Richard Burgess

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

39 Victoria Street 
London 
SW1H 0EU 

23 August 2021 

Derek Winter DL 
HM Senior Coroner, Sunderland 
The Coroner’s Office 
Sunderland Civic Centre 
Burdon Road 
Sunderland SR2 7DN 

Dear Mr Winter, 

Thank you for your letter of 19 May 2021 about the death of Richard Burgess.  I am 
replying as Minister with responsibility for mental health and I am grateful for the additional 
time in which to do so.     

Firstly, I would like to say how saddened I was to read of the circumstances of Richard 
Burgess’s death, and I offer my sincere condolences to his family and loved ones. The 
circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention.  

In preparing this response, enquiries have been made with NHS England and NHS 
Improvement and their regional and local partners, and the Care Quality Commission 
(CQC).   

You raise a number of concerns in your report that I will address in turn. 

Ensuring that we have a workforce that has the right values, skills and knowledge, is 
essential to providing a high-quality service for all those who have need of care services, 
including those living with dementia.  This is why the Department continues to commission 
and fund a range of training opportunities and other programmes to help recruit people into 
the sector and develop career pathways, and to support staff to progress to more senior 
management and leadership roles. 

In addition, we want all relevant staff to have received appropriate dementia training.   The 
requisite training needs are set out in the Dementia Training Standards Framework 
(Framework) , which includes the competencies expected of staff across three tiers of 
training.  There is particular focus on person-centred care within the Framework and in 
relation to training, the existing knowledge and competencies required are covered at Tier 
1 (Care Certificate), and Tier 2 of the Framework, and in a number of places, for example:  

• Section 3.4 Care Certificate - makes reference to staff needing to be able to “Deal

with Incidents, errors and near misses”, and

 
 •  Section 4 - refers to “understanding the importance of clear documentation to 

communicate the care needs of the person with dementia”. 

Awareness of the different types of dementia and associated symptoms are covered in 
Section 1 the Framework, such as - dementia awareness; know what is meant by the term 
dementia; and understand the importance of recognising a person with dementia as a 
unique individual. 

Since 1 April 2015, newly appointed health care assistants and social care support 
workers, including those providing care to people with dementia and their carers, have 
been undergoing training as part of the national implementation of the Care Certificate. 

Good progress has been made to date in training the social care workforce, with around 
half of those estimated to require Tier 2 level training, having undertaken training to a level 
equivalent to it. The Department is currently exploring options for increasing uptake of Tier 
2 training by everyone who needs it, and in March 2019, the Minister for Care co-signed a 
letter with the Chief Executive Officers of Skills for Care and Health Education England 
which was circulated to health and care organisations highlighting the importance of 
training.  

In relation to the provision of person-centred dementia care, that takes account of 
individual needs and risks, and uses detailed assessment and dynamic, proactive 
approaches to care, you may wish to note that the Care Act 2014 promotes a personalised 
approach to safeguarding which should be person-centred and outcome-focused.  Care 
providers should carry out appropriate assessments, and work with the individual to 
safeguard them in a way that promotes choice and improves quality of life, whist also 
keeping them safe from abuse and neglect. 

In relation to the assessment of patients specifically, the Care Act 2014, sets out statutory 
guidance on how individuals should be involved in assessments.  It makes it clear that 
from their very first contact with the local authority, people must be given as much 
information as possible about the assessment process, as early as possible, to ensure a 
personalised approach.  The process must be person-centred throughout, involving the 
person and supporting them to have choice and control. This might range from offering 
guidance and information to arranging for services to meet those needs. 

Where a person may have difficulty engaging with care and support or safeguarding 
processes, advocacy services are available to assist a person to understand how their 
needs can be met by the local authority or otherwise.  This includes understanding how a 
care and support plan can be personalised and tailored to meet specific needs. 

The Care Act 2014 also requires each local authority to set up a Safeguarding Adults 
Board (SAB) in order to provide assurance that local safeguarding arrangements and 
partners are acting to help and protect adults who they suspect are at risk of abuse or 
neglect.  Adult Safeguarding Boards have the authority to carry out a Safeguarding Adult 
Review (SAR), which should be undertaken in instances when serious abuse, neglect or a 
fatality has occurred and there is concern that providers could have worked more 
effectively to have better protected the vulnerable adult. 

 
 
 
 
 
 
 
 
 
 
 
 If it has not done so already, the relevant SAB should consider if it is appropriate to 
undertake a SAR in relation to Mr Burgess’ death.  The aim of the SAR should be to 
identify the lessons to be learnt from Mr Burgess’s death and apply those lessons to future 
cases.  This is essential in promoting effective learning and preventing future deaths or 
serious harm occurring again. 

As the independent regulator of social care, the CQC monitors, inspects and regulates 
services to make sure they meet fundamental standards of quality and safety.  Person-
centred care is a fundamental standard, and personalised care plans are a key element in 
ratings of provider responsiveness.  The CQC considers how comprehensive plans are, 
staff awareness of plans and how the needs, goals and preferences of users are 
considered. 

The CQC also monitors how well registered providers are protecting people from harm.  
As part of its regulatory approach to registering, monitoring, inspection and enforcement, 
the CQC checks that care providers have effective systems and process in place to keep 
people safe from abuse and neglect.  The CQC will respond as appropriate to identified 
risks within a registered provider and act promptly on safeguarding concerns identified 
through its monitoring or inspection functions.  The CQC will raise concerns with the 
provider, seek assurance that people are protected from further harm and, where 
necessary, raise safeguarding concerns with the local authority, clinical commissioning 
groups and the police. 

In addition, Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2014, details the actions that providers must take to ensure that each person 
receives appropriate person-centred care and treatment that is based on an assessment 
of their needs and preferences.  Providers must work in partnership with users, make any 
reasonable adjustments and provide support to help them understand and make informed 
decisions about their care and treatment options, including the extent to which they may 
wish to manage these options themselves. 

Providers must also work within the requirements of the Mental Capacity Act 2005, which 
includes the duty to consult others such as carers, families and/or advocates where 
appropriate. 

In summary, we recognise that personalised care is vital to those people that need care 
and support.  It has demonstrated the ability to improve outcomes and enhance quality of 
life, enabling people to take control and responsibility for the things that are important to 
them as well as the care they need.  Work is underway to deliver more person-centred, co-
ordinated social care, that is responsive to individual needs, promotes choice, and 
maintains independence. 

Promoting integrated care is a priority for this Government and our aim is to join-up care 
around a person’s needs so that, from their perspective, the experience of care is 
seamless.  The proposals in the Health and Care Bill, such as “Integrated Care Systems”, 
will help to address the barriers which prevent effective join-up between health and social 
care services and support local systems to implement solutions that work best for them 
and the individuals they support.  

 
 
 
 
 
 
 
 
 
 Finally, I expect the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust to 
reflect on the findings of your investigation, and take appropriate action to strengthen and 
improve services.  I am aware that the Trust has provided a response explaining the action 
it has taken following Mr Burgess’s death, particularly in relation to the way patient care is 
reviewed and monitored.  I understand that the Trust’s strengthened review process now 
provides a more detailed analysis on each patient, which will assist multi-disciplinary 
teams to effectively plan care for dementia patients.     

I hope the above response is helpful and provides the necessary information to address 
your concerns. 

NADINE DORRIES 

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

Executive Medical Director 
Executive Suite 
St Nicholas Hospital 
Jubilee Road 
NEWCASTLE UPON TYNE 
NE3 4RT 

HM Senior Coroner Derek Winter 
The Coroner’s Office 
Sunderland Civic Centre 
Burdon Road 
Sunderland 
SR2 7DN 

Dear Sir 

Inquest into the death of Richard Burgess 

This letter is written in response to the Regulation 28 Report which you issued against the Trust following 
the inquest into the death of Mr Richard Burgess. As you are aware, the Trust takes all patient deaths 
very seriously and investigates them very thoroughly to establish if lessons can be learned or services 
improved  and  this  case  was  no  exception.  Following  the  inquest,  the  findings  of  the  Trust’s  Serious 
Incident Report have been shared again at the Trust’s Locality Quality Standards and Safety Meetings, 
in addition to the findings of the inquest and the reports of the independent expert. On 27 July 2021, the 
Central Business Unit will also feedback to the Locality Quality Standards Meeting the outcome of their 
discussions on the findings of the inquest and the independent expert reports to see if any additional 
learning can be identified.   

For  the  purpose  of  responding  to  your  specific  concerns  raised  in  the  Regulation  28  Report,  I  shall 
address each of them in turn.  

1. 

The  provision  of  a  multi-disciplinary  team  and  professionals  with  suitable  skills, 
qualifications  and  competencies  commensurate  with  their  role  and  the  speciality  of 
dementia care. 

1.1. 

As presented at the inquest, all staff employed by the Trust have the relevant skills, 
qualifications and competencies for their role. All staff working with dementia patients 
have  received  appropriate  dementia  care  training,  with  relevant  staff  receiving  care 
planning formulation training, in addition to observation and engagement training. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.2. 

As part of the multi-disciplinary team (MDT), Mr Airey explained that the Trust employs 
specialist Psychiatrists who are trained to work with patients with dementia, in addition 
to Care of the Elderly nurses, who provide training and support to staff. The Trust also 
employs Activity Coordinators who are all actively involved as part of the MDT process 
and has recently trained 10 members of staff to provide dementia care mapping training 
across the relevant wards.  

2. 

A  prevention  model  and  approach  for  dementia  care  that  proactively  uses  detailed 
assessment,  intervention  and  evaluation  of  changing  care,  needs  and  risks  of  the 
individual  in  order  to  provide  therapeutic  interventions  and  reduce  the  need  of 
medication. 

2.1. 

2.2. 

2.3. 

As presented at the inquest, the Trust does adopt a preventative approach to person 
centred care. Tools such as the Newcastle Model, life stories, dementia mapping etc., 
are  used  to  help  formulate  care  plans,  which  include  activities  linked  to  these 
assessments and ways to engage patients in therapeutic interventions that are tailored 
to their specific needs. Staged behavioural support plans also, by their very nature, set 
out  proactive  steps  to  try  and  prevent  behaviour  from  escalating  from  one  stage  to 
another, with medication prescribed only if required.  

As presented at the inquest, changes have been made to the way in which reviews of 
patient  care  takes  place,  with  an  emphasis  now  on  regularly  reviewing  all  of  the 
information available, which includes, but is not limited to, the environment, medication, 
physical health, engagement by staff, incidents, observation levels, risks, patterns in 
challenging behaviour and analysing how these are all impacting the patient so care 
plans can be adapted accordingly.  

As explained by 
, due to the nature and degree of presentations with dementia 
that  require  admission  and  detention  in  hospital,  patients  sometimes  require  regular 
medication to assist with their behaviour. With the new review process there is more 
detailed  analysis  at  MDT  meetings,  with  the  input  of  a  Pharmacist,  as  to  how  often 
medication  is  being  used,  its  effectiveness  and  whether  a  regular  prescription  is 
required,  in  addition  to  any  changes  in  such  medication.  There  are  also  safeguards 
within the Mental Health Act that monitor and review these treatments. 

3. 

The  evidence  of  assessments  or  the  application  of  assessments  of  the  impact  of  the 
persons’  difficulties,  including  cognitive  and  neurological  difficulties,  polypharmacy, 
psychological  and  personality,  mental  and  physical  health,  social,  environmental  and 
care practises, emotions, beliefs and thoughts of a person. 

3.1. 

As described above, all of these factors are regularly reviewed and analysed, with the 
relevant information translated into care plans.  

4. 

A  continuous  engagement  with  the  family  in  the  “triangle  of  care”,  including  regular 
communication and updating life stories. 

4.1. 

As presented at the inquest, triangulation of care is an important aspect of care and 
the Trust regularly engages with families to help formulate care plans. As per 
evidence, care planning is an ongoing process, which evolves with the patient. Whilst 
the Trust uses life stories in the first instance to inform care plans, other information 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 which  is  acquired  over  time,  from  ongoing  assessments  of  the  patients  and 
communication  with  friends  and  families  are  used  to  inform  care  plans,  which  are 
reviewed regularly.  

5. 

A  focus  on  the  person,  asserting  absolute  value  of  the  person  and  individualised 
approach, whilst understanding the world from the person’s perspective and provision 
of a social environment that supports psychological and physical needs. 

5.1. 

As presented by 
 at the inquest, the Trust adopts a person centred focus for 
each  individual  and  uses  models  such  the  Newcastle  Model  and  Kitwood’s  flower, 
which  focuses  on  the  key  principles  of  personhood  (love,  comfort,  attachment, 
inclusion, occupation and identity) to inform care plans. Life stories, ‘this is me’ boards 
and flashcards, were some of the examples given to show how individual information 
is used to tailor care plans and activities to individuals.  

6. 

Converting policy into practice. 

6.1. 

6.2. 

6.3. 

All Policies and guidelines which are implemented by the Trust are put into practice, 
with  staff  receiving  information  and/or  training  on  the  implementation  of  them.  As 
explained  at  the  inquest,  audits  are  put  in  place  to  monitor  compliance,  with  some 
policies, such as the observation and engagement policy, requiring staff to complete 
yearly competency based training.  

Compliance with training is also monitored to ensure that all staff are fully up to date 
with  relevant  policies  and  practices,  with  additional  training  provided  if  a  need  is 
identified.  

In addition to formal training, the Trust also sends out regular bulletins and emails to 
staff  to  keep  them  updated  about  any  relevant  news  and/or  changes  in  polices  or 
guidance,  as  well  as  relaying  key  information  via  team  meetings  and  individual 
supervision.  

6.4. 

The Trust also has champions for some of its policies/initiatives so that extra support 
is provided to assist in embedding practices, especially when they are new.  

I hope that the information provided offers you the assurance that the Trust have invested significant 
time, effort and resource into investigating this incident and looked again at the findings of the inquest 
and independent expert with a view to improving patient care and safety.  

Yours sincerely 

Executive Medical Director