;

e Inspection teams of specialist inspectors, experts by experience and
professional experts;

e Ratings for mental health services — services will be rated outstanding, good,
requires improvement, or inadequate;

e New ways of engaging with people who use services, their careers and
families, during inspections and at other times;

e Greater focus on community mental health services:

e Making sure we have better information about mental health services and
developing our intelligent monitoring system for these services;

e Looking at how people are cared for as they move between services;

e Recognising that mental health treatment and support is part of services in all

sectors;

¢ The appointment of new Chief and Deputy Chief Inspectors of Hospitals. This
includes the appointment a as Deputy Chief Inspector of
Hospitals with a portfolio of ealtn services. It is hoped that those

appointments will provide important specialist leadership for our regulatory
and MHA monitoring roles.

It is hoped that the proposed changes will help identify poor mental health care and
point to interventions when things need to be put right. We are testing out our new
methodology with “Wave 1” inspections of NHS mental health trusts occurring during
this financial year. We hope to learn from these inspections to ensure our regulatory
responses are robust, proportionate and sustainable.

In our most recent annual report on the use of the Mental Health Act, we have also
stated our expectation that we hope to see improvements in certain key areas
including an expectation that Commissioners and providers of mental health services
being proactive in initiating and embedding learning from the deaths of people
subject to the Mental Health Act. We expect to see alignment of local preventative
and investigative work with the national findings on mental health related deaths.
This includes emerging guidance from national bodies and the use of the National
Confidential Inquiry into Suicide and Homicide by People with Mental Illness toolkit.
We expect services to notify us of deaths of detained patients and patients who are
on a community treatment order at the time of their death.

10

The Commission has also identified five key areas of action. These are in line with,
and complement, our strategic intentions including recognising that people in the
care of specialist mental health services are a high risk group for suicide and
unidentified, poorly treated or preventable physical ill-health. We are concerned
about how services respond to, review and report on deaths, so we are committing to
include the information we hold on deaths in psychiatric detention in all future annual
reports. We will work with partners, including NHS England and the National
Confidential Inquiry into suicide and homicide by people with mental illness, to look at
how we can do this in a way that offers better intelligence and opportunities for
shared learning and preventative action. The Commission will also work with key
partners in developing the Mental Health Crisis Care Concordat. This will focus
attention on the issues that have been highlighted around emergency mental health
care. The Commission has committed to delivering a thematic programme around the
experiences and outcomes of people experiencing a mental health crisis, and will
take this forward over the course of 2014 with the intention of publishing a national
report in the autumn.

Conclusion

We greatly value the intelligence that you have provided us in your report. The
information contained informs our intelligence mechanisms, which in turn directly
influences the planning for future inspections, both in respect of The Priory Hospital
Roehampton specifically as well as elsewhere. In broader terms it also informs
broader policy discussions within the Commission in relation to considerations about
improvements to our regulatory approach.

Please do not hesitate to contact us with any questions or concerns.

Yours sincerely

Interim Head of Hospital Inspections (Mental Health)
Care Quality Commission — London Region

PRIORY

GROUP OF COMPANIES

Private and confidential

Dr Sean Cummings
Assistant Coroner
25 Bagleys Lane
Fulham

SW6 2QA

Wednesday 30 April 2014

Dear Dr Cummings

Neil Carter Inquest - Regulation 28: Report to Prevent Future Deaths

! am writing in response to your Regulation 28: Report to Prevent Future Deaths dated
Wednesday 5 March 2014. Your report arises from the inquest into the death of Mr Neil James
Carter, which concluded on Thursday 5 December 2013.

The matters of concern that you have raised under Regulation 28 are as follows:
1. There were repeated failures to perform basic nursing observations.

2. You heard evidence that indicated an enduring situation where the ward frequently had
inadequate numbers of staff with an inappropriate skill mix and with an inappropriate lay
out over two floors. There was a lack of discipline with staff failing to accept a nurse in
charge’s authority. You have stated that management were informed of some issues but
failed to listen or act.

3. There was a deliberate falsification of the nursing record.

You have exercised your powers under Regulation 28 by issuing this report and indicating that
action should be taken to prevent future deaths.

Applying the above numbering:

1. In response to points one and three, | understand that the records falsification and a
number of key missing observations in Mr Carter's case for the afternoon he absconded
from the ward, fell to one nurse, | am informed that the relevant individual was disciplined
through Priory's internal processes and dismissed from employment. She was also referred
to the NMC as her actions fell short of the standard required.

We recognise, however, that we should strive to improve compliance with observations
and the documentation of those observations in accordance with the risk assessments
undertaken. In respect of staff carrying out patient observations, | am informed that these
improvements have included changes to the staff induction programme at Roehampton
and better registration and monitoring of patients at ward therapy groups. There has also
been a review of the overarching Priory Group Healthcare Division Observation and
Engagement Policy.

Priry Contrat Serves are accredited by
Priory Group, Fifth Floor, 80 Hammersmith Road, London, W14 8UD ‘ ; =)
Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com . v
Priory Group No. 1 Limited trading as the Priory Group, Registered Office: Fifth Floor, 80 Hammersmith Road, London, W14 8UD. CH KS Rod
Registered in England No. 07480152. Part of the Priory Group of Companies. based oa

PGOI38YOct13

To support compliance, standards across Roehampton Hospital are also monitored
internally through the use of Healthcare Division ‘Quality Walk Rounds’ which are
undertaken on a weekly basis and operate to a set four-week rolling programme of
monitoring. For example, week one involves an assessment of the environment and week
two involves an assessment of patient care which includes a review of the completion of
patient observations and care plans.

The Quality Walk Rounds, which were introduced in September 2013, are undertaken by
staff external to the particular ward (for example, a Ward Manager from another ward
together with members of the Roehampton management team). The results of the Quality
Walk Rounds are reviewed at the monthly Roehampton Hospital Clinical Governance
Meetings. These meetings are chaired by the Roehampton Hospital Director and attended
by representatives of the medical and therapy teams. Where improvements are required,
these are recorded and monitored.

In point two you state that ‘.... the ward frequently had inadequate numbers of staff with
an inappropriate skill mix and with an inappropriate layout over two floors...’

! am informed that following Mr Carter's death, Garden Wing was separated into two
distinct wards. Each ward has its own ward manager and nursing team together with
therapists and activity co-ordinators. | am informed by the hospital that the two smaller
wards are sufficiently staffed and that the managers and nursing staff of the wards are
sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital
Director and additional clinical support is provided by the Clinical Services Manager. They
will continue to monitor staffing levels and skill mixes to ensure they are appropriate.

You also are concerned that: ‘There was a lack of discipline with staff failing to accept a
nurse in charge’s authority’. | understand this arose from the experience of one nurse
giving evidence at Mr Carter's inquest, who had found that certain individuals had not
respected her more senior role. We of course accept that such a situation is unacceptable
and whilst there may be differences of opinion between members of staff, | am informed
there is now much more emphasis at Roehampton Hospital on there being an effective
framework of supervision and appraisals so that the risk of issues in relation to authority
can be identified more rapidly and managed. Further, | understand there is now a local
Human Resources function at Roehampton Hospital with trained staff who can provide
faster support and advice to those with staff management responsibilities who may feel
their authority is being challenged.

You also state that: ‘Management was informed of some issues but failed to listen or act’.
In order to facilitate communications between management and staff, | am informed the
following are now in place at Roehampton Hospital:

e Daily monitoring visits have been embedded across the hospital. These visits are
undertaken to each ward by either the Hospital Director or the Clinical Services
Manager as a means of checking patient care and responding to any immediate
concerns expressed by staff.

e The introduction of a daily ‘flash’ meeting which is held every weekday morning
attended by the nurse in charge from each ward, the hospital duty doctor and
members of the hospital management team. The purpose of the meeting is to
understand ward and hospital activity during the previous 24 hours/weekend and to
plan for the forthcoming 24 hours/weekend.

e Amonthly staff meeting which enables a broad cross section of staff to meet with the
hospital management team and to both provide and receive feedback on safety,
quality and compliance within their area.

In addition to the issues you have raised, | would also like to advise you that the Priory Group
has a dedicated team of experienced compliance inspectors who undertake a rolling
programme of detailed compliance inspections. The compliance inspections audit standards
over and above those standards audited by external regulators. These internal inspections act
as an early warning system to inform divisional and hospital management if improvements or
adjustments are needed to be taken in relation to patient care.

| hope that this response provides you with sufficient assurance in respect of your concerns
but please do not hesitate to contact me if | can be of further assistance.

Yours sincerely, ~

Tom Riall
Chief Executive Officer
Priory Group

Copy to: EEE virector of Safety for further managed circulation.