Philippa Day

Mr Gordon Clow  
Her Majesty’s Assistant Coroner for the area of 
Nottingham and Nottinghamshire 
The Council House,  
Old Market Square,  
Nottingham NG1 2DT 

12 April 2021 

Dear Mr Clow, 

Regulation 28: REPORT TO PREVENT FUTURE DEATHS  
Philippa Jane Louise Day (died 16 October 2019) 

On behalf of Capita, I would like to say how very sorry we are for the mistakes we made in processing 
Philippa’s Personal Independence Payment claim and the additional stress this caused her.  

We have conveyed our apologies and condolences to Philippa’s family and offered to meet them to 
explain the improvements we have already made and will be making to how we deliver our Personal 
Independence Payment service.   

In partnership with the Department for Work and Pensions, we have very carefully considered the issues 
raised in your Findings of Fact, Conclusion and Prevention of Future Deaths Report of 27 January 2021.  

We strive at all times to ensure that we safely deliver our  services for the benefit of members of the 
public. It is a source of profound regret that we made mistakes in this case. We are determined to learn 
from these mistakes. 

On 12 February 2021, you issued a Regulation 28 Report to Prevent Future Deaths (the Report). Paragraphs 
1 and 2 of the Matters of Concern in the Report were addressed to the Department for Work and Pensions. 
We  understand  the  Department  for  Work  and  Pensions  will  be  responding  to  those  paragraphs  and 
separately addressing paragraph 3 of the Matters of Concern.  

We respond below to paragraph 3 of the Matters of Concern. We have divided paragraph 3 into three 
separate sections and explained the steps we are now taking to address the concerns expressed in each 
section.  

Paragraph 3 of the Matters of Concern states the following: 

The change of assessment process did not allow for a decision, which was incorrect, to be rectified 
without evidence of a subsequent change of circumstances. In addition, when a change of review process 
was appropriate, there was no means by which upcoming appointments could be cancelled without 
causing prejudice to Philippa Day. A misleading letter was sent which led Philippa Day to consider that 
her benefits would be stopped if she did not attend the upcoming appointment.   

Capita Business Services Limited 
Registered office: 65 Gresham Street, London, EC2V 7NQ   Registered in: England Company No. 02299747 

 
 
 
 
 
 
 
  
 
 
 
   
 
 
 
 
 Section 1 of Paragraph 3 

“The change of assessment process did not allow for a decision, which was incorrect, to be rectified 
without evidence of a subsequent change of circumstances”.  

When a case is referred to Capita by the Department for Work and Pensions for assessment, an Initial 
Review is undertaken by one of our Disability Assessors. Our Disability Assessors  are all trained and 
qualified health professionals (nurses, physiotherapists, paramedics or occupational therapists) with at 
least two years’ experience. They are required to select the most appropriate and safest assessment route 
for assessing a Claimant. This may result in a paper-based review or a face-to-face  assessment which 
could be completed in a clinic or at home (and now, following changes made to our processes due to the 
current pandemic, by telephone).   

Review of the Initial Assessment Route Decision 

Currently, once the Initial Review decision has been communicated to the Claimant, the outcome of the 
Review may only be reconsidered if either new evidence is made available to Capita, or a health 
professional involved in the Claimant’s care notifies us that the setting chosen at Initial Review is not 
appropriate. 

Capita will now amend its processes so that any change of assessment request made by Claimants or their 
representatives will be reviewed by one of our Disability Assessors within 3 working days of the request, 
whether or not new evidence is provided (the Change of Assessment Review).  

The Change of Assessment Review will check the decision that was made by the original Disability 
Assessor at the Initial Review and, if appropriate, select a different assessment route.  

To improve objectivity and prevent unintentional bias, the Change of Assessment Review will be 
undertaken by a different Disability Assessor to the one who completed the Initial Review. The second 
Disability Assessor will be able to contact the Claimant and the Claimant’s representatives for further 
information, if required. 

In addition, the process will be amended so that on receipt of a change of assessment request, the Personal 
Independence Payment claim will be paused to allow for the Change of Assessment Review. 

Within 24 hours of a change of assessment request a Capita employee will contact the Claimant: 

-  Notifying them of the pause in the process and that a Change of Assessment Review will be 

undertaken; 

-  Confirming that the Change of Assessment Review will not prejudice their claim but will pause the 

processing of it while the Review is being undertaken; and 

-  Asking how they would like to be informed of the outcome of the Change of Assessment Review. 

We will suspend any further appointment letters being sent to the Claimant during the period of the 
Change of Assessment Review. 

In agreement with the Department for Work and Pensions, the pausing of the case during the Change of 
Assessment Review will be recorded in our system and will have no detrimental impact for the Claimant. 
While the processing of the Claimant’s claim will be paused during the period of the Review, the 
Department for Work and Pensions will backdate any award to the date of the original claim and existing 
Claimants should continue to be in receipt of current disability benefits.  

Capita Business Services Limited 
Registered office: 65 Gresham Street, London, EC2V 7NQ   Registered in: England Company No. 02299747 

 
 
 
 
 A Capita employee will notify the Claimant of the outcome of the Change of Assessment Review within 
24 hours of its completion regardless of whether the original Initial Review decision has been changed.  

Further Review following the Change of Assessment Review  

After being notified of the outcome of the Change of Assessment Review, the Claimant will be offered 
two options:  

1.  To accept the outcome of the Change of Assessment Review - unless the Claimant wishes to 

challenge their assessment route, following the Change of Assessment Review, they will be informed 
that their application will proceed under the assessment route determined by such review.  

2.  To seek a Further Review - if the Claimant wishes to challenge the assessment route, determined by 
the Change of Assessment Review, they will be invited by a Capita employee to provide further 
evidence as to why they believe the assessment route should be changed. If further evidence is 
provided, Capita will undertake a further review of the assessment route (Further Review).  

Any further evidence must be provided to Capita within 15 working days of notifying the Claimant of the 
outcome of their Change of Assessment Review. The claim process will remain paused during this period.  

We will provide clear guidance to the Claimant on: 

-  The type of evidence that would be considered relevant; 

-  That Capita will accept verbal evidence from a third party or written evidence; and 

-  How, where and when the evidence needs to be provided.  

The Claimant will also be informed by the Capita employee that a Further Review will lead to a pause in 
the processing of their claim for the period of the Further Review. 

We will suspend any further appointment letters being sent to the Claimant during the period of the 
Further Review. 

In agreement with the Department for Work and Pensions, the pausing of the case during the Further 
Review will be recorded in our system and will have no detrimental impact for the Claimant. While the 
processing of the Claimant’s claim will be paused during the period of the Further Review, the 
Department for Work and Pensions will backdate any award to the date of the original claim and existing 
Claimants should continue to be in receipt of current disability benefits.  

If new evidence is provided, this will be recorded on our system and the case will be passed to one of 
Capita’s Disability Assessors for the Further Review.  

To improve objectivity and prevent unintentional bias, the Further Review will be undertaken by a 
different Disability Assessor to those who completed the Initial Review and the Change of Assessment 
Review. The Disability Assessor conducting the Further Review will contact the Claimant and the 
Claimant’s representatives for further information, if required. 

A Capita employee will notify the Claimant of the outcome of the Further Review within 24 hours of its 
completion regardless of whether the Change of Assessment Review decision has been changed.  

If no evidence is received within the 15 working days and unless a good reason has been provided for the 
failure to produce that evidence we will assume the Claimant no longer wishes  to challenge their  

Capita Business Services Limited 
Registered office: 65 Gresham Street, London, EC2V 7NQ   Registered in: England Company No. 02299747 

 
 
 
 assessment route. Once this has been confirmed, the Claimant will be informed that their application will 
now continue to proceed as per the assessment route determined by the Change of Assessment Review.  

If further evidence comes in after the 15 working day period we may elect to pause the process and 
undertake a Further Review if appropriate. In other words, the 15 working day period is not an absolute 
time deadline. However, we would like to avoid unnecessary delays to the consideration of claims for the 
benefit of our Claimants. 

Following the outcome of the Further Review, the Claimant will be informed by a Capita employee that 
their application will proceed under the assessment route determined by such review.  

Section 2 of Paragraph 3 

“In addition, when a change of review process was appropriate, there was no means by which 
upcoming appointments could be cancelled without causing prejudice to Philippa Day.   

Currently, the Department for Work and Pensions process entitles the Claimant to cancel their 
appointment on one occasion without suffering any detriment. In accordance with Capita’s contract with 
the Department for Work and Pensions, should a Claimant attempt to cancel on a second occasion, they  
will be informed that they must attend their appointment. If the Claimant does not attend, their case is 
returned to the Department for Work and Pensions, which then establishes whether there was good cause 
for the Claimant’s failure to attend. This may result in a delay in the processing of the claim. 

In agreement with the Department for Work and Pensions, and as outlined above in Section 1, the 
assessment process will now be paused while Capita undertakes any Change of Assessment Review or 
Further Review. 

During this period, any appointments will be cancelled by Capita and will not be classified as a Claimant 
cancellation. The  Claimant will not suffer any detriment as a result of challenging the assessment route as 
any award will be backdated to the date of the original claim.   

Section 3 of Paragraph 3 

“A misleading letter was sent which led Philippa Day to consider that her benefits would be stopped if 
she did not attend the upcoming appointment. “  

The changes to be made to our systems will prevent the issue of any appointment letters being sent to the 
Claimant during the period when a Change of Assessment Review or Further Review is being conducted, 
other than a letter confirming that the assessment process has been paused while the relevant review is 
conducted. 

We are also working closely with the Department for Work and Pensions to further review the tone and 
language used in any written communications with Claimants. This is being done to ensure, not only that 
they impart clear and important factual information, but also to ensure that they do not cause any 
unnecessary distress, anxiety or upset to those going through the Personal Independence Payment process. 

Timings and Progress 

Capita is already adopting the Change of Assessment and Further Review processes outlined in section 1 
above. Full implementation of the remaining improvements require process and system developments, 
training and contractual amendments which will enable all changes to be in place as soon as possible and 
by no later than 30 September 2021.  

Capita Business Services Limited 
Registered office: 65 Gresham Street, London, EC2V 7NQ   Registered in: England Company No. 02299747 

 
 
 
 
 Capita truly cares about the Claimants we support through the Personal Independence Payment process. 
We are fully committed to learning from this tragedy and to continuously improving how we safely 
deliver services for the benefit of members of the public. 

As noted above, we will also seek to discuss the changes described in this letter with Philippa’s family 
and our stakeholder groups. 

Please do not hesitate to contact me if you require any further clarity or have any queries about any 
aspects of this letter. 

Yours sincerely 

Chief Executive Officer 
Government Services 
Capita Business Services Limited  

Capita Business Services Limited 
Registered office: 65 Gresham Street, London, EC2V 7NQ   Registered in: England Company No. 02299747

HMAC Mr Gordon Clow 
The Council House 
Old Market Square 
Nottingham 
NG1  2DT 

Dear Mr Clow, 

  Caxton House 
Tothill Street 
London 
SW1H  9NA 

  12 April 2021 

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

Introduction  

This is the Department for Work and Pensions’ (“DWP”) response to HMAC Clow’s Report 
to  Prevent  Future  Deaths  made  under  Regulation  28  of  the  Coroners  (Investigations) 
Regulations 2013 dated 12 February 2021. The report arose from an inquest held between 
8 and 20 January 2021 into the death of Philippa Jane Louise Day, who was a Personal 
Independence Payment (“PIP”) claimant with DWP. 

I  would  like  to  take  this  opportunity  to  add  my  condolences  to  Philippa  Day’s  family  and 
acknowledge the tragic nature of this case. I would also like to thank the Coroner for his 
report. 

The Report to Prevent Future Deaths covered three matters of concern to the Coroner. This 
response is structured accordingly. Those matters were: 

1. Call  handlers  as  the  DWP  had  not  received,  in  their  preparatory  course  prior  to 
commencing work taking calls from claimants, specific training as to how best to interact 
with  persons  suffering  from  mental  ill  health  in  such  a  way  as  to  avoid  inadvertently 
exacerbating  the  difficulties  experienced  in  progressing  claims  for  benefits  by  such 
persons;  

2. Records of calls handled were very brief and, at times, inaccurate. The records did not 
facilitate  accurate  decision  making  or  enable  queries  to  be  dealt  with  efficiently  and 
without  inadvertently  exacerbating  the  difficulties  experienced  by  Philippa  Day  in 
progressing her benefits claims; and  

3. The change of assessment process did not allow for a decision, which was incorrect, to 
be  rectified  without  evidence  of  a  subsequent  change  of  circumstances.  In  addition, 
when  a  change  of  review  process  was  appropriate,  there  was  no  means  by  which 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 upcoming appointments could be cancelled without causing prejudice to Philippa Day. 
A misleading letter was sent which led Philippa Day to consider that her benefits would 
be stopped if she did not attend the upcoming appointment.  

This  response  therefore  firstly  covers  action  that  DWP  is  taking  to  increase  the  level  of 
training relating to mental health conditions that call handlers will undertake before they take 
their first call from a claimant on their own (i.e. without a more experienced colleague  on 
hand  to  advise  them,  a  standard  approach  to  initial  training  in  service  centres  in  many 
organisations in both the private and public sector). It then describes the steps underway to 
improve record-keeping and note-taking during and after calls. It then reports on changes to 
the  assessment  process  we  are  developing  in  conjunction  with  the  PIP  Assessment 
Providers. Finally, I relate a number of other relevant actions DWP is either taking or has 
already taken to help mitigate the risk of these circumstances happening again in the future. 

Capita Business Services Ltd (“Capita”), who deliver parts of the PIP service to claimants on 
DWP’s  behalf,  have  submitted  a  separate  response  where  the  Report  to  Prevent  Future 
Deaths touches on matters for which they are responsible. However, the two organisations 
are working together (and with Independent Assessment Services, “IAS”, who also deliver 
assessments as part of the PIP system) to address the concerns raised in both the Coroner’s 
findings on Philippa Day’s death and his subsequent Report to Prevent Future Deaths.  

Mental health awareness training 

DWP has taken significant steps to improve its staff’s ability to understand the wide range 
of mental health issues that benefit claimants may face. It may help if I cover in some detail 
the training in place before and after this case. 

In August 2018 DWP began including an existing training module on supporting vulnerable 
customers  to  all  new  entrants  joining  any  of  its  service  delivery  teams.  This  provides  a 
foundation level understanding to colleagues of the kinds of issues people with mental health 
conditions may face; what constitutes good practice when working with those claimants; and 
where claimants can be directed to find sources of expert help and support.  

From  July  2019  we  began  rolling  out  further  training,  on  mental  health,  behaviour  and 
relationships. This enables colleagues to recognise the effect of their personal impact on 
people with mental health conditions, and to respond appropriately to unexpected customer 
behaviour and identify a claimant’s ability to proceed with a call or a face-to-face meeting. It 
also helps colleagues identify a claimant’s needs and signpost them to sources of help and 
support, where appropriate. 

We  recognise  the  need  to  treat  everyone  with  empathy  and  care;  especially  those  with 
mental health conditions. Because of this, and in response to the Coroner’s concerns, we 
have amended our training for new entrants. From 1 April 2021 all new entrants handling 
PIP and Employment Support Allowance (“ESA”; an income-maintenance benefit for people 
with a disability or health condition that limits their capacity to work or engage in work-related 
activity) will therefore undertake the mental health, behaviour and relationships  training in 
addition  to  the  “supporting  vulnerable  customers”  training  before  they  handle  calls  from 
claimants on their own. We are also arranging for existing colleagues  in those roles who 
have not yet received the training to undertake it by 30 June 2021.  

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 Improvements to record-keeping and note-taking 

I  would  now  like  to  outline  activity  that,  together  with  a  major  change  in  how  DWP 
approaches decision making in PIP and ESA claims, will go some way towards reducing the 
risks associated with incomplete or inaccurate note-taking. 

We issued internal communications to all staff working on PIP and ESA early in March 2021 
to  reinforce  the  importance  of  recording  notes  on  the  appropriate computer systems  and 
remind them that all colleagues are required to ensure that notes: 

a.  are  made following  all  interactions  with  customers or third parties where  an  accurate 

record of it is needed, and 

b.  are  an  accurate  and  factual  account  of  the  conversation,  including  both  any  action 

agreed or taken, and the full reasons for decisions made. 

To ensure a consistent focus on recording accurate notes on the system we are now building 
the  subject  into  our  PIP  decision-making  “quality  assurance  checks”  and  updating  the 
documents that define quality standards for PIP colleagues.  Dedicated “quality checkers” 
within  DWP  check  notes  are  compliant  with  those  standards;  are  recorded  in  a  standard 
format  and  accurately  represent  conversations  and  decisions.  Updating  these  processes 
requires an IT change, which we have planned. We also plan to add a new section, about 
recording notes on the PIP computer system, to the instructions that colleagues working on 
PIP claims use for guidance. We expect both of these actions to be completed by the end 
of Summer 2021. 

At the same time we have also strengthened the guidance around note-taking for colleagues 
who manage ESA claims. We plan to issue two further communications to those colleagues, 
covering specific aspects of ESA claims, in the next few months. As in PIP, we have set new 
quality standards around note-taking. Quality checkers will now deem only notes that meet 
the standards outlined in the best-practice guides to have complied with ESA processes. 
The changes to quality assurance checks in ESA came into effect from March 2021. 

In  addition,  since  August  2019  DWP  has  been  rolling  out  training  and  new  guidance  for 
colleagues working on PIP and ESA claims to promote a new approach to making decisions 
that  considers  a  wider  range  of  evidence  that  could  be  relevant  to  a  claim.  This  new 
approach,  known  as  “holistic  decision  making”  involves  decision-makers  proactively 
contacting claimants to gather evidence, and spending more time considering all evidence 
available to them before making a decision. It is now embedded across all teams handling 
PIP and ESA claims. 

Holistic  decision  making  by  necessity  requires  more  extensive  record  keeping  and  note-
taking on case files for decision makers to explain their decisions. In turn, that means that 
notes recorded on claimants’ files that might have been considered acceptable in internal 
quality assurance checks up to the time of Philippa Day’s PIP application would now result 
in feedback and appropriate action taken with the colleague involved, ranging from informal 
coaching  conversations  to  more  formal  management  action  where  consistent  poor 
performance is identified. 

The process regarding note-taking in Universal Credit (“UC”) claims has always been slightly 
different to that used in ESA and PIP. UC is an online-based service, which means a certain 

3 

 
 
 amount of written record keeping is built in to it automatically. We encourage claimants to 
use an online ‘Journal’ to share information with their work coach or case manager via online 
messages,  which  are  free  text  in  format.  Similarly,  case  managers  and  work  coaches 
communicate with claimants in the same way. Journal messages remain on a claimant’s UC 
record for future reference for the duration of the claim, forming a permanent written record 
of conversations. 

There would of course be a risk that key information could be lost within the detail of what 
can be lengthy conversations with a claimant. To guard against this, UC case managers and 
work  coaches  can  ‘pin’  information  shared  either  via  the  journal  or  as  the  result  of  a 
conversation with a claimant (face-to-face or by telephone) that they deem critical. Pinning 
a note to the claim means it will be flagged to anyone viewing a claimant record as soon as 
they open that record. 

Colleagues working on UC claims are trained on the effective use of journal messages and 
pinned notes effectively, and also on the standard of messaging and note-taking required. 

Changes to the health assessment process 

I  now  turn to  the  third  matter of  concern  described by  the  Coroner. DWP is working  with 
Capita and IAS, to ensure a process is put in place that allows assessments to be paused 
even  when  an  appointment  has  already  been  scheduled  to  allow  for  the  gathering  of 
additional information or changing the type or location of the assessment. The new process 
ensures that a claimant’s assessment can be paused without affecting that claim while the 
reason for the pause is addressed. Elements of this change have already been implemented 
with the full process, including the IT elements, being implemented across the whole of the 
PIP assessment service by the end of September 2021. 

This  process  will  be  supported  by  new  letter  templates  to  be  used  in  correspondence 
between the PIP Assessment Provider (i.e. Capita or IAS) and the claimant, which DWP will 
review before approving. These will ensure clear communication around the reason for the 
pause; confirming any steps that are being taken; and reassuring claimants that their claim 
will not be affected during this pause. Letter templates will be clear and easy to understand, 
adhering to existing guidelines for writing in plain English in Government communications. 

Other action 

Finally, I would like to update you on additional steps taken by DWP in response to concerns 
raised throughout the inquest that we committed to addressing at the time. 

These include: 

a.  We have amended the script that call handlers use in new PIP claims, strengthening 
wording around additional support to clearly identify claimants with vulnerabilities such 
as mental health conditions, as well as those who have difficulties communicating with 
DWP and who therefore may need additional support to manage their claim. We have 
also strengthened guidance for DWP case managers who may speak to claimants after 
the initial application has been completed, aiming to give them greater confidence when 
considering when they may need to apply an additional support marker to a claimant’s 
records and when it may be needed. We have improved training to help call handlers 
better identify those who may need that support. 

4 

 
 
 In developing the script changes we have worked with behavioural science experts in 
DWP  to  maximise  the  effectiveness  of  the  wording.  We  have  sought  feedback  from 
front-line  call  handlers  and,  via  DWP’s  Operational  Stakeholder  Engagement  Forum, 
external stakeholder organisations. 

These changes require changes to the PIP IT system to implement them and they will 
be live by the end of May 2021. 

b.  We have strengthened the wording in the PIP application script when Disability Living 
Allowance (“DLA”, a benefit for people with long-term disabilities and health conditions, 
which PIP is replacing for working age people) claimants start a PIP application. The 
revised wording warns them that their DLA will stop in most cases if they do not return 
their “PIP2” form (the questionnaire that claimants complete setting out their ability to 
undertake daily living and mobility activities in PIP). The new wording will be introduced 
by early May 2021. 

c.  We enhanced the PIP computer system in February 2021 by introducing a highly visible 
“watermark”,  prominently  displayed  on  the  first  page  that  appears  when  accessing  a 
customer’s  records,  showing  if  the  customer  currently  holds,  or  has  previously  had, 
Additional Support Indicated or Additional Support Determined markers on their records 
to  indicate  to  any  PIP  colleague  dealing  with  the  customer  that  they  have,  or  have 
previously had, additional support needs.  

DWP is determined to learn from this deeply tragic case and takes the Coroner’s concerns 
very seriously. We are constantly reviewing the service we provide to claimants across all 
DWP services and are committed to improving them for all our customers and especially the 
many vulnerable people who receive benefits like PIP to help them manage the effects of 
health conditions and disabilities on their daily lives. 

Yours sincerely, 

DWP Director General, Service Excellence 

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