Daniel Rennoldson

Mr Derek Winter 
HM Senior Coroner for the City of Sunderland 
Sunderland Civic Centre 
Burdon Road  
Sunderland  
SR2 7DN 

Dear Mr Winter 

Inquest into the death of Daniel Rennoldson  
Response to Regulation 28 Report; Prevent Future Deaths Response 

We write in response to your Regulation 28 Report dated 17 June 2021 following your investigation into 

the death of Daniel Rennoldson. This response has been prepared by Cumbria, Northumberland, Tyne 

and Wear NHS Foundation Trust (“The Trust”) and addresses the concerns as set out by HM Senior 

Coroner.  

The Trust will respond to each of those concerns in turn.  

The Trust considers that in future cases where there are concerns about operational issues, appropriate 

representation from the Trust would assist HM Senior Coroner in his investigation.  

Response  

The Trust is committed to ensuring that lessons are learned when any serious incident occurs. At the 

time of the incident a Serious Incident (“SI”) Investigation was undertaken and the Trust formed an action 

plan. Both the SI investigation and action plan were shared with HM Senior Coroner in advance of the 

inquest.  

Below is set out the response to each of HM Senior Coroner’s concerns:  

1.  There appeared to be no contingency to deal with more than one face to face response 

at a time, leaving other callers potentially at risk. 

At the inquest HM Senior Coroner heard evidence in relation to Crisis Team contingency plans. 

Evidence highlighted the following information: 

a.  There  are  3  assessing  teams  available  to  carry  out  face  to  face  assessments.  This 

included an adult team, an older persons team and a team for children.  

b.  On occasions where there were a number of assessments waiting to be undertaken on 

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 commencing a shift, the usual multi-disciplinary meeting would be postponed to ensure 

that any potential delays were reduced.  

a.  The  Crisis  service  has  the  capacity  to  respond  to  more  than  one  face  to  face 

assessment: 

i. 

The  day  shift  works  between  08:00hours  and  21:00hours  and  has  3 

assessment teams. Each assessment team has a  Working Age Adult (WAA) 

clinician  and  a  specialist  clinician  (older  adult  or  children  and  young  person 

clinician).  

ii. 

The twilight shift works between 16:00hours to 3:30hours. This shift was agreed 

in order to provide additional support during the busiest part of the 24 hours 

period. 

iii. 

The  nightshift  works  between  20:45hours  and  08:15hours.  From  21:00hours 

there are 2 assessment teams and a triage clinician, although staff are able to 

flex between roles to meet demands.  

iv. 

The above shifts have been agreed based on the intelligence of referral rates 

over a 24 hour period, allowing resources to be flexed to peak times.  

v. 

Each assessment team will respond predominantly to their area of specialism, 

but  will  also  provide  cross  cover  across  pathways  depending  on  pressure 

points. There is also flexibility to reconfigure assessment teams and utilise staff 

from mid-shift, home based treatment and/or shift coordination should patient 

need require this. 

b.  At the time of this incident, a member of the assessment team was on sick leave which 

reduced  the  assessment  provision  for  that  night  only.  At  the  time  of  DR’s  call,  the 

children  and  young  person’s  clinician  was  engaged  in  clinical  interventions  and  the 

other assessment team were engaged in assessment at the time.  

c.  Notwithstanding point (b) above, the assessment team could have responded to a home 

visit  for  DR  within  the  national  recommended  response  time  for  Crisis  services  of  4 

hours. DR however, had provided information to the assessing clinician that he wished 

to sleep and would prefer an assessment the following day. 

d. 

It is common practice for Crisis Teams to cross cover and draw upon resources from 

other locality Crisis Teams should this be required. 

e.  Nationally,  Crisis  Services  are  recommended  to  provide  a  4  hour  response  and 

therefore  do  not  provide  an  emergency  response.  In  the  event  an  immediate  risk  is 

identified, the emergency services would always be the most appropriate contingency 

to ensure patient safety. 

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 2.  Almost 12 hours had elapsed from Daniel’s call to someone visiting his home address 

with no mechanism to identify cases, which had not been progressed.  

The Trust can confirm that there are already robust mechanisms in place to track referrals 

active to the Crisis Team, including those still awaiting an assessment.  

The inquest heard that the following was in place when a referral was received: 

a.  The assessing team were notified of DR’s call on their return to base. This provided 

an awareness of DR in the event he called back and requested an assessment at an 

earlier than planned time. 

b.  Referrals requiring an assessment the following day are handed over to the day duty 

team. 

c.  The assessment is placed on the Trust ‘At a Glance Board’ to ensure teams are able 

to see outstanding assessments. The assessment will only be removed from the ‘At a 

Glance Board` once the assessment has an outcome of complete or the referral is 

closed to the service. The `At a Glance Board` is a wall mounted electronic system 

which is integral to the daily functioning and co-ordination of clinical work within the 

team. It is therefore unlikely that any assessment pending on this board would be 

missed.  

d.  The requirement for an assessment is discussed within the multi-disciplinary team 

meeting to discuss risk and prioritisation. 

In the above instance, it was noted that DR told the assessing clinician that he would usually 

sleep between 05:00hours and 10:00hours. The day duty assessing team called DR at 

10:30hours in order to organise an assessment however, the call was not answered and a 

message was left requesting a call back. The initial 6.5 hours that elapsed following DR’s call 

with the triage clinician was therefore due to his request to rest. 

At 11:00hours it is acknowledged that Mr Rennoldson’s assessment was passed to another 

Crisis Team locality as they were considered more appropriate to undertake assessment and 

treatment. The Trust After Action Review acknowledged that there was learning to be 

undertaken in relation to patients who may cross two Crisis Team localities. On 9th June 

2021a reminder and flow chart outlining the long standing cross boundary agreement was 

sent to the team and discussed in individual supervision.  

The Trust action plan, already shared with HM Senior Coroner, highlights that where an 

assessment is agreed and considered an emergency in line with the urgent and emergency 

response times, an assessment should be carried out within 4 hours. The action plan confirms 

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 that a monthly review of response times has been undertaken to ensure that agreed standards 

continue to be met. The Trust can confirm that within the monthly review there were no issues 

identified. 

Response times continue to be monitored within the team on a weekly basis and any issues 

explored and addressed. Any breaches in response times are escalated and discussed at 

monthly Trust wide forums. 

We hope that the information provided offers you the necessary assurances that the Trust already have 

in place effective contingencies and mechanisms to avoid delays and are committed to ensuring that 

the national recommended time of 4 hours for Crisis assessment is achieved.   

Yours sincerely  

Executive Medical Director 

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