Allan Cunliffe

Corporate Services 
Trust Headquarters 
225 Old Street 
Ashton-under-Lyne 
Lancashire 
OL6 7SR 

Telephone: 0161 716 3000 

8th June 2020 

PRIVATE & CONFIDENTIAL 
Mr J Wells 
HM Assistant Coroner 
Coroners Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Mr Wells, 

RE:  Allan William Cunliffe 

Thank you for your Regulation 28 Report dated 22nd April 2020 and for bringing to 
my attention the concerns you have after hearing evidence at the inquest of Allan 
William Cunliffe.  Your concerns have been reviewed and Pennine Care’s response 
is outlined below: 

Concerns: 
“The physical care of vulnerable patients on Summers Ward was poor.  Whilst the 
experience of different junior doctors will inevitably vary, communication between the 
doctors and nurses was poor and the recording of clinical observations/NEWS score 
and action thereon (designed to alleviate some of the clinical decision making) was 
inaccurate/lacking.  There was further confusion regarding the administration of 
oxygen, with at least one nurse being apparently unaware of the mandatory training.” 

Response:   
Pennine Care’s Physical Health Policy for Mental Health and Learning Disability 
Service Users (CL042) identifies that the NEWS2 has now received formal 
endorsement from NHS England and NHS Improvement to become the early 
warning system for identifying acutely unwell patients in hospitals in England.  
Completion of the NEWS2 scoring system can help to recognise sepsis, raise the 
alarm quickly to a senior colleague or health care professional.  The NEWS2 should 
be completed more frequently if the service user shows signs of deterioration, 
commenced on antibiotics, prescribed certain medication (e.g. rapid tranquilisation) 
and/or placed on neurological observations.  The policy goes onto say that, if there is 
indication that physical health is deteriorating or a service user is complaining of 
physically unwell, nursing staff should ensure, where possible, that observations are 
recorded and that a National Early Warning Score is calculated.  Other tests may be 
carried out depending on the patient’s presentation.  Observations should be 
recorded and reported as agreed with the doctor to ensure effective ongoing 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 monitoring.  The observations and communication with the doctor must be recorded 
in the service user’s hospital notes.  This policy along with Pennine Care’s 
Resuscitation Policy (CL009) indicates staff must ensure that all communication is in 
line with SBARD principles.  These principles and its associated documentation are 
taught within the ILS courses and NEWS2 training across the organisation. 

Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work 
has been undertaken within the Older Adult’s In-Patient Service in Tameside.  A 
memo has been sent to all staff members reiterating the importance of ensuring that 
NEWS2 scores are calculated accurately and signed appropriately.  All refusals of 
observations or escalations of concern must be documented clearly in the patient’s 
records.  This is now discussed regularly in individual team member’s supervision.  
In addition to this the ward manager or physical health lead now completes a 
monthly audit of five randomly selected NEWS2 charts.  This allows oversight and 
assurance that quality standards are maintained.  NEWS2 training is now provided 
by the modern matron on a rolling programme.  This training details the history of the 
NEWS and the importance of completing this in full.  Staff are informed that the early 
warning system can: 

a)  Help to recognise that a patient is deteriorating 
b)  Support clinical judgement (whilst not replacing it) 
c)  Help secure appropriate help, including transfer for emergency treatment 
d)  Aid communication by providing a common language. 

The parameters of each physiological observation are discussed along with how to 
score these on the NEWS2 chart.  Attendees are provided with a copy of the 
NEWS2 and guided In terms of the completion of this.  It is reiterated that all 
observations need to be completed in order to obtain an accurate NEWS2 score.  At 
the end of the course a number of scenarios are used to ensure attendees 
understanding of the tool and the need for escalation as required.  Attendees are 
also made aware of the signs of sepsis. 

The use of the SBARD tool is widely recognised within Pennine Care.  However, it is 
acknowledged that this is difficult to evidence as this communication is often verbal.  
To assist in the documentation of the handover provided in the event of a physical 
health concern and/or medical emergency it is envisaged that an A4 document will 
be produced which will, not only prompt staff members in relation to the principles of 
SBARD, but also serve as a log of the information that has been handed over.  This 
can then be added to the clinical record.  It is hoped that this piece of work will be 
complete by August 2020. 

In addition to the above a series of meetings have taken place this year between the 
Older People’s Mental Health Service and the Digital Health Team which is part of 
Tameside Integrated Care Foundation Trust (ICFT) to explore ways of providing a 
holistic and consistent approach to accessing timely specialist advice in relation to 
the physical health needs of older people on the inpatient mental health unit at 
Tameside Hospital who often have complex co-morbid physical and mental health 
needs.  

 
 
 
 
 
 
 Both organisations are progressing towards an agreement to work together which 
would allow the clinical inpatient teams on Summers & Hague Wards to access 
further specialist advice and guidance from the Digital Health Team to aid care and 
treatment of patients who are experiencing a decline in their physical health ensuring 
patient assessments are safe and effective resulting in early identification of a 
deteriorating physical health status.   

By accessing the Digital health Team it is hoped that attendance at A&E for patients 
from Summers & Hague Wards can be reduced as the Digital health Team will be 
able to signpost to more appropriate services or arrange direct admission to the 
ICFT if clinically safe and indicated. 

I am aware that you heard evidence from a Pennine Care member of staff which 
caused concern regarding their knowledge relating to the administration of oxygen 
and their awareness of the mandatory training provided by the Trust.  The 
administration of oxygen is covered in the Immediate Life Support training that it is 
mandatory for all registered nursing staff working on in-patient wards in Pennine 
Care.  This details that, in the event of an emergency, high flow oxygen should be 
administered via a non-rebreathe mask.  It further details the use of airway adjuncts 
and a bag valve mask if the patient’s presentation indicates such. 

More recently Pennine Care now also provides Acute Illness Management training 
for both registered and unregistered nursing staff.  A workshop covering the 
systematic approach to assessing a deteriorating patient is delivered.  During this 
airways and breathing are discussed and includes how to assess, and take action 
(inclusive of oxygen), in the event of an emergency.  A demonstration/simulation is 
also delivered.  The course details why a person needs oxygen to survive and the 
consequences of our body not receiving enough whilst also detailing normal and 
abnormal signs relating to the airway and breathing.  

Attendees are advised, in the event of a medical emergency and having assessed a 
person’s oxygen saturations, oxygen should be administered through a reservoir 
(non-rebreathe mask) mask at a rate of 15 litres per minute.  Reservoir masks are 
stored with the emergency equipment in the resuscitation grab/bags/trolley on the in-
patient wards along with a bag-valve mask that is used for patients whose 
respirations have fallen below 10 respirations per minute.  Acute Illness 
Management handbooks are given to all staff attending the course and are also 
available on each ward for reference.   

Those attending the course aimed at unregistered staff are advised that they can 
take a person’s physical observations (including oxygen saturations) and recognise 
when oxygen therapy is necessary but must rely on the registered staff to administer 
it as per Pennine Care’s Standard Operating Procedure on the safe administration of 
oxygen to patients of the Trust (SOP 0029).   

 
 
 
 
 
 
 
 
 
 
 
 A 7 minute briefing will be circulated to raise awareness of the content of this training 
and staff’s responsibility of maintaining compliance with such. 

I hope this response assures you that the Trust has taken your concerns seriously 
and is taking measures to address the concerns raised. 

Yours sincerely 

Clare Parker 
Executive Director of Nursing, Healthcare Professionals & Quality Governance 

Email – 

@nhs.net