Fred Reynolds

Sonia Hayes 
Assistant Coroner 
Mid Kent and Medway  

Chief Executives Office  

Trust Headquarters 

Farm Villa 

Hermitage Lane 

Maidstone 

Kent 

ME16 9PH 

Website: www.kmpt.nhs.uk 

10 August 2021 

Dear Assistant Coroner Hayes 

Inquest touching upon the death of Mr Fred Malcolm Reynolds 
Trust Response to the Regulation 28 Report to Prevent Future Death 

I write in response to the Regulation 28 Report dated 15th July 2021, sent to Kent and Medway NHS 
Social Care Partnership Trust (KMPT) following the conclusion of the inquest, touching on the very sad 
death of Mr Fred Reynolds on 30th October 2019. 

In your report to the Trust, you raised the following matter of concern: 

Specialist neurology advice was given to conduct neurological observations every two hours 
for 48 hours following head injury. These observations were commenced but not continued. It 
was not possible to understand why these observations has been discontinued and there was 
no entry made in the medical records. 

We fully recognise the importance of continuing with any recommended treatment as advised by 
clinical experts from the acute trusts, and have endeavoured to establish why, in Mr Reynolds’s case, 
the neurological observations recommended were stopped. We have been unable so far to identify the 
decision point or decision maker This appears to be a matter where on this occasion an appropriate 
record for ceasing the neurological observations was not made, but we consider that the changes 
made since will mitigate the risk of this occurring again. We describe these below. 

Significant changes have been made and sustained since 2019 when Mr Reynolds sadly died, which 
now mitigate the risk of neurological observations being stopped without careful assessment and 
medical approval.  

Set out below is a description of the new and more robust systems we now have in place.  The new 
systems and in particular, electronic monitoring have significantly reduced the risk of neurological 
observations being stopped without careful assessment and medical approval. 

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 1.  Our Falls Policy, which is NICE compliant, provides guidance regarding neurological 

observations. It clearly sets out that neurological observations should be completed every thirty 
minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this 
becomes hourly observation for the next four hours, and then two-hourly after that, until 
medical review has occurred. Staff are sufficiently trained and compliance with this quality 
standard is monitored through our Falls Care Pathway and incident reporting. We have a well-
established system for sharing lessons learnt through our quality governance meetings, and Mr 
Reynolds’s story has been presented there.  

2.  Neurological observations are part of every handover if clinically indicated, as set out in the 

Inpatient Handover Protocol which was introduced in protocol in December 2018, and on the 
patient status board/at a glance board. Shift handover processes are regularly reviewed, and 
are subject to quality checks through our programme of CLIQ Quality assurance audits, in 
order to ensure ongoing quality improvement.  

3.  All patients on our wards have a set of vital signs recorded via NEWS2, i.e. the National Early 

Warning Score 2 since an electronic observations project was rolled out across 2019.  This is a 
system designed to standardise the assessment and response to acute illness.  Any patient 
returning from a visit to A&E, or the general hospital, have their vital signs recorded on eObs, 
an electronic recording system, that will calculate National Early Warning Score (NEWS2). This 
encompasses a consciousness level assessment, and will identify the need for Glasgow 
Comma Scale (GCS) to be completed. Neurological observations utilising GCS are 
implemented when clinically indicated, or following a reduced consciousness score from 
NEWS2. 

4.  Within NEWS2, which was launched in 2019, there is a 5-point consciousness scale. This is 
the standard observation undertaken for all our inpatients, and is completed as a minimum. 
NEWS2 is monitored through CLIQ Quality assurance audits on a bi-monthly basis. Results of 
these audits are shared and discussed at ward, service and Trust level, including up to Sub-
Board Quality Committee.   

5.  At the time of Mr Reynolds’s death, we had commenced a Trust wide programme of work to 
gradually implement electronic observations (eObs) using National Early Warning Score 2 
(NEWS) across all our wards. eObs is an electronic recording system accessed through a 
tablet device. The physical observations results are linked to Rio, our health record system, 
and can be accessed virtually by clinicians. This electronic system was not available on 
Woodchurch ward at the time of Mr Reynolds’s treatment; it came into effect in March 2020. At 
the time of Mr Reynold’s treatment, a paper version of Modified Early Warning System 
(MEWS) including assessment of conscious level was in place.  

The new electronic NEWS2 system has significantly improved the way in which we undertake 
and monitor physical health observation for our patients. It has importantly also improved our 
ability to monitor and scrutinise compliance with our standards, at multiple levels across the 
Trust. This means that when observations indicated for a patient are not completed at the 
agreed time, an alert is issued as a reminder for staff. The NEWS2 system also indicates to 
staff the frequency required for ongoing monitoring, depending on the score. For senior 
clinicians such as Doctors, they can easily access the results remotely and act if there are 
abnormal readings.  

As part of the roll out of this new system, training was provided and completed by all members 
of staff, and there is ongoing training offered to new nursing and medical staff. Their 
competencies are assessed and signed off as part of this training, further demonstrating the 
steps we have taken to improve staff knowledge, skills, and confidence with undertaking neuro 
observations.    

 
 
 
 6.  In addition to staff training, the use of digital technology, and the improved quality governance 
and assurance systems in place, we have also employed specialist Physical Health Nurses on 
each ward as part of our nursing skill mix. This ensures that we have staff with relevant 
technical expertise to teach, support and supervise provision of high-quality physical health 
care to our patients. This was not in place at the time of Mr Reynold’s treatment.  

7.  Our resuscitation service has further developed a Trust-wide “Train the Trainer” course for 

neurological observations and the Glasgow Coma Scale, and has delivered this to all physical 
health nurses. Since March 2021, all the physical health nurses across the Trust have been 
trained, and we now offer a short refresher training session for each team, and will continue to 
facilitate these sessions as required. This training is also available via iLearn (virtual learning 
platform) for all staff to access as needed.  

8.  Following Mr Reynolds’s death, the Older Adults Care Group developed and disseminated a 

learning bulletin to all staff, reiterating the need for neurological observations to be completed 
for any seen or unseen incident where a patient is presenting with a head injury, possible 
stroke symptoms or any medical emergency. It clearly reminded staff that observations should 
be completed using the Glasgow Coma Scale. 

We are sincerely sorry for the shortcomings in our care of Mr Reynolds and are committed to ensuring 
that the improvements we have made are sustained.  

I hope that the detailed information provided offers you a level of assurance about both the 
seriousness with which we have received and responded to your concerns, and the significant 
improvements we have made since the sad passing of Mr Reynolds. 

We are, as always, happy to provide further information or evidence if that would be helpful. 

Yours sincerely 

Chief Executive