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C.G.BUTLER
SENIOR CORONER + BUCKINGHAMSHIRE

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. The Governor, HMP Woodhill
2. The Chief Executive, Central & North West London NHS Foundation Trust

CORONER

lam CRISPIN GILES BUTLER, Senior Coroner for BUCKINGHAMSHIRE

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (investigations) Regulations 2013.

htto:/Avww legisiation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

htto:/Avww legislation.gov.uk/uksi/2013/1629/pdfs/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 31" December 2015 Senior Coroner Richard Alexander Hulett commenced an
investigation into the death of JACK OLIVER PORTLAND, aged 29 years. The investigation
concluded at the end of the inquest on 3 February 2017. The conclusion of the inquest was
set out in the Jury's narrative conclusion contained in their answers to a questionnaire.

CIRCUMSTANCES OF THE DEATH

Mr Portland was a prisoner at HMP Woodhill until release at the end of a sentence on 16"
October 2015. Whilst at HMP Woodhill he was diagnosed with substance-induced psychosis.
Two separate ACCT documents were opened during his last period of detention at HMP
Woodhill. Following release he could not be assessed at Stoke Mandeville Hospital as he
was under the influence of substances and he was subsequently detained at HMP Lewes
from 18" October 2015. Upon release from HMP Lewes on 4" November 2015, Mr Portland
was sectioned under Section 2 of the Mental Health Act and detained at the Dene Hospital.
On 4" December he was detained under Section 3 of the Mental Health Act and was
transferred to the Whiteleaf Centre, Aylesbury, Buckinghamshire on 5" December 2015
where he remained a patient until his death on 27" December 2015, which occurred at
Wycombe Hospital, High Wycombe whiist Mr Portland was on unescorted S17 leave from the
Whiteleaf Centre. Mr Portland had been found and was attended to by paramedics at a house

Coroner’s Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ
Tel: (01494) 475505
Fax: (01494) 673760
E Mail: coroners@buckscc.gov.uk

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C.G.BUTLER
SENIOR CORONER + BUCKINGHAMSHIRE

in High Wycombe.
The medical cause of death was morphine and ethanol toxicity.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. in my
opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) It was identified that some elements of the management of the ACCT documents during
Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in
the caremap and in post-closure review, late completion of a post-closure review,
communication between healthcare staff (who have access to the healthcare SystmOne
records) and prison staff (who do not) were of concern and remain so, notwithstanding
general evidence indicating that the prison have been implementing ACCT quality review
measures, automatic referral for a mental health assessment on opening of an ACCT anda
NOMS-led taskforce.

(2) The standard letter notifying a family of the opening of an ACCT was non-specific and
dependent upon prisoner consent, yet it was identified that the engagement of families in the
ACCT process was important, particularly in the context of risk assessment. It appeared that
the same letter is still in use, directing families to telephone extensions for prison staff and
healthcare or a 24-hour help line. The family evidence was that communication with the
prison in response to a letter received during the first ACCT was of significant concern and
that they were not notified of the second ACCT. There was evidence suggesting that the
helpline is now attended regularly and messages dealt with but the overall communication
paths appear to remain the same.

(8) There were concerns about the assessment and management of Mr Portiand’s discharge
needs from admission, particularly with regard to post-release accommodation and positive
identification of registration with a GP, given that Mr Portland was homeless and that aftercare
ultimately would be dependent upon GP engagement. It was accepted that it is mandatory for
prisoner discharges to be undertaken in accordance with the relevant Prison Service
instruction and Early Days and Discharge Specification with all that those encompass. There
remains a concern regarding the discharge of prisoners presenting with issues such as those
of Mr Portland — a risk of self-harm, substance addiction, homelessness, resolving substance-
induced psychosis, vulnerability.

(4) In relation to the coronial investigation and the inquest itself, there were significant
concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume
disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via
Government Legal Department. Emails in which prison staff and/or healthcare staff were
participants and which were very relevant to issues raised in the inquest became identifiable
only through probation records and there was a concern that relevant communications should
have formed part of the specific prisoner records and been part of the HMP Woodhill
disclosure. Whilst significant urgent work was undertaken by Government Legal Department
during the inquest itself to assist the court with additional and correct documentation, these

Coroner's Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ
Tel: (01494) 475505
Fax: (01494) 673760
E Mail: coroners@buckscc.gov.uk

3
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SD & Xp,
ET MON,

C.G.BUTLER
SENIOR CORONER - BUCKINGHAMSHIRE

concerns, together with late identification of relevant witnesses and provision of witness
statements caused delays to the coronial investigation which may have also have delayed the
overall learning process and compromised the ability of HMP Woodhill to implement change
in a manner specific to the issues and concerns identified, rather than in the broader terms
described during the inquest.

6 | ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the |
power to take such action.

7 | YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely
by 48 April 2017. |, the coroner, may extend the period. |

Your response must contain details of action taken or proposed to be taken, setting out the |
timetable for action. Otherwise you must explain why no action is proposed.

8 | COPIES and PUBLICATION |

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Messrs Leigh Day, acting for Mr Portland’s family.

Government Legal Department, acting for the Ministry of Justice, HMP Woodhill

Messrs Radcliffes LeBrasseur, acting for Central & North West London NHS Foundation
Trust

| have also sent it to the Prison & Probation Ombudsman, to HM Inspector of Prisons and to
Senior Coroner Osborne, Milton Keynes Coronial Area who may find it useful or of interest.

Tam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.

9 | Dated: 21* February 2017

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Senior Coroner for Buckinghamshire

|
|

Coroner’s Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ
Tel: (01494) 475505
Fax: (01494) 673760
E Mail: coroners@buckscc.gov.uk

ae Safer Custody and Public Protection
Group

Hy M Pri & Her Majesty's Prison and Probation
Service
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Probation Service London, SW/iH 8HD

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C.G. Butler

HM Senior Coroner
Buckinghamshire
H.M Coroner's Office
29 Windsor End
Beaconsfield
Buckinghamshire
HP9 2JJ

2 May 2017
Dear Mr Butler

Inquest into the death of Jack Portland

Thank you for your Regulation 28 Report of 21 February 2017, addressed to the Governor of
HMP Woodhill and the Chief Executive, Central and North West London NHS Foundation Trust
(CNWL), following the conclusion of the inquest into the death of Jack Portland on 27 December
2015. Your report has been passed to the Safer Custody and Public Protection Group in Her
Majesty's Prison and Probation Service (HMPPS — the agency that has replaced NOMS), which
is responsible for sharing learning from deaths in prison custody. | reply on behalf of the
Governor of HMP Woodhill.

Your report raises four main concerns covering:
1. ACCT management
2. Family involvement in the ACCT process and contact with the establishment
3. Discharge arrangements
4. Coordination of disclosure and witnesses statements.

ACCT Management

You will be aware from the evidence given at the inquest of the significant amount of activity that
has taken place at HMP Woodhill to ensure that ACCT procedures are managed robustly and in
line with Prison Service policy. Extensive training in suicide and self-harm prevention has been
delivered to staff since Mr Portland’s release from HMP Woodhill in 2015. During 2016 HMP
Woodhill prioritised such training, and as a result over 93 per cent of managers at the prison
have received Case Manager training, a significant improvement on previous years.

In addition to the prioritisation of training delivery, new procedures have been introduced to
ensure more robust management of the process. During 2016 the Safer Prisons team
introduced Case Manager Allocation and ACCT review booking systems, the aim of which is to
ensure a manageable caseload for Case Managers and to ensure consistent multi-disciplinary

attendance at ACCT reviews. The team works extremely closely with the prison’s healthcare
providers, and CNWL were fully involved in the development of the new processes. Prison and
healthcare staff work together to ensure attendance at the planned reviews.

In order to provide assurance that new procedures are fully embedded and effective, a review of
the establishment's ACCT quality assurance processes took place in 2016. This led to the
introduction of two new quality checks, one undertaken weekly by the wing manager and the
other on a monthly basis by the Duty Governor, which assess the quality and completeness of
ACCT reviews and post-closure reviews. Both checks include a section which requires
managers to assess and comment specifically on the quality of caremaps, and where
deficiencies are found, feedback is given to the case manager and/or wing manager who are
required to take the appropriate action to rectify this.

After closure of an ACCT a post closure check will be completed by the Safer Prisons team. A
quality assurance template is used to check that the post closure process has been completed
within timescales, that caremap actions were considered and completed prior to closure and
that the prisoner has been invited to complete the closure questionnaire. As with all quality
assurance checks any feedback required will be provided to the Case Manager involved.

The Governor is confident that the increased focus on the training of staff on the requirements
of the ACCT process, and the robust quality checks now in place, have led to a significant
improvement in the quality, focus, and effectiveness of ACCT documents in supporting
prisoners at risk of suicide and self-harm.

Family contact

The value of family involvement for prisoners, and the significant resettlement opportunities that
contact with family members presents, are recognised. However, the prison can only prompt
this contact (and it could only be effective) with the consent of the prisoner.

During 2016 the prison has sought to further raise awareness of the value and importance of
family contact and has seen significant improvement. Family members have been invited to and
attended ACCT reviews, made telephone contributions and been involved in release planning
for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case
Managers using some of the local examples with contributions from family members and
prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family
pathway’ will be developed to ensure active involvement of families wherever possible.

Discharge

Since 1 June 2014 the provision of resettlement services for prisoners serving 12 months and
under has been the responsibility of Community Rehabilitation Companies (CRCs). The prison
works closely with the provider of resettlement services at HMP Woodhill, MTC Novo CRC,
which is required to provide support services relating to housing and accommodation,
employment training and education, finance benefit and debt.

CRC staff meet all newly arrived prisoners to assess their immediate needs and necessary
interventions. They then coordinate, deliver and signpost prisoners to interventions. Each
prisoner will meet CRC staff 12 weeks prior to release and a review of resettlement plans will
take place, with outstanding issues dealt with in an action plan. The prison actively supports the
work undertaken by the CRC within the establishment.

Since Mr Portland’s release from HMP Woodhill, the prison has introduced a new database
system for the management of complex cases, which allows for the live sharing of information
between the establishment, the CRC, Westminster Drug Project (the providers of substance
misuse support) and CNWL. The database allows a coordinated approach to resettlement
planning, providing information relating to any concerns or issues and appointments upon

release, for example with GPs, drug services and housing. This ensures that no referrals are
being repeated and that everyone involved in the resettlement plan is fully aware of ongoing and
required actions. The use of the database will be reviewed in July 2017 to ensure that it is fit for
purpose and to consider how this information sharing is used to provide multi-disciplinary
support to the most vulnerable and at risk individuals approaching release.

It has also been agreed at the multi-agency meetings that any immediate concerns regarding
resettlement issues in complex cases will be shared with relevant departments by an immediate
phone call, and recorded on the prisoner case notes. This is to identify and address
safeguarding issues, such as prisoners with accommodation issues and those suffering with
mental health concerns.

From July 2017, prisoners will be able to register with a GP practice before they leave prison.
The agreement includes the timely transfer of clinical information from the prison to the GP
practice, with an emphasis on medication history and substance misuse management plans, to
enable better care when a new patient first presents at the practice. Prisoners will be actively
supported to register with a GP.

Disclosure

We regret that the provision of documents to this inquest was not achieved in the way that we
would wish, and would like to apologise to you for the impact that this had on the inquest
process. Much of this difficultly arose from the fact that, as Mr Portland died some months after
his release from HMP Woodhill and when he was not in prison custody, the usual process by
which prisons ensure that the paperwork required for disclosure to assist the Prison and
Probation Ombudsman’s investigation and the Coroner's Inquest is collated was not initiated. In
consultation with GLD, we have agreed that in future all disclosure to the Coroner's Court will be
done through GLD to avoid confusion.

The late submission of written statements was the result of our desire to fully assist the inquest
process by providing them from the most relevant members of staff. Due to a miscommunication
we were not immediately aware that one member of staff would not be able to address all the
issues raised.

We have noted your concerns and will be addressing these in the longer term by increasing the
resource in place to facilitate Coroner's inquests.

Thank you for bringing these matters to our attention. | trust that this letter has provided you
with assurance that your concerns have been addressed.

Yours sincerely
bA- Ate

afer Custody and Public Protection Group

Mr Crispin Butler 
HM Senior Coroner for Buckinghamshire 
Coroner’s Office 
29 Windsor End 
Beaconsfield 
HP9 2JJ 

Also sent by email to: 

Chief Executive’s Office
Trust Headquarters 
Warneford Hospital
Warneford Lane
Headington
Oxford
OX3 7JX

www.oxfordhealth.nhs.uk

5th April 2017 

Dear Mr Butler 

Regulation 28 Report to Prevent Further Deaths following the inquest concerning the 
death of Mr Jack Portland 

I  am  writing  in  response  to  the  concerns  raised  in  your  Regulation  28  report  dated  21 
February  2017,  which  followed  the  inquest  relating  to  Mr  Portland’s  death.    Thank  you  for 
bringing these concerns to my attention.  

I will address your concerns in turn using your numbering. 

Concern 1 

The  provision  of  copies  of  leave  forms  is  not  in  fact  mandatory  under  either  the  Mental 
Health Act Code of Practice or Trust policy (the Trust’s current granting of leave form, which 
suggests that this is the case, is misleading).  Nevertheless, it is acknowledged that in many 
cases patients and their families find it useful to have a copy of the form in addition to being 
involved  in  discussions  around  the  granting  of  any  leave  and  conditions.  The  section  17 
leave  form  has  been  amended  and  is  currently  going  through  the  Trust’s  governance 
processes for approval. It is anticipated that use of the new form will be implemented no later 
than 28th April 2017.  The newly designed form allows the consultant to indicate, following 
discussions with patients and families, if copies should be provided and, if so, to whom. 

In  addition,  a  new  standard  operating  procedure  (SOP)  for  managing  leave  (appendix  1) 
includes the need for staff to have a discussion with the family, where appropriate consent is 
given  by  the  patient,  regarding the  patient’s  leave from  the  ward  and  to do  this  every  time 
there is a change to the leave agreed. 

 
 
 
 
 
 
 
 
 
 
 
 
 This  SOP  has  been  welcomed  by  Sapphire  ward  staff  as  it  clarifies  responsibilities  and 
standards in relation to leave. After the testing period on Sapphire ward and a review, which 
is planned for end of April 2017, this SOP will be expanded and implemented across all adult 
wards. 

Concern 2 

The new SOP referred to above is being tested on Sapphire ward.  It clarifies and simplifies 
the management of leave on the ward. It gives clear instruction as to how leave is granted, 
the  nursing  level  assessment,  and  simplifies  the  recording  of  leave  on  one  collective  ward 
document (appendix 2). 

The  Trust  acknowledges  that  the  risk  of  human  error  when  recording  information  in 
numerous  places  is  unacceptable,  and  has  therefore  ended  this  practice.  The  team  now 
works from one central document, and no longer records leave on a whiteboard. 

Concern 3(i)  

The  new  SOP  includes  the  physical  handover,  once  an  hour,  of  the  general  observation 
chart  between  allocated  staff.  At  handover  both  members  of  staff  must  now  assure 
themselves that the sheet is fully filled in and in order. 

Staff have been strongly reminded that it is not appropriate to fill in observations paperwork 
prospectively or retrospectively. This is now monitored by the Matron. We are in the process 
of  reviewing  the  Trust’s  Observation  Policy,  and  will  ensure  that  this  is  also  made  very 
explicit within the new version. This policy review will be complete by the end of April 2017. 

Concern 3(ii) 

The responsibility  for  ensuring that  patients  are back from  leave  now  clearly  rests  with  the 
person  allocated  to  carry  out  general  observations.    That  staff  member  is  also  responsible 
for  informing  the  shift  co-ordinator,  who  will  co-ordinate  the  implementation  of  the  AWOL 
policy, if a patient does not return on time (appendix 3).  The shift co-ordinator is always a 
qualified nurse.  

On  occasions  when  a  patient  is  AWOL  the  attached  guidance  clearly  lays  out  the  actions 
required and, in accordance with the AWOL Policy, staff should complete the Missing Patient 
Action Checklist to give a clear record of action taken. 

This  has  been  clearly  communicated  to  the  team  and  added  to  every  staff  member’s 
supervision  sheet  to  ensure  that  individuals  have  the  opportunity  to  discuss  the  procedure 
and check their understanding.  Copies of the attached guidance and Missing Patient Action 
Checklist are available on all acute inpatient wards for ease of reference and use.  

For all acute wards there is ongoing work using quality improvement methodology aimed at 
increasing the number of patients who return from leave on time. This work includes weekly 

 
 
 monitoring and review by the Matron of data collected on the wards showing the number of 
patients returning on time and late, which assists in identifying trends or issues. The team’s 
compliance with SOPs and any breaches are explored and relevant supervision and training 
implemented for individual staff when necessary. 

An existing SOP which covers shift co-ordination has had a new action added, which is that 
the  shift  co-ordinator  signs  off  all  relevant  sheets,  including  observation  charts,  to  ensure 
that  all  staff  have  fully  completed  the  required  paperwork,  including  the  leave  record  form, 
and it is in order before handing over to the next shift. 

Concern 4 

The  admission  checklist  for  the  wards  includes  the  requirement  to  update  the  risk 
assessment  upon  admission.  This  is further  prompted  by  the  electronic ‘patient  status  at  a 
glance’  (PSAG)  board  in  the  nursing  office.  All  qualified  staff  receive  the  Clinical  Risk 
Assessment and Management training which includes consideration of the various sources 
of information a clinician may use to evaluate risk.  

In  Mr  Portland’s  case,  there  was  evidence  of  a  handover  from  the  Dene,  however  it  is 
acknowledged that more effort should have been made in obtaining historic information from 
HMP Woodhill. This has been discussed with staff in the ward’s business meeting, and the 
Matron will continue to work with the team to ensure they meet the required standards of the 
Trust Clinical Risk Policy. This will be the responsibility of the Senior Matron who will ensure 
that  historic  risk  information  is  obtained  for  those  patients  who  have  received  care  and 
treatment in a prison setting.  

Concern 5 

An  initial  review  is  completed  for  every  serious  incident,  as  was  the  case  following  Mr 
Portland’s death. Each initial review report should be completed within 5 days of the incident/ 
death,  reviewed  by  the  senior  clinical  team  and  also  by  a  weekly  Trust  wide  executive 
meeting.  The  purpose  of  the  initial  review  report  is  to  set  out  the  initial  facts  known,  to 
identify any immediate action or learning required and to help develop the scope for the RCA 
investigation.  The  initial  review  report  into  Mr  Portland’s  death  identified  three  immediate 
actions all around the timeliness of initiating the AWOL procedure. The initial review report 
was shared with the CQC. 

The first RCA investigation report was shared with the family, Coroner, commissioners and 
the  CQC. We  have  acknowledged  the  mistakes  in  the  timeliness  and  thoroughness  of  the 
first  RCA  investigation.  In  response  to  the  concerns  raised  by  the  family,  about  the 
omissions  in  this  first  investigation  report,  identified  at  the  first  pre-inquest  meeting,  a  third 
investigator did review the report. The initial plan was to add an addendum to the first RCA 
investigation  report.  However,  this  work  highlighted  weaknesses  in  the  first  investigation 
approach  and  identified  further  omissions,  as  well  as  learning  around  documentation. 
Therefore,  following  discussion  with  the  CQC,  commissioners  and  Buckinghamshire 

 
 
 Safeguarding Adult Review Group, the Director of Nursing made the decision to re-open the 
serious incident and to commission a new investigation with new authors. The timescale for 
completing  the  second  RCA  was  31  November  2016.  This  timescale  was  based  on  the 
national  timescale  of  aiming  to  complete  an  investigation  within  60  days.  The  family, 
commissioners  and  CQC  were  informed  of  this  decision  to  commission  a  second  RCA 
investigation and the timescale. 

The  second  RCA  investigation  was  completed  by  two  new  investigators  and  a  second 
internal  review  panel  was  convened  (with  different  members  from  the  first  panel)  by  31 
November  2016.  The  report  was  then  shared  with  the  family,  coroner,  commissioner  and 
CQC. We did not send a copy of the second final RCA investigation report to the family until 
15  December  2016.    We  apologise,  this  was  unacceptable  and  we  do  not  have  any 
satisfactory reason for this delay; it was as a result of an internal confusion about who was 
going to send the final report.  

The  initial  review  report  (completed  within  days  of  Mr  Portland’s  death)  identified  the 
immediate concerns and actions to be taken. The second RCA report therefore did not focus 
on the immediate actions taken, as this was not the purpose of this investigation.  

Concern 6 

The Trust’s approach to the RCA process is that it is an open and supportive process with a 
focus  on  learning.  Investigators  do  not  routinely  take  formal  statements  or  transcripts  of 
meetings  as  part  of  the  investigation;  personal  notes  are  kept  to  inform  the  investigation. 
Drafts of RCA reports are routinely shared with  all staff interviewed and  they are invited to 
feedback on content and accuracy at that stage. In this case, it was not felt that there was 
additional  documentation  available  from  the  RCA  investigations  to  further  inform  the 
Coroner’s  investigation.    The  Trust  does,  and  will  continue  to,  cooperate  in  sharing 
information requested by Coroner, where such information or documentation is available.  

Concern 7 

The  second  (final)  RCA  investigation  report  identified  4  recommendations  based  on  the 
contributory  factors  to  Mr  Portland’s  death,  each  with  an  action  and  timescale.  It  is 
acknowledged  that  there  were  additional  concerns  identified  at  inquest  which  included  the 
understanding  and  implementation  of  the  AWOL  procedure,  and  the  need  to  review  how 
leave  is  managed,  specifically  around  how  information  is  recorded  and  the  use  of  the 
whiteboard.  The  additional  concerns  will  be  added  to  the  second  RCA  investigation  report 
with appropriate corresponding actions, and the actions will be monitored centrally. 

In relation to concerns 5-7 (those specifically relating to the investigation of incidents), I can 
confirm that the following action has been taken: 

-  Communication and involvement of the family in the investigations did not meet the 
standard  the  Trust  expects  of  staff.  Therefore  from  March  2016  the  patient  safety 
manager became the family’s single point of contact to improve communication.  

 
 
 -  A  series  of  training  sessions  were  held  on  promoting  the  status  of  families  in 
investigations,  ensuring  they  are  central  to  the  process  (‘Making  Families  Count’), 
which were co-delivered with the charity Hundred Families in May and June 2016 
-  The  Trust  has  improved  its  capacity  for  completing  comprehensive  and  timely 
investigations,  including  appointment  of  a  dedicated,  full  time  post  of  RCA 
investigator/author in the adult mental health directorate. This person was appointed 
in February 2016. 

-  Weekly  monitoring  processes  were  introduced  from  July  2016  to  better  identify  the 
right  investigators,  timely  allocation  of  investigators  and  review  of  the  progress  of 
investigations. We  now  report  on  the  timeliness  of  RCA  investigations  on  a  weekly 
basis to the Executive Team and quarterly to the Board of Directors.  

-  A  survey  completed  of  RCA  investigators  in  August  2016  to  ensure  changes  in 

training meets their needs. 

-  The  Trust  commissioned  an  external  review  of  the  quality  of  SI  investigations 
completed in November 2016 to help the Trust to identify where and how to improve. 

The following further actions are currently being or will be undertaken: 

-  A  review  of  RCA  training  for  investigators,  including  an  additional  module  on 
. 

involving  and  working  with  families  during  an  investigation  (Lead: 
Timescale: new training to be delivered from 30th June 2017). 

training at least every 3 years (Lead: 

-  The introduction of a new standard that all investigators will complete refresher RCA 
. Timescale: from 1st Nov 2017). 
-  New staff and family information leaflets to describe the RCA investigation process, 
standards and what families can expect with central senior contact points for further 
support as needed are currently being developed (Lead: 
. Timescale: 
introduced from 1st July 2017). 

-  The  second  RCA  investigation  relating  to  Mr  Portland’s  case  is  to  be  amended  to 
include  the  additional  concerns  arising  at  inquest  and  actions  will  be  added  to  the 
action plan (Lead: 

. Timescale: 30th April 2017). 

Once again, I thank you for bringing your concerns to my attention.  I hope the information in 
this  letter  addresses  your  concerns  and  provides  you  with  some  reassurance  that  your 
concerns  have  been  or  are  being  addressed.    If  you  require  any  clarification  of  further 
information, do not hesitate to get in touch. 

Yours sincerely 

Stuart Bell  
Chief Executive Officer 
Oxford Health NHS Foundation Trust