Sheila Johnson

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aS ‘ From the Rt Hon Jeremy Hunt MP
Secretary of State for Health

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Dr Robert W Hunter

Senior Coroner, Derby and Derbyshire Coroner’s Area
Coroner’s Court
5-6 Royal Court

Basil Close
Chesterfield $41 7SL 17 JUN 2015

Dw a. Wk,

Thank you for your letter of 19 May enclosing the Regulation 28 Report on the
inquest into the death of Sheila Johnson.

I share your concern following your comments on the lack of co-operation by the
Tameside Hospital NHS Foundation Trust. Departmental officials have made
enquiries with the Trust, and I have been assured that it will be responding
appropriately to your Regulation 28 Report.

Officials have shared your letter with the Care Quality Commission (CQC). The
CQC advises that it will follow up any actions identified as a result of the Trust’s
response as part of its ongoing engagement with the Trust. The CQC will also
reinforce the duties of the Trust in relation to its duty of candour and being open,
transparent and cooperative with key stakeholders and statutory bodies.

You are right that improving transparency and reinforcing a culture of openness and
honesty is a key focus for the NHS and it is crucial that NHS trusts meet
expectations in this area. The fundamental standards require that providers assess,
monitor and improve the quality and safety of services. The CQC’s guidance about
complying with this regulation, to which all providers must have regard, states that
providers should share relevant information. This would include sharing
information about incidents with relevant bodies, including coroners.

In addition, the CQC has a number of actions in hand that are intended to improve
working between healthcare providers and coroners, including the establishment of a
Memorandum of Understanding with the Coroners Society of England and Wales to

achieve better working relationships and improve the sharing of information, as well
as developing a single protocol for handling information from coroners, which
includes storing and passing on information.

You will also be aware that there is existing legislation in relation to how public
bodies and professionals should behave with respect to coronial processes.

Finally, you may be aware that one of the recommendations made by
in his report into the deaths of mothers and babies at the University Hospitals of
Morecambe Bay NHS Foundation Trust was around the setting out of duties of all
NHS trusts and their staff in relation to inquests. The Government hopes to respond
formally and fully to the Morecambe Bay investigation recommendations shortly,
which may be of interest to you. While I am not able at this point to give an
indication of the Government’s response to the recommendations, I hope you will be
assured that we are giving thought to whether further measures are required to guide
appropriate behaviour in relation to coroner investigations and inquests.

I have also copied your letter to Monitor, as the Foundation Trust sector regulator for
health services in England, so it is aware of your concerns in relation to Tameside.

I hope this reply is helpful.

GA yinonhy

JEREMY HUNT

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Tameside Hospital
NHS Foundation Trust

Tameside General Hospital

ually one Department Fountain Street
Tameside General Hospital Ashton-Under-Lyne
Ashton-Under-Lyne Tameside
OL6 SRW OL6 SRW

[ee Telephione: 0161 922 6000
Fax:

9" June 2015

Dr Robert W Hunter
HM Senior Coroner
Coroner's Court

5 — 6 Royal Court
Basil Close
Chesterfield
Derbyshire

S41 7SL

Dear Dr Hunter,

Re: Regulation 28: Report to Prevent Future Deaths following Inquest
into the death of Mrs. Sheila Johnson

| am in receipt of your Regulation 28 Report to Prevent Future Deaths dated
19" May 2015. ! am very sorry that you have had cause to identify concerns
regarding the quality of the Trust’s internal investigation process and in
relation to the system for the urgent recall of patients discharged with
potentially life threatening conditions. We accept in full your verdict and
requirements.

It was recognised by the Keogh Review Team who visited the Trust in May
2013 that at the time of Mrs. Johnson’s death the Trust fell below expected
standards in relation to a number of areas associated with the governance of
care and treatment. As a result, the Trust was placed in Special Measures.
The Trust engaged a new Leadership team and accepted all the
recommendations made by the Keogh Review and CQC which resulted in a
Trust-wide review and improvement programme. The improvement plan has
been extensively monitored by the CQC, Monitor, NHS England and
Tameside and Glossop CCG with independent third part scrutiny

Since Mrs. Johnson’s inpatient treatment, her tragic death and the 2013
investigation into the circumstances surrounding her death; considerable
changes have been made both to improve the quality of the Trust's internal
investigations and the process for discharging patients.

As part of the improvement programme across the Trust, a review of senior
nursing staff took place, and medical staffing underwent a review with the
intention of improving Senior Doctor presence within the Trust and their
availability out of hours to improve quality, safety and patient care.

The Trust has implemented a programme of Leadership Development for
Clinical Leaders and Ward and Senior managers to develop leadership
capabilities, abilities and build a more collaborative organisational culture.

In relation to your particular concerns regarding the quality of the internal
investigation undertaken at this time, the Trust's processes have been revised
significantly and beyond all recognition. The current policy for the
management of serious incidents including their investigation has been
rewritten and implemented. The policy provides clear guidance to Trust staff
in relation to incident reporting and the investigation process, with the aim of
improving the quality of the Trust's investigations. We have had this monitored
by the CQC and CCG and reported to external oversight groups.

All serious incidents are reviewed by Directors who assign a level of
investigation and an investigation team to each serious incident, consisting
either of appropriate individuals from the Trust or where relevant external
independent persons. Professional advice relevant to the specialty is now

obtained.

We recognise that staff undertaking incident investigations need to be
appropriately trained. Since the investigation into Mrs. Johnson's death the
Trust has invested significantly in additional training provided by an external
facilitator. This has delivered root cause analysis and investigation training
across all divisions of the Trust, the most recent training taking place in March
of this year. More than 75 senior officers have been trained in RCA. This has
underpinned the revised policy to ensure investigations are more robust and
recommendations are acted upon and patient care and safety is improved.

A sample of serious incident investigations conducted since the training were
audited during the period November 2014 and March 2015 by independent
third party auditors (MIAA) and the audit demonstrated that the individuals
involved in those investigations were appropriately trained.

The auditors concluded in their report dated 10" March 2015 that the serious
incident processes provided significant assurance to the Trust that systems
and processes were in place.

We have also introduced improvements to the process for internal review of
serious incident reports. There is now an Executive led Serious Incident
Review Panel which reviews all serious incident investigation reports and
action plans and scrutinises and challenges them, providing feedback to the
investigation teams when further clarity is required. The panel also require
that responsible nursing and medical leads attend the meeting to feed back
what changes have been made and what lessons have been learnt from
investigations.

As part of the investigation process appropriate recommendations and actions
are identified either within the investigation report or in a separate action plan
to address issues that have been highlighted. The Serious Incident Executive
Review Panel discusses actions arising from serious incidents and how they
will be addressed by the divisions of the Trust.

The Trust has a number of improvement work streams into which the actions
arising from serious incidents have been mapped, including patient safety
programme work streams that are monitored and feed into the Trust's
Governance arrangements which report to Trust Board. The Quality &
Governance Unit has developed processes to work with the Trust’s Clinical
Divisions and follow-up on the implementation of actions identified and further
assurances are gained through the ward accreditation process, Board
leadership walk-rounds to wards and departments, and patient experience
feedback.

The complaints processes, HM Coroner’s Inquest processes and mortality
review processes are now coordinated into one process to oversee the

Statutory Duty of Candour requirement.

! also note your concern that the audit of the nursing and medical
documentation undertaken during the investigation into Mrs. Johnson’s care
confined itself to establishing that the entries were accurately dated and timed
with a legible signature.

The revised investigation process and procedure includes the requirement
that incident and complaint investigations consider relevant best practice and
policies and that the investigation should include whether the recommended
systems and processes were followed, as well as whether record keeping

standards were adhered to. It signposts the user to the Incident Decision Tree
which also includes the requirement to assess decisions made and actions
taken against policies and procedures to identify whether there were failures
in systems and processes or individual failures.

The Trust acknowledges your concerns and accepis them in full. The fact that
there was no formal system for the urgent recall of patients discharged with
potentially life threatening conditions, has been addressed by the Patient Flow

Manager.

Staff will be directed to attempt to contact the patient or relatives in the first
instance and contact the General Practitioner and Community staff should the
patient or relatives not be contactable, if necessary staff will be directed to
contact the Police and ask for a ‘safe and well’ check.

The procedure will be defined in a simple flowchart which signpost will staff to
the correct actions and responsibilities should any staff member identify that a
patient has been discharged and needs to be recalled urgently. We are
closely monitoring the quality of discharges with our CCG. The process will
also be included as an appendix within the Admission and Discharge Policy.

| am writing directly to the family of Mrs. Johnson extending my apologies and
sincere condolences.

! hope that the above clarifies the improvements that we have made and
addresses your concerns and findings in relation to Mrs. Johnsons Inquest.
Piease do noi hesitate to contact me again if any more information is required.

Yours sincerely

Karen James
Chief Executive

cc. Monitor
cQc
Tameside and Glossop CCG