Emma Dorman

30.4.2021 

HM Assistant Coroner (West Yorkshire 
Western), Dr Howard 
City Courts 
The Tyrls 
Bradford 
BD1 1LA 

Director of Nursing & Quality & 
Deputy CEO  
Trust Headquarters  
Fieldhead 
Wakefield  
WF1 3SP  

Dear Sir, 

Regulation  28  Report Response  –  Emma  Dorman  – Inquest  21st  January 2021  and 15th  February 
2021 

In response to the Regulation 28 the Trust wish to respond with the following information. 

As you will recall, you heard evidence regarding Regulation 28 matters in both written and oral evidence 
from 
  provided  two 
,  General  Manager  for  Inpatient  Services. 
statements to assist with the proceedings; these were dated 20th January 2021 and 12th February 2021. 
This  response  therefore  builds  upon  the  evidence  provided  by 
  as  part  of  the  inquest 
proceedings. 

1.  The decision of leave was dominated by the non-clinical team through the Bed Manager and 
clinical staff felt they could not object. The draft amended clarification still enable those not 
directly responsible for patient care to effect clinical management of the patient. 

Our Response 

The  Trust  has  a Patient Flow  Procedure  that  provides  a framework for  staff  relating  to  activities 
around pre-admission, bed allocation and management processes, the inpatient stay and discharge 
of service users. The procedure is used to support decisions and management of service users 
from the point when they require access to an inpatient bed, through to their discharge from a ward. 
The  Patient  Flow  (Bed  Management)  Team  are  involved  in  the  application  of  the  patient  flow 
process across the Trust by working in partnership with the Inpatient services. The Patient Flow 
Team is a clinically led service. 

The Trust notes your continued concern over the decision making by Registered Clinical Staff (Bed 
Flow Managers) who are not always involved at ward level. Over the past 2 years the Trust has 
undertaken an extensive review of its clinical structures and has employed several Matrons within 
its  Inpatient  settings.  The  Matrons  are  clinically  and  operationally  responsible  for  each  Ward 

To protect the environment and save money this letter is printed on recycled and unbleached paper. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Manager  and  have  a  senior  clinical  oversight  role  in  relation  to  inpatient  services  and  also  the 
general running of the wards. 

The  process  of  allocating  an  inpatient  bed  starts  with the  Nurse in Charge  of the  ward  on  each 
given day. This nurse is under the supervision of a Senior Registered Nurse (i.e Team Leader) who 
is also available and working in the ward with the service users. 

The Patient Flow Procedure is available to the Nurse in Charge and the Senior Registered Nurse 
when considering new admissions. On the rare occasions the pressure on beds is such that we 
must look at utilising our leave beds to manage critical situations in the community. 

The Nurse in Charge is responsible for assessing the appropriateness of an admission to the ward 
and advising the Bed Flow Manager of any available beds. In the event that the Bed Flow Manager 
and the Nurse in Charge cannot agree whether a bed can be utilised, then the matter is escalated 
to  the  Senior  Registered  Nurse  on the  ward.  As indicated  previously,  it  is  important  to  note  that 
whilst we have registered nursing staff on shift running the ward, there is also a Ward Manager and 
a Matron (both of which are registered professionals). The Matrons provide a 7 day service and as 
stated previously are clinically attached to the wards. Any issue that cannot be resolved within the 
normal ward structure are escalated to the Matron who has clinical operational responsibility for the 
wards. 

The  liaison  between  the  ward  staff  and  the  bed  flow  managers  is  one  of  risk  management  and 
resource  allocation  which  can  be  very  difficult  but  remains  patient-centred  and  with  their  best 
interest at the heart of decision making. We would wish to assure you that the decision making is 
clinically led and is heavily influenced by senior clinical staff who are allocated to the wards.  

In light of the above and your concerns, the Trust have provided all staff within the Inpatient setting 
a copy of the current Patient Flow Procedure, accompanied with information specifically detailing 
theirs and their colleague’s roles as part of the patient flow process.  

I can confirm that inpatient staff understanding of the procedure, and the responsibilities of those 
involved  in the  patient flow  process  (including that  of  ward  staff  and  of  patient  flow staff)  will  be 
monitored through the Matron’s monthly checklist. 

2.  That there was no psychologist input on the ward, which had persisted for over three years 
prior to this incident. The only steps taken to alleviate this vacancy was to re-advertise the 
same post with the same level of remuneration. 

Our Response 

Unfortunately, the Trust has had a high vacancy rate for Clinical Psychologist posts over the last 
couple of years as a result of the national shortages surrounding the profession.  

The  Trust  has  taken  various  approaches  to  attract  applicants  to  such  posts,  including  redesign, 
flexible  working  and  job  sharing,  but  sadly  the  national  shortage  from  Clinical  Psychologists 
continues to impact on the Trust’s ability to appoint to these posts. 

 
 
 
 
 
 
 
 
 
 
 
 NHS England are actively considering these shortages as part of their long-term planning for the 
NHS Psychology Services and National Health Education England have increased training places 
on  Clinical  Psychology  Course  across  England  by  25%  in  2020-2021  and  again  for  2021-22. 
However, it is noted that these courses take three years to complete and therefore the output from 
the  increased  placements  will  take  time  to  have  an  impact  on  the  current  shortages  of  Clinical 
Psychologists within NHS Psychology Services.  

The Trust successfully arranged for retired Clinical Psychologists to support its Psychology services 
to respond to increased demand as a result of the on-going COVID-19 pandemic, but unfortunately 
we were unable to attract someone to temporarily fill the Ward 18 vacant post. 

Additionally, the Trust’s Professional Lead for Psychology is a member of the West Yorkshire and 
Harrogate ICS Psychology Workforce Group. This group are currently seeking ways to develop the 
Psychological  workforce  in  the  area,  but  the  number  of  HCPC  registered  Clinical  Psychologists 
remain  limited  due  to historical  training  output  from  the  Clinical  Psychology  Course  provided  by 
National Health Education England. 

 addendum statement dated 12th February 2021, subsequent to the six failed 
As per 
attempts to recruit a part time Psychologist to Ward 18, an agreement was made for the Ward 18 
part time Psychologist post to be incorporated into the Psychology services that are based within 
Community Services. 

The Community Services are currently reviewing the skill-mix for existing vacant psychology posts 
in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological 
Therapy  Lead  will  review  and  update  the  Job  Description  and  Person  Specification  for  the  role. 
Once the updated Job Description and Person Specification has been drafted, it will be submitted 
to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be 
advertised. We anticipate this process to conclude in June 2021. 

In  the  interim  and  until  we  have  recruited  to  the  above  psychology  post  a  Clinical  Psychologist 
working within the CORE community team will provide in-reach psychology support to Ward 18. 

I do hope the above information is of assistance and answers the concerns raised within your Regulation 
28 report following the sad death of Emma Dorman. 

Yours faithfully, 

Director of Nursing & Quality & Deputy CEO