Charlotte Grace

22nd January 2020 

Dr N Shaw 
HM Coroner for County of Cumbria 
Fairfield  
Station Road 
Cockermouth 
Cumbria 
CA13 9PT 

Executive Suite 
1st Floor  
St Nicholas Hospital 
Jubilee Road 
Gosforth 
Newcastle upon Tyne 
NE3 3XT 

 (0191) 245 6801 

Dear Dr Shaw 

RE: 

Inquest into the death of Charlotte Grace 
Regulation 28 Report to Prevent Future Deaths Response 

I write in response to your Regulation 28 Report dated 29th October 2019 following your 
investigation into the death of Charlotte Grace.  This response has been prepared by 
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (“The Trust”) and 
addresses the concerns as set out by HM Coroner.  

As you are aware Mental Health Services at the time of Ms Grace’s death were provided by 
Cumbria Partnership NHSFT.  As of 1st October 2019, those services are now provided by 
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.  

The issue you raised at the time of the inquest and within your regulation 28 report is as 
follows:  

Agencies to whom a patient is discharged and families or friends (with consent) who 
will need to be supportive are not routinely involved in the discharge process.  

The evidence at the inquest confirmed that it was clearly documented within Ms Grace’s 
records/care plan that her next of kin was to attend discharge planning however, the 
discharge meeting was changed at short notice and Ms Grace’s next of kin did not attend. 

The evidence at the inquest confirmed that following the Serious Incident Investigation, a 
recommendation was made to improve clinical staff attendance at discharge planning 
meetings, a recommendation that the Home Treatment Team should be involved in 
discharge planning and where necessary attend meetings. The evidence of 
Consultant Psychiatrist and
that this recommendation was not being consistently implemented at the time. 
also indicated that whilst he had requested a conference telephone so that meetings could 
take place, this was not yet available.  

, Team Leader, Home Treatment Team, indicated 

, 

Response  

The Trust recognises the concerns that have been raised with regards to attendance at 
discharge meetings. The Trust is committed to ensuring that lessons are learned when any 
serious incident occurs and therefore following the investigation into Ms Grace’s death, and 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 as a result of matters raised at the inquest, the Trust has put in place a number of measures 
to ensure optimal attendance at all future discharge meetings. These changes can be 
summarised as follows: 

1.  A learning review was carried out following the investigation on 16th November 2018 in 

which it was discussed that attendance of significant clinicians involved with the 
patient’s care at the time and those responsible for providing future care would be 
best practice. The learning review suggested that where geographical barriers or 
workloads prevent face to face attendance at meetings, teleconferencing / 
videoconferencing could be used as an alternative.  

2.  Where geographical restrictions exist, teams utilise phone dial in and will move to 

Skype facilities within the next 3 months as part of the Trust’s IT mobilisation planning 
and roll out.  

3.  In order to ensure family/next of kin collaboration each admission will detail family/next 
of kin involvement. The Trust currently holds a weekend family clinic at the Hadrian 
ward at the Carlton Clinic to work with families in terms of their support and collecting 
additional supportive information as part of each admission. This clinic is purposely 
held on a weekend in order to support working families. It is the Trust’s intention to 
extend this process to each inpatient ward as part of the long term family engagement 
plan. The Trust intend to extend this within a 3 month timescale. This reflects a 
broader plan to increase and improve family engagement in all aspects of the 
admission in the service.  

4.  In order to ensure that the relevant teams/services are invited to discharge meetings, 
this is monitored as per the Trust’s discharge flow chart. This flow chart provides 
prompts for teams to be invited and indicates that meeting arrangements will be 
agreed at least 2 days ahead unless urgent. Where attendance is not possible the 
flow chart states that this should be escalated to team leaders. Although this flow 
chart was in existence at the time of the incident, it is apparent that it was not being 
used consistently however, following a safer discharge project staff have been 
reminded to utilise this. The project includes a commitment to ensure that an agreed 
follow up is in place within 48 hours of discharge.  

5.  In addition to the above, weekly interface meetings take place which incorporate all 
community and inpatient services and ensure that complex cases are discussed 
alongside discharge meetings. If issues with attendance are identified, this is raised 
and actioned with clinical leads. Where regular non-attendance is identified, this is 
now being escalated to the Associate Director of the Clinical Business Unit.  

6.  In order to monitor the discharge process the Trust use a safer discharge audit. This 

audit is used on each ward and monitors the following information:  

a.  The dated the discharge meeting was held; 
b.  Was the Community Mental Health Treatment Team/Home Treatment Team 

invited; 

c.  Did family/carer attend; 
d.  Did the care co-ordinator/allocated worked attend the meeting; 
e.  Was a discharge 48 hour follow up visit agreed prior to the discharge; 
f.  Who has agreed to undertake the 48 hour follow up. 

7.  As a result of the concerns raised by this case, the audit was amended to ensure that 

family/carer attendance is also now monitored. 

 
 
 
 
 
 
 
 
 8.  This audit is reviewed on a weekly basis at a Clinical Business Unit meeting with the 
clinical managers and ward managers. This acts as a check to ensure that discharge 
is not arranged without prior family involvement or communication. The audits have so 
far shown a consistent compliance with the new safer discharge process and will 
continue to be reviewed on a weekly basis.  

9.  The audits are reported through monthly quality standards meeting as a record and 

audit trail.  

I hope that the information provided offers you the necessary assurances that the Trust have 
invested time, effort and resource into investigating the issues you have highlighted with a 
view to improving patient care and safety and reducing the risk of any adverse incidents or 
outcome in the future.  

Yours sincerely 

JOHN LAWLOR 
Chief Executive