William McKibbin

Chris Morris 
HM Area Coroner 
Greater Manchester South 

                                                                                                  29th December 2020 

Dear HM Area Coroner Mr Morris, 

Regulation 28: Report to Prevent Future Deaths William Ivan McKibbin 

I have received your regulation 28 report following the inquest into the death of 
William Ivan McKibbin at Trafford Hospital on 20th August 2018. As 
Chief Executive is currently on annual leave I am responding to you on behalf of the 
Care Quality Commission (CQC). 

, 

This response relates to the matters of concern raised in your report, specifically you 
ask CQC to address the following: 

In order to enhance learning from deaths, consideration should be given to 
modifying the Statutory Notification process following the death of a service 
user so as to require Registered Providers to lodge specified relevant 
evidence as to how the death occurred within a defined period. 

CQC are the independent regulator of health and social care in England. We make 
sure health and social care services provide people with safe, effective, 
compassionate, high-quality care and we encourage care services to improve. 

The notification requirements in relation to a death of a service user are contained 
within Care Quality Commission (Registration) Regulations 2009: Regulation 16 (1), 
(2) & (3),which states: 

16.—(1) Except  where  paragraph  (2)  applies,  the  registered  person  must 

notify the Commission without delay of the death of a service user— 

(a)whilst services were being provided in the carrying on of a regulated 

activity; or 

(b)as a consequence of the carrying on of a regulated activity. 

(2) Subject to paragraph (4), where the service provider is a health service 

body,  the  registered  person  must  notify  the  Commission  of  the  death  of  a 

service user where the death— 

(a)occurred— 

 
 
 
 
 
 
 
 
 
 
 
 
 (i)whilst services were being provided in the carrying on of a regulated 

activity, or 

(ii)as a consequence of the carrying on of a regulated activity; and 

(b)cannot, in the reasonable opinion of the registered person, be attributed to 

the course which that service user’s illness or medical condition would 

naturally have taken if that service user was receiving appropriate care or 

treatment. 

(3) Notification of the death of a service user must include a description of 

the circumstances of the death. 

The duty to notify CQC directly does not apply if and to the extent that the registered 
person has reported the death to the National Health Service Commissioning Board 
which is interpreted in CQC’s published guidance (CQC’s published guidance for 
NHS providers) to mean NHS England’s National Reporting and Learning System 
(NRLS).   

This guidance indicates that NHS providers should notify relevant deaths to the 
NRLS using their LRMS or relevant eForm. These reports must meet the standards 
for the relevant mandatory fields. In relation to these standards, every NHS 
organisation should report patient safety incidents with an actual degree of harm of 
either “severe” or “death” to the NRLS within two working days of the incident 
occurring. 

The NRLS staff guidance for completion of e-forms states: 

•  Please describe the patient safety incident in your own words. It is 

important that the information you provide is factual and not simply an 
opinion. 

•  Think about the sequence of events. Try to identify who was involved at 
the different stages and their particular role (but do not give any names). 
End with a description of how the incident was concluded. 

As such specific and relevant information should be reported within a short period 
following the death of a service user. Serious Incidents (as defined in the Serious 
Incident Framework 2015) are also reported to the Strategic Executive Information 
System (STEIS).  

CQC then obtains the relevant information about an incident through our information 
sharing processes. Key information from the NRLS/STEIS reports is made available 
for review by the relevant CQC inspection team, who decide whether to follow up 
with the relevant provider about the incident.  

Our inspection lead for Trafford Hospital reviewed the NRLS/STEIS incidents in 
relation to the death of Mr McKibbin on the 30th October 2018. The reports indicated 
that his fall was unwitnessed and that he was found face down on the floor with 
obvious injuries; that he acquired a large subdural haematoma and was reviewed by 

 
 
 
 
 
 
 the neuro team at Salford, but was not appropriate for surgical intervention; that he 
was placed on an end of life care plan and, that his death was unexpected/ 
potentially avoidable. 

The reports did not include the full details of the events leading to Mr McKibbin’s 
death although there is provision in NRLS and STEIS for these details to be 
reported. On consideration, our inspection lead found that in this case sufficient 
information was provided in order to fulfil our regulatory role. 

There was a comprehensive inspection of the trust including Trafford Hospital over a 
four week period in October 2018 and a well led inspection in November 2018. The 
hospital was rated as good. Inspectors review incidents and other patient safety 
information before, during and after inspections to inform the on-site visit and the 
subsequent report.  

At the inspection we found that: 

•  The trust told us it had a quality and safety strategy 2018 - 2021 which 

focused on a range of quality and safety priorities. For instance, reducing the 
number of falls that result in harm to patients. As an example of this, we 
attended a falls meeting, attended by ward managers, where staff openly 
shared cases of falls to explore what could be done differently and share 
organisational learning.   

•  The trust had a process for ensuring that deaths were reviewed within at least 
one month of the death using the structured judgment review method with any 
learning presented to group/hospital level mortality groups. The trust’s 
standardised mortality ratio was within the ‘as expected’ range. 

In accordance with the Serious Incident Framework 2015, the trust reported four 
serious incidents (SIs) in medicine at Trafford General Hospital which met the 
reporting criteria set by NHS England from October 2017 to May 2018. Three of 
these incidents were for patients with slips, trips or falls, and one was due to 
treatment delay meeting the SI criteria.     

Our inspection team reviewed a root cause analysis report for one of the serious 
incidents above and found actions plans and lessons learnt were identified.  Actions 
included providing further training or feedback to staff. 

The current arrangements by which CQC receives notifications of deaths via the 
NRLS rather than directly from NHS Trusts was put in place to reduce the complexity 
of reporting routes and minimise burden on NHS providers. Although direct 
notifications to CQC contain questions which have the potential to elicit more detail 
about a specific incident, the quality of the data is equally dependent on staff 
reporting culture and practice.  

Any changes to the current arrangement for reporting of deaths would require 
legislative change brought forward by the Department of Health and Social Care. 
CQC’s view is that creating a separate, and potentially parallel reporting requirement 
for providers could create confusion and undermine appropriate reporting to both 
routes with an impact on national learning from patient safety incidents. Therefore, 

 
 
 
 
 
 
 
 
 
 our preferred option is to continue to receive this information through the NRLS 
/STEIS routes and promote the right level of reporting through our regulatory 
activities. 

In general, we consider that the information received through NRLS/STEIS reports is 
adequate to enable CQC to fulfil its regulatory responsibilities. However, we will 
review our existing notifications guidance in light of the findings from Mr McKibbin’s 
death, to determine if it could be clearer about the reporting requirements relating to 
the circumstances of a person’s death. We have a programme to improve how we 
receive, analyse and assess the information we receive via NRLS and STEIS to 
monitor patient safety.  

Kind regards, 

Chief Inspector of Hospitals

Your Ref: 
Our Ref: 

Mr Christopher Morris 
HM Area Coroner, Manchester South 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport SK1 3AG 

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

 27 January 2021 

Dear Mr Morris, 

Thank you for your correspondence of 28 September 2020 to the Secretary of State for 
Health and Social Care about the death of William McKibbin.  I am replying as Minister 
with responsibility for hospital care quality and patient safety and I am grateful for the 
additional time you have allowed for my response. 

I was saddened to read the circumstances of Mr McKibbin’s death and wish to offer my 
sincere condolences to his family and loved ones. Your investigation of Mr McKibbin’s 
death provides important learnings to improve patient safety across the NHS and I am 
grateful to you for bringing your concerns to my attention. 

In preparing this response, my officials have made enquiries with NHS England and NHS 
Improvement (NHSE/I), to understand the action taken locally by the Manchester 
University NHS Foundation Trust (the Trust), and with the Care Quality Commission 
(CQC), as the independent regulator of care quality.  

I am advised that the Trust, of which Trafford General Hospital is a part, has apologised 
unreservedly for the failings in Mr McKibbin’s care and the standard of the investigation 
conducted into Mr McKibbin’s fall, as well as the quality of communication with Mr 
McKibbin’s family.   

I am further advised that the Trust has provided assurance in its response to you, that it 
did not seek to deliberately mislead or withhold information from Mr McKibbin’s family, or 
indeed your investigation into the circumstances surrounding Mr McKibbin’s death.  

I will not repeat the detail of the Trust’s response to you.  However, I note that the Trust 
has said that it has taken significant learning from its reflections on the investigation 
carried out into Mr McKibbin’s fall that will inform its investigation process and that the 
learning has been widely shared across the Trust’s hospitals, Board of Directors, its 
Governors and local commissioners, and to the CQC.  Further learning, incorporating the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 findings of the inquest into Mr McKibbin’s death and the concerns identified, have been 
shared within the Trust, with future learning events and opportunities planned.  

I note your residual concerns as to the prevailing culture at the Trust, and by extension, 
within the NHS with regard to the Duty of Candour. 

The Duty of Candour Regulations1 came into force in November 2014 for the NHS, which 
ensure that providers of NHS services are open and transparent with people who use 
services and their representatives in relation to care and treatment, when something goes 
wrong that appears to have caused harm or could lead to significant harm.  

The Regulations, set out specific requirements that providers must follow when things go 
wrong with care and treatment, including informing patients and their families about the 
incident, and providing reasonable support, truthful information and an apology. 

The CQC has the power to prosecute for failures to comply with Duty of Candour, however 
this has not been done to date. The Duty of Candour for NHS providers was introduced, 
alongside other measures, to cultivate a culture of learning to enable lessons to be learned 
quickly and patients protected from harm in the future. 

My officials have been informed that the Trust has a Duty of Candour policy in place and 
that internal Trust monitoring shows 95 to 100 per cent compliance from staff.  In 2018, the 
CQC inspected these arrangements and rated them ‘Good’. 

To support NHS Trusts to learn from mistakes in order to reduce risks to future patients 
and avoid tragedies from happening in the first place, we introduced the Learning from 
Deaths programme in April 2017.  The Programme was established in response to the 
CQC’s 2016 report Learning, candour and accountability: a review of the way NHS trusts 
review and investigate the deaths of patients in England,2 in which the CQC identified that 
learning from deaths needed much higher priority in the NHS and that many bereaved 
families did not experience the NHS as being open and transparent. 

The first ever National Guidance on Learning from Deaths 3was published in 2017 and 
introduced a more standardised approach to the way Trusts review, investigate and learn 
from deaths. Guidance is clear that Trusts must also engage meaningfully with bereaved 
families and carers.  

From 2017-18, we have required NHS trusts to publish locally the numbers of deaths 
thought to be due to problems in care on a quarterly basis, and to evidence what they 
have learned and the actions taken to prevent such deaths on an annual basis in their 
Quality Accounts.  This new level of transparency is fundamental to a culture of learning 
and ensuring the safety of NHS services.   

In March 2019, the CQC published a review of NHS trusts’ implementation of National 
Guidance on Learning from Deaths. It showed that trusts are at different stages of 

1 https://www.gov.uk/government/publications/nhs-screening-programmes-duty-of-candour/duty-of-
candour#duty-of-candour-regulations 
2 https://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf 
3 https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf 

 
 
 
 
 
 
 
 
 
 
 
 
 implementation but included case studies to demonstrate significant progress being made 
on Learning from Deaths.  

You may also be interested to note that a new Patient Safety Incident Response 
Framework4, to replace the Serious Incident Framework, is being developed by NHSE/I to 
facilitate examination of a wider range of patient safety incidents in the NHS and to 
improve the quality of patient safety incident investigation and how organisations can learn 
and change as a result.  The Trust, in its response to you, sets out specific actions it has 
taken with regards to ‘red flag’ warnings and other actions. 

Finally, with regards to falls prevention, the National Institute for Health and Care 
Excellence (NICE) has published a clinical guideline on Falls in older people: assessing 
risk and prevention (CG1615) that includes guidance on preventing falls in older people 
during a hospital stay.  The guideline says:  

1.2.2.1 Ensure that aspects of the inpatient environment (including flooring, lighting, 
furniture and fittings such as hand holds) that could affect patients' risk of falling are 
systematically identified and addressed 

This recommendation would apply to wards, toilets and other parts of the hospital.  The 
guideline recommends that for patients at risk of falling in hospital, an assessment of the 
patient’s individual risk factors should be conducted and where necessary, appropriate 
intervention put in place.  NHS trusts are expected to take account of NICE guidelines 
when planning care.   

I have been assured that the Trust’s falls investigation template has since been updated to 
include more detailed guidance around immediate action, including the requirement for an 
immediate check and documentation of the environment of a fall, including an unwitnessed 
fall. This includes changes to the Intentional Rounding Checklists in use at the Trust. 

In relation to the matter of concern about notification requirements in relation to the deaths 
of service users and the information that is required of providers within a specified time 
period, I am aware that the CQC has written to you explaining the process for the reporting 
of deaths, or incidents of ‘severe harm’, to NHSE/I’s National Reporting and Learning 
System (NRLS) and STEIS (the strategic executive information system), and the way in 
which the CQC can review, request and assess information relating to reported incidents.  

You will also be aware that the CQC reviewed the NRLS/STEIS incidents in relation to Mr 
McKibbin’s death and considered that sufficient information was provided by the Trust in order 
to fulfil its regulatory duties. Importantly, I note that the CQC is satisfied that current reporting 
processes, through NRLS/STEIS reports, are adequate to enable it to fulfil its regulatory 
responsibilities. However, the CQC will review its existing notifications guidance in light of 
the findings from Mr McKibbin’s death, to determine if further clarification is required.  

I trust this response is helpful.   

4 https://www.england.nhs.uk/patient-safety/incident-response-framework/ 
5 https://www.nice.org.uk/guidance/cg161 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely, 

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH 

NADINE DORRIES

Chief Executive’s Office 
Cobbett House 
Trust Headquarters 
Manchester Royal Infirmary 
Oxford Road 
Manchester 
M13 9WL 

Mr. Christopher Morris 
HM Area Coroner, Manchester South 
Manchester South  
1 Mount Tabor Street 
Stockport  
SK1 3AG 

23rd November 2020 

Dear Mr Morris, 

Re: Mr William Ivan McKibbin, Regulation 28: Report to prevent future deaths 

I would like to begin by offering condolences to the family of Mr McKibbin and my unreserved 
apologies for the failings identified in his care and the subsequent investigation into his fall. 
The care afforded to him, and to his family, fell far below the standard I would want or expect. 

Manchester University NHS Foundation Trust (the Trust) fully accepts the findings in respect 
of care and the quality of the investigation undertaken. It is to my deep regret that the quality 
of the investigation and the communication with Mr McKibbin’s family, both prior to and after 
the fall, left them with the view that the organisation was not being open with them. I would 
like  to  assure  Mr  McKibbin’s  family  and  yourself  I  have  seen  no  evidence  that  the  Trust 
intended to deliberately mislead or withhold key information.  

In the new Patient Safety Incident Response Framework 2020 - An introductory framework for 
implementation by nationally appointed early adopters, reference is made to trust, alongside 
the impact of a poor early organisational response to incidents. It is my view that the quality of 
the investigation, the presentation of evidence in your court and the communication in respect 
of the breaks and bed rails have left the family, and yourself, with the view that information 
was withheld when in fact it was not and for this I apologise unreservedly.  

Page 1 of 12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It is my understanding that Mr McKibbin’s family are of the view that information had to be 
extracted from the Trust via disclosure to your court. I would note here that this information 
was willingly provided to you in advance of the inquest hearing and that the Trust has never 
sought to cover up this information.  

Reflecting upon this, the family may not have thought this information was being deliberately 
withheld from them if the enquiries as to whether the bed brakes were on and also checks to 
see if the brakes were working, were openly discussed with the family at the time and fed into 
the  investigation  conclusion.  Even  if  the  investigation  concluded  they  were  on,  this  would 
demonstrate  the  investigation’s  rationale.  This  is  a  significant  learning  point  for  the 
organisation and is informing the changes being made to the investigation process which I will 
detail later. 

I come now to your concern that Professor 
 and Managers from the Trust “were aware 
at the very least that the breaks simply cannot have been applied at the time he [Mr McKibbin] 
sustained the fall” and that Professor 

 failed to confirm this fact in your court.  

The NHS Serious Incident Framework 2015 requires that any NHS body “Provide an account 
of the incident which, to the best of the health service body’s knowledge, is true of all the facts 
the body knows about the incident as at the date of the notification.” Our investigation process 
is designed primarily for two purposes; firstly to provide an account to a patient or their family 
of what went wrong and secondly to ensure organisational learning. Our staff are asked to 
ascertain facts and not provide opinion in these investigations unless it is a clinical discussion 
and NHS investigations do not to reach conclusions on the balance of probability as such. It 
is not uncommon for conclusions not to be reached on some matters, particularly if an incident 
is  unwitnessed.  As  unfortunately, this  fall  was  unwitnessed  and,  as  accepted,  early checks 
were not made and documented on the bed brakes, a conclusion was not reached.  

Professor 
 did not withhold this information from your court or Mr McKibbin’s family, 
the investigation did not conclude that the bed brakes were on, or off, and she therefore did 
not have that fact to present.  

The learning from Mr McKibbin’s care and subsequent investigation has been widely shared 
across our Hospitals and Managed Clinical Services. Reports have been made to the Board 
of Directors, the Trust Governors, our Commissioners and the Care Quality Commission. The 
events were also the subject of a Board of Directors Development Session in October. 

This  was  also  presented  by  the  Trust’s  Group  Director  of  Clinical  Governance  at  the 
September Group Patient Safety Forum, which is widely attended by clinical governance leads 
across  all  hospital  sites  and  Managed  Clinical  Services  across  the  Trust,  the  learning  for 
onward dissemination at a local level. At the Trust’s Wythenshawe, Trafford, Withington and 
Altrincham (WTWA) site1 specifically, the learning arising from the investigation and Inquest 
has been shared via a report delivered by the site Director of Nursing to the Trust’s hospital 
management  board,  via  a  paper  specifically  detailing  learning  arising  following  the  Inquest 
conclusion presented to the site Quality and Patient Safety meeting in September 2020, as 
well as the Trafford General Hospital Quality and Patient Safety meeting, and separately via 
the September 2020 Division of Medicine documented Governance Summary. The lessons 

1 The Group of Hospitals and services is divided into sites. Wythenshawe, Trafford, Withington and Altrincham 
hospitals form one site. Hereafter referred to as ‘the site’. 

Page 2 of 12 

 
 
 learned were also presented at the Trust Falls Collaborative Group meeting. A further session 
is due to take place in November 2020 at Trafford General Hospital specifically to present and 
share lessons learned with staff in the form of a patient story, which will then be formulated 
into  a  “7  Minute  Briefing”  document,  the  purpose  of  which  is  to  ensure  that  information  is 
shared  in  a  clear  and  concise  way  with  a  wide  group  of  staff.  It  is  also  intended  that  once 
presented at Trafford General Hospital, this will again be presented at the Professional Board, 
the site Quality and Patient Safety Meeting and the Division of Medicine Governance Meeting. 
This will ensure that all lessons are widely shared and that we have included any concerns 
raised by yourself or Mr McKibbin’s family. 

You have set out in your report several matters of concern and I have addressed them below, 
for ease, in the order in which they appear in your letter. 

Delay in diagnosis of peripheral ulcerative keratitis 

Noted under circumstances of death rather than a matter of concern but addressed here for 
completeness. 

The Trust accepts that there was a delay in diagnosing Mr McKibbin’s peripheral ulcerative 
keratitis (PUK), which is a rare (approximately 3 cases per million per year) complication of 
rheumatoid arthritis.  

As set out at the Inquest, the initial diagnosis of bacterial conjunctivitis was discussed with the 
on-call ophthalmologist and treated with chloramphenicol eye drops. As Mr McKibbin’s eye 
condition continued to deteriorate, his management was again discussed by Trafford General 
Hospital medical staff with the on-call Ophthalmology Registrar, and an eye examination with 
ophthalmoscope  and  application  of  a  topical  anaesthetic  and  fluorescein  (eye  dye)  was 
undertaken which identified corneal abrasions (scrape of the top layer, the epithelium).    

Conservative  management  was  advised  and  it  was  noted  that  the  on-call  Ophthalmology 
Registrar advised that he did not consider Mr McKibbin needed an Ophthalmology review at 
this time; it was recommended treatment was changed to chloramphenicol ointment (from eye 
drops) and Viscotears, but that if there was no improvement to repeat the fluorescein and re-
discuss with the results.  

  has  reflected  on  this  specific  aspect  of  the  care  provided  and  advised  that  in 
Dr 
hindsight  when  he  reviewed  Mr  McKibbin  again  and  his  condition  had  further  significantly 
deteriorated  with  severe  erythema  and  swelling  in  both  eyes,  he  should  have  obtained  an 
urgent review by Ophthalmology at this point and not delayed this review over the weekend. 
If the review had been undertaken at this time it is likely that the diagnosis of PUK could have 
been made and treatment commenced.  

Following this incident, the learning was presented as a case study at the Trust’s Audit and 
Clinical Effectiveness (ACE) day on 27th February 2019. This event is undertaken across the 
Trust, with staff attending according to their relevant speciality/division and provides a forum 
for clinical staff to contribute to clinical effectiveness and audit activity, sharing governance 
issues and learning arising in respect of patient safety. Staff are afforded protected time to 

Page 3 of 12 

 
 
 
 
 
 
 
 
 allow for full attendance at the ACE day with clinical duties covered to release staff, covering 
medical, nursing and Allied Health Professional staff. The presentation at the ACE day was 
led by the site Clinical Head of Division of Medicine to raise awareness of the condition and 
importance  of  timely  consultation  and  review  by  relevant  clinical  specialists  to  support 
diagnosis and treatment. The presentation was then shared with staff who could not attend on 
the day.  

Matters of Concern 

1.  Residual concerns on the culture at the Trust 

The Trust has in place a policy on Duty of Candour which I enclose as appendix 1. This policy 
sets out clearly the expectation that all staff at every level will be open and transparent when 
things  go  wrong  and  that  a  clear  explanation  and  an  apology  must  be  given.  The  duty  is 
recorded as part of the incident management process and this is done by recording what has 
been shared and with whom on the Trust electronic governance system ‘Ulysses’. This allows 
for  oversight  and  monitoring  which  in  turn  reminds  all  staff  that  duty  of  candour  is  a 
requirement. Compliance with duty of candour is monitored at the Group Clinical Governance 
Committee and scores are consistently at the 95-100% for stage one (the initial discussion, 
immediate sharing and apology).  

The  Care  Quality  Commission  inspected  the  arrangements  on  duty  of  candour  in  their 
comprehensive inspection of 2018 and noted them to be good. They continue to have regular 
discussions  on  incident  investigations,  findings  and  improvements  made  at  their  quarterly 
Engagement Meetings. 

The Trust has an agreed Values and Behaviours Framework, this has been communicated to 
all staff and individuals are held to account on their adherence to it. 

The  framework  comprises  of four  value  statements  one  of  which  is Open  and  Honest  (see 
appendix 2) This statement requires that staff: admit when they have made a mistake, and 
learn  from  these;  speak  out  if  standards  are  not  being  maintained  or  patient  safety  is 
compromised; deal with people in a professional and honest manner; share with colleagues 
and patients how decisions are made.  

This Framework underpins everything we do in the organisation and is widely recognised and 
understood  by  staff.  In  their  assessment  of  the  Well  led  standard  in  2018  the  CQC  noted, 
“There was a clear statement of vision and values, driven by quality and sustainability. The 
Trust  executive  directors  recognised  the  importance  of  a  shared  vision  and  values. 
Approximately 5,000 staff had been involved in establishing a set of core values for the new 
Trust. These values were ‘everyone matters, working together, dignity and care and open and 
honest.’ These were incorporated into the recruitment and appraisal process.” With specific 
reference to Trafford General Hospital they noted that there was a positive culture across the 
Hospital. 

With  respect  to  the  wider  culture,  there  are  a  number  of  ways  in  which  staff  can  and  are 
encouraged to raise concerns at the Trust. These include;  

Incident Reporting 

Page 4 of 12 

 
 
 
 This is done via an online system and supported by a policy included at appendix 3. The rates 
of incidents reported are generally accepted as one of the measures of safety culture within 
NHS Trusts. MFT has consistently been in the top quartile of similar organisations for the last 
10 years reporting 53.79 incidents per 1000 bed days in the period October 2019 to March 
20202. For context the range of data for the 9 similar organisations in the Shelford Group of 
NHS Trusts for the same period is 42.04 – 63.76 incidents reported per 1000 bed days with 
MFT being the fourth highest reporter in the group.  

The Trust monitors rates of reporting, themes in respect of what is reported and learning from 
incidents at a number of forums and shares learning widely through presentations and alerts 
to staff. The thematic information also informs our patient safety work plans throughout the 
year and reducing harm from falls has been a significant focus, the work on this is detailed 
later. 

Local Clinical Governance Arrangements 

All  staff  are  encouraged  to  raise  any  safety  concerns  and  discuss  incidents  with  their  line 
manager  and teams.  There  are  local  safety  huddles  and  meetings  across  all  clinical  areas 
where concerns can be raised. 

Every  hospital  in  the  Trust  has  a  local  Quality  and  Safety  Committee  where  concerns  and 
themes from incident reports, Inquest findings, claims, complaints and audits are examined 
and acted upon. The minutes of these meetings are submitted to the Group Quality and Safety 
Committee  for  review  and  discussion  in  order  that  learning  is  shared  across  the  Trust  and 
beyond. Feedback was provided to the site Hospital Management Board by the site Director 
of Nursing and site Head of Clinical Governance with a view to sharing the learning, as well 
as at the Quality and Patient Safety meeting specific to Trafford General Hospital.   

Whilst I cannot comment on the concerns about the wider NHS, I am confident that at a Trust 
level and locally at Trafford General Hospital the prevailing culture is one of openness and 
transparency. I am deeply sorry, as stated earlier, that the substandard management of the 
investigation  and  the  poor  communication  with Mr McKibbin’s  family  left  them  and  yourself 
with a different view. It is clear that the delays in sharing the report resulted in a lack of timely 
openness on our part but we sought to be honest at all times. 

Bed Brakes and Bed/Safety Rails 

I  will  now  address  the  specific  concerns  as  detailed  in  the  letter  in  regard  to  the  matter  of 
openness with regard to the bed brakes and safety rails. 

I share your concern that the assessment of the brakes was not undertaken immediately post 
Mr McKibbin’s fall. I also accept in full your findings in relation to the report completed, it was 
not of the quality I would expect and lacked some key questions and lines of enquiry. Those 
failings acknowledged; it is not accepted that the Managers from the Trust therefore knew the 
brakes could not have been on. Sadly, Mr McKibbin’s fall was unwitnessed and, as confirmed, 
the brakes were not checked at the time. The Trust position on this was that it could not be 
ascertained  as to  whether the  brakes  were  on  and  that  the  bed rails  were  applied.  I  would 
draw your attention to page 4 of the report where it is noted that “Upon entering the room Mr 

2 NHS Improvement National Reporting and Learning System (NRLS) Data 

Page 5 of 12 

 
 
 McKibbin  was  found  on  the  floor.  The  bedrails  were  in  an  up  position  as  requested  by  Mr 
McKibbin  and  the  bed  was  at  the  lowest  level.  The  mechanism  of  Mr  McKibbin’s  fall  is 
unknown”. I also draw your attention to page 32 of the investigation report where it is noted 
that “Given the nature of Mr McKibbin’s injuries it is likely on the balance of probabilities that 
he fell over the bed rails which will have increased the height of the fall.”  

The investigation report notes that the bed rails were in place and this was not questioned at 
any point in the investigation process. The application of the bed brakes was not confirmed, 
and this should have been assessed immediately following the fall and then detailed in the 
report. I apologise for the fact that this was not properly addressed at the time, but whilst the 
application of breaks was discussed by staff, none of whom were present when Mr McKibbin 
fell, at no time did any Manager confirm, or escalate, that they were aware that the brakes 
were not applied.  

The investigation relied on the statements of the staff that were present on the ward at the 
time of the incident and noted that “staff statements indicate that the brakes were on.” As early 
checks were not made at the time, the investigation failed to conclude on this matter and that 
is not acceptable, I will detail later changes we have put in place to address that.  

I would like to state again that there was at no time any intention to withhold evidence from Mr 
McKibbin’s family or yourself but it is wholly accepted that an attempt to withhold information 
was a conclusion that could have been reached on the basis of the quality of the investigation 
and the evidence presented in your court.  

Nursing Documentation 

Updated Falls investigation template, Falls Policy and Intentional Rounding 

The intentional rounding core documentation (attached at appendix 4) was adapted alongside 
the  Trust’s  Inpatient  Falls  Management  Policy,  Falls  Care  Plan,  and  Falls  Investigation 
Template,  with  changes  publicised  via  the  Trust’s  iNews  communication  on  9th  September 
2020  which  included  a  spotlight  on  falls  prevention  and  management.  The  updates  to 
documentation  were  also  circulated  by  the  Group  Deputy  Chief  Nurse  on  11th  September 
2020. The changes were also highlighted specifically at Trafford General Hospital via the site 
Falls Specialist Nurse, with a poster and publicity campaign.  

The changes to the investigation templates as a result of the response to this investigation 
and  the  recommendations  you  have  made  require  the  Nurse  in  charge  or  a  delegate  to 
complete appendices to capture the immediate scene of a fall, via a newly developed “First 
Responder” document. Furthermore, changes to the Trust’s Falls Policy include reference to 
the additional falls safety checks in rounding documents, amongst other changes.  

The changes to the intentional rounding documentation incorporate additional safety checks, 
including requiring specific confirmatory checks in respect of patient bed brakes and bed rails. 
These changes are detailed within the updated Trust Falls Policy (section 4.4), which details 
that  care  and  communication  rounding  is to  be  completed  in  line  with the  Trust’s  and  local 
ward  standards.  This  includes  four  specific  questions  which  have  now  been  added  to  the 
Trust’s Care and Communication / Intentional Rounds under the heading “Patient Safety” in 
relation to falls reduction:  

Page 6 of 12 

 
 1. Have the brakes been applied to the chair/bed/trolley?  

2. Is the floor clean/dry/clear of debris?  

3.  Has  the  Trust  bed  rails  assessment  been  completed  and  are  the  bedrails  in  the  correct 
position?  

4. Has the Trust falls risk assessment been completed and is this up to date with care planned 
appropriately?   

The Falls Collaborative Research Sub-Group, co-chaired by the Trust’s Group Deputy Chief 
,  Director  of  the  National  Institute  for 
Nurse  and  international  expert  Professor 
Health Research’s Older People & Frailty Policy Research Unit, has reviewed and approved 
the  Trust’s  Intentional  Rounding  documentation.  The  evidence  base  for  rounding  was 
considered at the Falls Collaborative meeting on 21st September 2020. Subsequently, a Task 
& Finish Group has been established within the Trust with support from academic partners to 
review the current nursing documentation and its effectiveness in contributing to the delivery 
of an individualised care plan for patients. A high-level literature review has been conducted 
on intentional rounding to inform this work programme. The Task & Finish Group will report to 
the Trust’s Policy & Practice Group, which reports to the Professional Board chaired by the 
Group Chief Nurse.  

First Responder document 

In addition, in response to the learning arising out of the review of Mr McKibbin’s care, a First 
Responder document has been developed and brought into use Trust-wide from September 
2020, included as part of the updated Falls Investigation template. This document has been 
designed to support staff in investigating the immediate scene following an inpatient fall. Key 
considerations for completion of the First Responder document have been disseminated to 
staff using the “Feedback Friday” campaign. This has included communicating that the First 
Responder  document  must  be  completed  for  all  falls,  even  where  patient  harm  is  not 
suspected. The initial priority is stressed as being to ensure that the patient is safe and that 
necessary post-fall actions have been completed in line with Trust Falls Policy, however the 
First Responder document is required to be completed in addition as soon as possible. It has 
been  emphasised  that  timely  completion  of the First  Responder  document  is  essential;  the 
document must be completed by the first responder to the fall, or if this is not possible the 
Nurse in charge must complete the document in the course of the same shift during which the 
fall occurred, after discussion with the first responder. The First Responder document requires 
completion of a simple but effective diagram to demonstrate the layout of the scene, including 
the direction the patient is facing, with symbols for ease of navigation, and obvious hazards 
(wet  floors,  unlocked  brakes,  bedrail  position)  clearly  identified.  The  First  Responder 
document must be filed in the patient’s clinical notes and easily accessible to an investigating 
officer.  

An audit of compliance with the First Responder document and gauge of staff opinion was 
undertaken  at  two  sites,  across  seven  wards  at  Trafford  General  Hospital  on  13th  October 
2020, and across seven wards at Wythenshawe Hospital on 14th October 2020. These wards 
were specifically selected using the Trust’s weekly falls report given the most recent falls had 
occurred  at  these  locations,  and  the  wards  include  all  three  clinical  divisions.  The  audit 
demonstrated a 79% compliance rate in completion of the First Responder document, forming 

Page 7 of 12 

 
 a basis for future work on embedding and improvement towards an aim of 100% compliance, 
to be overseen by the Falls Specialist Nurse for the site. The First Responder document is 
being revised in line with feedback from staff to ensure it is as helpful and user friendly as 
possible. A further audit is due to be undertaken in December 2020. 

2.  Proforma / documentation communication paradigm 

The matter of the clinical record is a valid concern and one that the Trust has recognised. To 
that end we have a detailed assessment of the risk and have been working with teams widely 
on the mitigation of the risks associated with paper and electronic records across our hospitals 
and services.  

In  order  to  fully  mitigate  the  risk  the  organisation  is  in  the  process  of  establishing  a  fully 
electronic patient record across the entire Trust.  

The Trust took the strategic decision to go to market and procure a new Trust-wide Electronic 
Patient Record (EPR) for the MFT organisation in January 2018. The procurement process 
commenced in August 2018 with a go live of the new EPR in September 2022. 

Work to date has included the following: - 

•  Board  agreement  of  a  significant  financial  investment  in  the  project  and  on-going 

support; 

•  Establishment of the senior leadership and governance arrangements; 
•  Signed a contract with Epic Systems to provide the system; 
•  Creation and launch of Innovation Council; 
•  Significant work on communications and engagement; 
•  Series of benefit workshops undertaken with staff; 
•  Creation of five programme work streams. 

The programme is now in its start-up phase.  Since approval by the Board of Directors and 
then  contract  signature  with  Epic  Systems  at  the  end  of  May  we  have  set  up  the  design 
authorities  and  operational  readiness  board  chairs  have  been  identified  and  they  and  the 
design working groups will be setup by March 2021 to support the design process. We expect 
to setup working groups with subject matter experts including clinicians from all disciplines. 

The system is a significant project and is set to revolutionise the way care is delivered across 
all of our hospitals. That said, the project is of a medium time frame and to that end the Trust 
is aware of the risks associated with the current hybrid record and the need to communicate 
clearly on issues of patient care across our own different hospitals and more widely with other 
referring hospitals. All of our hospitals have a detailed risk assessment in place in relation to 
the management and quality of the patient record and work with staff on ensuring the safe 
communication of patient information. That work includes training for staff on the importance 
of compliance with professional record keeping standards and continued efforts to share the 
hybrid record across all sites through systems such as All Scripts and Chameleon (existing 
site electronic records). 

With respect to the specific issue of ophthalmology advice, a focus in respect of the evidence 
arising  from  Mr  McKibbin’s  review  was  a  failure  of  communication  by  Trafford  General 
Hospital’s clinical team with specialist colleagues at Manchester Royal Eye Hospital.  

Currently specialist colleagues receiving referrals from across the Trust have access to the 
Chameleon/Sunquest ICE Desktop clinical records system or the Allscripts EPR, containing 

Page 8 of 12 

 
 
 
 
 
 
 
 diagnostic  test  results  and  other  specific  electronic  records  such  as  correspondence.  It  is 
acknowledged  by  the  Trust  however  that  not  all  records  will  be  viewable  by  specialist 
colleagues across sites, i.e. those that are paper-based. Therefore, until the Trust-wide Epic 
EPR  is  live  across  the  organisation,  the  usual  process  for  specialist  advice  would  be  that 
relevant information from clinical records would be sought when receiving a request for advice.  

Generally, for ophthalmological advice, a request would be made to see the patient physically 
for a face-to-face assessment. A decision to transfer however is a clinical risk assessment for 
those who are frail, and at risk from the consequences of transfer. If the patient is clinically 
able to travel, a transfer to Manchester Royal Eye Hospital would be arranged the same day. 
The Trafford General Hospital records would be brought to Manchester Royal Eye Hospital 
with the patient along with the written referral. Manchester Royal Eye Hospital specialists will 
then assess the patient in person via the emergency eye department or clinic, and the advice, 
treatment plan and any medication advice will be documented in the Trafford General Hospital 
notes,  which  return  with  the  patient.  If  the  patient  is  not  fit  for  transfer,  a  specialist  from 
Manchester Royal Eye Hospital will attend at Trafford General Hospital or elsewhere within 
the Trust to provide face to face specialist review.  

The same principles apply to hospitals outside the Trust who access specialist services for 
advice, as the Trust cannot access notes from hospitals outside the Trust. The expectation 
would be that relevant clinical information will be sought when receiving a telephone referral 
for advice. 

The  use  of  the  Situation,  Background,  Assessment,  Recommendation  (SBAR)  structured 
communication tool is recommended to facilitate efficient communication between clinicians 
or clinical teams. The SBAR allows staff to communicate assertively and effectively, reducing 
vagueness and the need for repetition. The SBAR process is available for staff to use should 
they wish but is not always the appropriate format in which to document or structure clinician 
to clinician discussion. I have asked my Medical Director to explore the use of the tool further 
to agree in what circumstances it should be used. All clinician to clinician discussions should 
be supported by professional record keeping and decisions clearly documented. Medical staff 
have been reminded of this as part of the shared learning in response to the concerns raised 
with regard to Mr McKibbin’s care. 

Weekend Care 
In  respect  of  the  specific  point  this  gives  rise  to  around  weekend  care,  the  Trust  actively 
participates in the national improvement project ‘Seven Day Hospital Services’, which aims to 
ensure that patients receive consistently high-quality safe care every day of the week.  

For  context,  the  inpatient  services  provided  at  Trafford  General  Hospital  are  non-acute, 
including day case and short stay elective surgery and reablement. Inpatient medical services 
are focussed on patients that do not require specialist inpatient care. Trafford General Hospital 
provides specialist complex rehabilitation to the local population following Fractures Neck of 
Femur, other fragility fractures and Stroke services.  

Patients are Trafford General Hospital have access to a senior clinical decision maker and 
diagnostics seven days a week. A Consultant is based on site at the weekend, 08.00 – 17.00 
hours, and is on call out of hours to provide support and clinical guidance. In addition, two 

Page 9 of 12 

 
 
 
 junior grade doctors, a Registrar and anaesthetist are available on site 24 hours a day, 7 days 
a week. An ‘Out of Hours’ nursing team provides support to the on-site medical team.  

Specialist  advice  is  available  from  the  relevant  clinical  specialists  based  either  within 
Wythenshawe  Hospital  or  Manchester  Royal  Infirmary  (or,  as  above,  in  the  Trust’s  other 
specialist services such as at Manchester Royal Eye Hospital). Advice will either be provided 
over the telephone, review and assessment if required will either be undertaken at the Trafford 
General  Hospital  site,  or  arrangements  made  for  transfer  if  clinically  indicated,  as  stated 
above.  

There  is  24-hour  support  for  radiology  investigations,  including  CT  and  x-ray,  to  be 
undertaken,  with  a  radiographer  on  site  between  08.00  –  04.00  hours  7  days  a  week.  A 
Consultant radiologist is also available to discuss any requirements for Magnetic Resonance 
Imaging (MRI), and if required arrangements would be made for this to be undertaken at either 
the Wythenshawe Hospital or Manchester Royal Infirmary sites.  

Physiotherapy  and  Occupational  therapy  are  also  provided  7  days  a  week  on  the  elective 
Orthopaedic ward and the Early Limb Mobility (ELM) rehabilitation unit.  

3.  Investigation Processes 

I will now turn to action in response to the findings in respect of the investigation process. 

The Trust operates an Incident Reporting and Investigation Policy which sets out standards 
for  instigation  when  incidents  occur. One  of  these  standards  is: “The  report  should  include 
evidence found and RCA techniques used and ensure that conclusions are evidenced and 
reasoned” It is clear to me that in this investigation and care review that did not happen.  

What is also clear to me is that there were a number of red flags (warnings) present early in 
the  investigation  process  that  should  have  been  picked  up  and  addressed  at  the  time.  Of 
particular significance were that Mr McKibbin’s family were raising early concerns about the 
process and that staff statements on the events did not concur.  

The early problems with the investigation into the fall should have prompted escalation but did 
not. This was a fundamental issue and one that has been addressed as part of the response.  

The  Trust  undertakes  a  number  of  investigations  every  year  to  ensure  that  explanation  is 
provided  to  patients  and  their  families,  and  lessons  are  learned.  Most  of  the  investigations 
undertaken meet the standards set out but sadly there are a small number that have not. The 
Group Clinical Governance Team have reviewed these, alongside Mr McKibbin’s, and noted 
that  some  of  these  red  flags  are  common  to  complex  investigations3.  The  team  have  now 
formalised these and are using them at all initial incident review panels to identify where there 
may  be  a  risk  of  the  investigation  standards  not  being  met.  If  a  risk  is  identified  additional 
oversight arrangements are made and the issues openly discussed with investigation team 
members. 

3 Red flags identified include family concerns about the process, early statement discrepancies, the 
investigation involving more than one Hospital or service, investigation team unplanned absence and 
unwitnessed events. 

Page 10 of 12 

 
 
 Discussion has been undertaken with all Hospitals and Managed Clinical Services across the 
Trust and all services have reviewed their local incident investigation oversight processes to 
ensure that they have applied the learning as a result of a review of this case. 

The  falls  investigation  template  has  now  been  updated (attached  at  appendix  5) to  include 
more detailed guidance around immediate action, including the requirement for an immediate 
check and documentation of the environment of a fall, including an unwitnessed fall.  

The  importance  of  an  immediate  review  of  the environment  and  gathering  of  evidence  has 
been reiterated in guidance and shared across our Hospitals and Managed Clinical Services 
and, as previously stated, added to the Falls Investigation template. 

Nationally  there  has  been  recognition  that  the  investigation  processes  in  the  NHS  require 
review and a framework is currently being tested in a small number of Trusts before National 
originally  planned  for  roll  out  in  2021  but  now  pushed  back  to  2022  in  response  to  the 
pandemic.  

The National Patient Safety Incident Response Framework 2020 (PSIRF) recognises that the 
issue faced by many Trusts is the requirement to investigate so many incidents and that that 
is now hindering rather than supporting progress. The report builds upon the earlier ‘Opening 
the  Door  to  Change’  report  by  the  CQC  recognising  that  many  of  the  policy  and  protocol 
barriers  have  now  been  implemented  and  that  it  is  culture  and  behaviour  that  need  to  be 
addressed.  The  Framework  makes  it  clear  that  despite  the  best  efforts  of  staff  and  the 
continuing advances in patient care, the inherent risks and complexity of healthcare mean an 
NHS entirely free of incidents is an unrealistic expectation. 

The  investigation  process  and  MFT  policies  on  same  have  largely  been  informed  by  the 
national requirements of the Serious Incident Reporting Framework 2015. This has now been 
reviewed and the National Patient Safety Incident Response Framework will replace it.  

The  framework  is  being  trialled  by  some  early  adopters  and  once  this  is  complete  a  final 
version will be available for Trusts to implement in 2022. An introductory version was published 
for review on 11th March 2020 in order that organisations could start to prepare for adoption 
of this.  

In  preparation  for  this  the  Trust  has  already  implemented  some  changes  including,  the 
implementation  of  a  Rapid  Learning  Review  which  includes  a  process  for  agreeing  the 
response to each incident and a revised Serious Incident Panel process, this will be supported 
by the red flag identification described earlier. The Serious Incident Panel process will be a 
time-limited measure for a period of 12 months to strengthen oversight of investigations whilst 
the PSIRF is implemented.  

The plan for implementation of PSIRF is included in MFT Patient Safety work programme for 
2020/21 and key steps have been agreed at the Trust Quality and Safety Committee, whilst 
timeframes  are  included  some  of  these  may  need  to  move  dependent  on  the  final  PSIRF 
publication following the trial within early adopter sites.  

In addition to the above changes at Group level Trust-wide, at the WTWA site specifically, a 
local Serious Incident Panel has been established to review serious incidents requiring further 
response. This will be overseen by the site Medical Director, Director of Nursing and Head of 

Page 11 of 12 

 
 independent 
Clinical  Governance  and  will  support 
investigation team. The new WTWA Quality Assurance Serious Incident Panel process will 
support  the  identification  of  clinical  incidents  that  require  further  investigation,  to  ensure 
accountability,  oversight and  coordination  of  investigations,  with  a  process  aligned  with  the 
formal complaints process. 

the  appropriate 

identification  of 

A  Mortality  Review  process  is  firmly  embedded  at  Trafford  General  Hospital  to  facilitate 
identification of learning arising from patient deaths.  

I am of the view that these lessons and the changes implemented following Mr McKibbin’s 
investigation  and  subsequent  Nursing  Review  will  significantly  improve  processes  and 
mitigate the risk of similar problems arising in the future. 

I  apologise  unreservedly  for  the  failings  identified  and  hope  that  the  content  of  my  letter 
provides assurance to you and Mr McKibbin’s family that significant changes have been made 
to prevent such events from occurring again in the future. 

Yours Sincerely, 

Chief Executive 

Page 12 of 12

Mr Christopher Morris 
HM Area Coroner, Manchester South 
Manchester South 
1 Mount Tabor Street 
Stockport 

By e-mail: 

Dear Mr Morris, 

                 National Medical Director 
                                  Skipton House 
                              80 London Road 
                                          SE1 6LH 

 25th February 2021 

Re: Mr William Ivan McKibbin, Regulation 28: Report to prevent future deaths 

Thank you for your Regulation 28 Report dated 28th September 2020 concerning 
the death of Mr William Ivan McKibbin, Firstly, I would like to express my deep 
condolences to Mr McKibbin’s familiy.  

I have been sighted on the Trust’s comprehensive response and that as part of our 
commitments in the People Plan, NHS England and NHS Improvement is 
promoting and encouraging NHS employers to complete the free online free online 
Just and Learning Culture training and accredited learning packages to help them 
become fair, open and learning organisations where colleagues feel they can speak 
up. 

Thank you for bringing this important issue to my attention and please do not 
hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director   
NHS England and NHS Improvement  

NHS England and NHS Improvement