Felicity Clough

• 

Department 
of Health & 
Social Care 

Ms Rachael  Griffin 
Coroner's Office for the County of Dorset 
Town Hall 
Bournemouth 
Dorset 
BH26DY 

Dear Ms  Griffin, 

Minister of State for Care and Mental Health 
39  Victoria  Street 
London
SW1H0EU 

23  May 2022 

Thank you for your letter of 26  November 2021  about the death of Felicity Clough . 
am  replying  as  Minister with  responsibility for Care and  Mental  Health,  and  am 
grateful for the additional time allowed. 

Firstly,  I would  like to  say how deeply sorry I was to  read  the circumstances of 
Felicity Clough's death and  I offer my most heartfelt condolences to  her family.  The 
circumstances your report describes are very concerning and  I am  grateful to you  for 
bringing these matters to my attention.  We must do all we  can to  ensure such 
failings in the health care system do not occur again. 

With  regard to your concerns about the  lack of accessibility to  records within the 
Yeovil District Hospital Trust,  my officials have made me aware that the  Trust has 
taken immediate action  and  implemented  measures in  order to mitigate the  risk of 
staff not accessing pre-hospital information.  In  addition, the Care Quality 
Commission, the regulator,  has  informed the  Department that they are in  receipt of 
the Trust's action plan which  is  noted to  be  comprehensive. 

To share information lawfully,  NHS organisations must comply with  the principles set 
out in the General  Data  Protection  Regulations,  and the common  law duty of 
confidence.  They should  also apply the Caldicott Principles which  have been 
established by the  National  Data  Guardian for Health  and  Social Care to govern  how 
data is  shared  by health  and care organisations. 

It is my understanding that Ms  Clough was taken to hospital by the  Police under the 
Mental Capacity Act 2005  (MCA).  The  MCA's Code of Practice allows for 
information about someone who lacks the relevant capacity to  be shared where it is 
in  the best interests of the patient or the public to  do so1 . 

1  See  paragraphs  16.19-16.25; 
h ttps:/ /assets .publish inq. service .gov. uk/governmen t/uploads/system/upload s/attachment  data/file/92 
1428/Mental-capacity-act-code-of-practice.pdf 

 
 
 For those patients subject to the Mental Health Act  1983,  information  sharing 
between  professionals can  contribute to and  support the  care and treatment of 
patients and  help to protect people from harm,  including  information sharing as part 
of the care  programme approach.  Chapter 10 of the  Mental  Health Act 1983 Code of 
Practice~ sets out the circumstances in  which  it may be  permissible to  share patient 
information.  The Code makes clear that,  before considering such disclosure of 
confidential patient information, the  individual's consent should normally be sought. 
If a person  lacks the capacity to consent to  the disclosure,  it may be  acceptable and 
appropriate to disclose the information in  the  person's best interests. 

Healthcare professionals should  use their professional judgement to determine what 
is  in  the  patient's best interest.  This should  include consultation with  colleagues, and 
the organisation's Caldicott Guardian,  and  should take into account the  patient's 
previously expressed wishes and  views.  All  NHS organisations,  as part of their 
information governance arrangements,  are required to have in  place Caldicott 
Guardians who have responsibilities to  safeguard and govern the  use of patient 
information and  can  provide advice  in  circumstances where there may be  uncertainty 
about disclosure. 

Difficulties within the sharing of information  between  different parts of the health and 
care systems is a well recognised  issue.  Currently,  NHS England's Shared Care 
Records initiative is  seeking to rectify this.  The focus of the programme is  on  sharing 
of information within the boundaries of the  Integrated  Care Systems - in  this  case 
within  Dorset and  Somerset.  So far,  41  of the 42 Integrated Care Systems have 
already implemented a basic solution.  Furthermore, the NHS Priorities and 
Operational Planning Guidance for 2022/23 set out a commitment to get these 
systems to work within  regions by the end  of 2022/23 and  nationally no later than 
2023/243

. 

The  NHS Long Term Plan  Implementation Framework4  makes several commitments 
to  improve information sharing.  By 2024,  all secondary care providers should  be 
fully digitised and  integrated with other parts of the health and  care system, for 
example, through a local health and care record  platform.  Shared  care records 
ensure that information and care  plans are available across health and  social care to 
support planning,  better risk management and  ensure care is  more joined up and 
delivered around an  individual's needs. 

The exchange of information between police forces  is not a matter the Department 
can  comment on.  However, the  importance of being  able to have insight into the 
health status of an  individual when  determining a police  response is well recognised, 

2https://assets.publishing .service.gov.uk/government/uploads/system/uploads/attachment  data/file/43 
5512/MHA  Code  of  Practice .PDF 
3  Further details of the  Dorset Care Record  are  at https://www.dorsetccg.nhs.uk/project/dorset-care-
record/ and the Somerset Integrated Care Record  at https://www.somersetccg .nhs.uk/about-
us/digital-projects/sider/ 
4  https://www. longtermplan .nhs .uk/wp-content/up loa ds/2019/06/long-term-plan-i m plementation-
framework-v 1 .pdf 

 although providing the police with direct access to personal confidential health 
information  is  a highly sensitive matter and one where Caldicott Guardians may 
advise. 

Finally,  it is concerning to hear about the circumstances in which  Ms Clough  left the 
A&E  Department.  Under the hospital discharge guidance,  no person should  be 
discharged until it is  safe to do so. 

The NHS Long Term  Plan  committed to introducing mental health nurses in 
ambulance control  rooms and  building  mental health competency of ambulance staff 
to ensure that ambulance staff are trained and equipped to  respond effectively to 
people experiencing a mental health crisis by 2023/24.  Mental health liaison services 
will also be  available in  all  acute hospital A&E departments (70% will  be at 'core 24' 
standards in  2023/24,  expanding to  100% thereafter.  It is vital that these actions 
prevent such  a tragedy from  happening in  the future. 

I hope this response is  helpful. 

 Home Office 

' 

Ms  Rachel Griffin - Dorset Senior Coroner 

By email only 

Rt  Hon  Kit  Malthouse MP 
Minister of State for Crime,  Policing 
and  Probation 
2 Marsham Street 
London  SW1 P 4DF

I~  February 2022 

Re:  MIN/0212540/21  - REG  28 notice:  Felicity Jane CLOUGH 
(ref:  1631166): 

I write  in  response to your letter dated 26th  November 2021  and the enclosed 
Regulation 28 - Report to Prevent Future Deaths which  relate to the tragic 
death of Miss Felicity Jane Clough. 

Firstly,  please express my sincerest condolences to Miss Clough's family. 

Upon receipt of your report,  I requested the  National Police Chiefs' Council 
and the Home Office Police and  Public Protection Technology department to 
review the circumstances surrounding the case and to  make any 
recommendations they consider necessary to  reduce the  risk of such an 
incident occurring in the future. 

The review was performed by a joint Task and  Finish  Group comprising  a 
team of subject matter experts for the  Police National Computer (PNC) and 
the  Police National Database (PND) which are the two current national 
policing  data services shared  across all  UK Police Forces. This team  was 
jointly led  by Deputy Chief Constable (DCC) 
for PNC and  by 
Enforcement Data Portfolio. 

, the  Home Office Director of the National Law 

 who is the  NPCC Lead 

The  review was performed against the findings set out in  the Regulation 28 
report referred  to above and  DCC 
and  conclusions in  his attached letter. 

 has provided  a detailed  response 

Following the conclusion  of the review of detail  related to this incident,  the 
following  recommendations were made: 

 
 
 Action 1:  For Operational  Police Officers/Police Staff to ensure greater 
utilisation of the Police National Database (PND).  This would  include 
encouraging uploading safeguarding information to PND,  to ensure it is 
accessible country wide,  as well as Officers asking for the  PND to be 
searched  against any vulnerable individuals when encountering seemingly 
vulnerable persons. 

Action  Owner:  DSU 
Lead). 

 - PND  Staff Officer (on  behalf of NPCC PND 

Action 2:  For Operational Police Officers/Police Staff to actively consider 
making referrals into the  Multi-Agency Safeguarding  Hubs and/or Control 
Room Triage services, which should  in  turn record any relevant information 
determined through  these collaborated  units onto PND . This will  ensure 
greater information sharing around vulnerability across all  UK Police Forces. 

Action  Owner:  NPCC Safeguarding Lead 

Action 3:  For Chief Officers and  Home Office Officials involved in  the design 
and delivery of the  PND transformation, to consider the development of a 
safeguarding capability and  how it can  add  greater operational effectiveness 
across safeguarding agencies/authorities. 

Action Owners:  DCC 
Office Director: NLEDP). 

 (NPCC PNC  Lead),  Mr.

 (Home 

In  respect of Actions 1 and 2,  the team  anticipate providing  a further update to 
you  by end of March 2022.  In  respect of Action 3,  the team  will  provide an 
update on  the progress in  six months' time. 

I thank you  kindly for your patience and  support in  this matter while the team 
reviewed the circumstances leading to this tragic incident and  hope that the 
actions resulting from this review will  help prevent similar incidents from 
occurring in  the future. 

Rt Hon  Kit Malthouse MP 
Minister of State for Crime,  Policing and Probation 

 Ms Rachel Griffin 
Coroner's Office for the County of Dorset 
Town  Hall 
Bournemouth 
Dorset 
BH26DY 

National Medical Director and  Interim Chief 
Executive of NHS Improvement 
NHS England & NHS Improvement
Skipton  House
80 London  Road
London
SE1  6LH

291h  March 2022 

Dear Ms Griffin 

Re:  Regulation 28 Report to Prevent Future Deaths - Felicity Jane Clough who died 
on  25 November 2019. 

Thank you for your Regulation 28 Report (hereinafter 'Report') dated 26 November 2021 
concerning the death of Felicity Clough  on  25 November 2019.  Firstly,  I would  like to 
express my deep condolences to Felicity's family. 

I note the recent inquest concluded  Felicity Clough's death was a result of: 

• 

1 a Hypothermia and excessive Tramadol use 

Following the inquest you  raised concerns in your Report to NHS England regarding : 

•  There could  be future deaths nationally due to lack of accessibility to records held  by 

different healthcare Trusts.  I would request consideration is given to the sharing of records 
between  healthcare Trusts. 

• 

• 

I have concerns that future deaths could occur due to the lack of access to  information held 
on individual Police force systems by other forces,  especially neighbouring forces who may 
have both have contact with  individuals.  Whilst I understand there is some work being done 
on  a regional  basis to address this,  I would  request that the issue is considered nationally as 
to  how information on  all  Police systems,  not just the Police National Database,  can  be 
shared to assist in  management and  assessment of individuals and the risk they pose to 
themselves and  others. 

I have concerns that future deaths could  occur at Yeovil  District hospital due to the missing 
of vital information within the pre admission documentation due to the fact the staff within the 
Emergency Department at Yeovil  District Hospital are not always accessing admission 
documentation, especially the paramedic records when a person  is  brought into the Accident 
Emergency department.  I request that consideration is given to issuing future guidance to 
remind staff of the need to  review this documentation or amending the current policy on 
place. 

The difficulty of sharing  information between different parts of the health and  care systems is 
well  recognised. 

NHS England  and  NHS Improvement 

00 

 
 NHS England have a programme of work - the Shared Care Records initiative - which is 
seeking to rectify this. 

The initial focus is on sharing within the boundaries of the Integrated Care Systems - in this 
case within  Dorset and within Somerset - and 41  of the 42  Integrated Care Systems have 
already implemented a basic solution.  There is  a commitment to get these to  interwork and 
this was set out in  the most recent NHS Priorities and Operational Planning Guidance for 
2022/23. The intention is for this to work regionally  by the end of 2022/23 and  nationally no 
later than 2023/24 
Details of the Dorset Care Record are at https:l/www.dorsetccg .nhs.uk/project/dorset-care-
record/ and the Somerset Integrated Care Record  at https://www.somersetccg.nhs.uk/about-
us/digital-projects/sider/ 
The exchange of information between police forces  is not a matter NHS England can 
comment on . 

However, the importance of being able to  have insight into the health status of an  individual 
when determining a police response is well  recognised,  although  providing the police with 
direct access to personal confidential health information is a highly sensitive matter. 

In  some forces a registered  health  professional works closely with the police control centre in 
order to  identify where the  provision of such  health  information is - in  their professional view 
- considered justifiable and in the person's best interest.  However, access to such 
information is also subject to the limitations expressed  in  recommendation  2i  and  needs to 
be addressed to ensure that such  attached professionals have ready access when they 
consider it justifiable. 

Regarding your concerns around future deaths at Yeovil  District hospital due to the missing 
of vital  information within the pre admission documentation  because the staff within the 
Emergency Department at Yeovil District Hospital are not always accessing admission 
documentation, especially the paramedic records when a person is brought into the Accident 
Emergency department.  I have read the Trust's reply and  consider concern answered and 
therefore does not need national response. 

Thank you for bringing these important patient safety issues to my attention and  please do 
not hesitate to contact me should you need any further information.  I do hope the above 
information goes someway to explain the steps being taken by  NHSEI to address these 
already recognised  issues. 

Yours sincerely, 

National Medical Director 

 
 Rachael Griffin 

Her Majesty's Senior Coroner 

The Coroner's Office for the County of Dorset, 

Bournemouth Town Hall, 

Bournemouth, 

BH2 6DY 

By email only: 

Your Ref:  1631166 

Date: 2nd  February 2022 

Dear Mrs Griffin, 

Regulation 28 Report - Ms Felicity Jane Clough 

I am  writing to you  on  behalf of the National Police  Chiefs  Council  (NPCC)  in  my capacity as  Chair of 

NPCC  Information Management and  Operational  Requirements  Coordination Committee  (IMORCC), 

in relation to paragraph 7,  Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 

of the Coroners (Investigations) Regulations 2013,  and to the prevention of future deaths report sent 
via email to the NPCC  dated 29th  November 2021. 

The  notice  sets  out concerns  that  arose  from  the  information  received  during the  inquest  into the 

death  of  Ms  Felicity  Clough  which  occurred  in  November  2019.  I  am  very  sorry  to  read  of the 

circumstances  of Felicity's  death.  My sympathies  are  with  her family and  friends,  and  I share  your 

commitment to addressing the issues that contributed to her untimely loss. 

The  notice sets out the following principal concerns in  relation to Policing : 

1) v.  In  addition,  each  Police force across  England  and  Wales  uses  a variety of databases and  record 

management systems. There is  a Police National Database (PND) which was created to collect data in 

a uniformed manner for crime, intelligence, custody, child abuse and domestic abuse from every force 

across  the  UK,  however there  is  no  means  to share  information  automatically  across  Police forces 

1st Floor,  10 Victoria Street,  London SWlH 0NN 

I 

 
   
 
 regarding concerns raised  about a person's welfare or health. To  do this would  require officers from 

one force to contact another force which requires knowledge of the contact in the first place. 

vi.  On  24th  November 2019  Dorset Police officer attended upon Miss Clough  at her home address in 

Dorset and transferred her to Yeovil District Hospital in Somerset under the Mental Capacity Act 2005. 

A short time later she was discharged and  left the hospital on foot to walk home. Following discharge, 

she  came  into contact with Avon  and  Somerset  Police  officers who were  not aware of her previous 

contact with Dorset Police or her admission to hospital. Evidence was given that had they been aware 

of this contact, it could have changed the way they checked upon Miss Clough that evening. 

vii.  Greater sharing of information therefore between Police  forces  in  England  and  Wales  regarding 

the welfare of those who come into contact with the Police could prevent future deaths. 

viii.  Evidence  was  given  that  it  would  be  wholly  beneficial,  both  within  the  Police  and  the  NHS,  if 

systems were able to talk to one another. This would  allow a wider understanding of the risk factors 

associated with an individual known and it could prevent a future death ifthere was more information 

known  about a person's vulnerability or risk.  It would be  beneficial to have  a national system  where 

healthcare trusts could access each  other's records and another national system where Police Forces 

can  access information re  health and wellbeing. 

2)  ii.  I have concerns  that future deaths could occur due to the lack of access  to information held on 

individual  Police  force  systems  by  other forces,  especially  neighbouring forces  who may  both  have 

contact with individuals. Whilst I understand that there is some work being done on  a regional  basis 

to address this,  I would request that the issue is  considered  nationally as to how information held on 

all  Police  systems,  not just the  Police National Database,  can  be  shared to assist in the management 

and assessment of individuals and the risk they pose to themselves or others. 

I will look to address the concerns you  have raised as follows : 

Policing recognises the challenges identified in the concerns you  have raised  and are working hard to 

address the difficulties of siloed  information within forces  as  well  as  the importance of information 

sharing  across  other agencies to help  protect the  public and  reduce the  risk  of harm.  Balancing the 

needs of individuals and privacy rights. 

The  National  Police  Chiefs  Council  (NPCC)  Information  Management and  Operational  Coordination 

Committee (IMORCC), aims to ensure that information is shared to reduce harm, make the public safe 

and  reduce  crime.  The  committee  oversees  several  working  groups  that  will  deliver  national 

information sharing agreements,  provide data that is  needed  from  national systems  and  on  mobile 

devices  and  share data with partners  where appropriate.  IMORCC  has  recently set  up a Data  Board 

 that is chaired by the Metropolitan Police Service Director of Data. This has seen data leads from across 

Policing,  Home Office,  PDS  and  National Crime Agency come together to specifically deal with  issues 

that relate to the quality, management and use of data to improve the service we  provide across the 

policing environment. 

Each  force  is  responsible  for  their  own  budget  and  how  they  allocate  this  will  depend  on  their 

individual needs. This is reflected in their ICT infrastructure with regards to systems and staffing which 

equates to the capabilities across each force  being significantly different. This can  also be  seen  in the 

Records  Management  Systems  (RMS)  each  force  holds  and  as  such  there  are  several  different 

suppliers and systems in use throughout the country that do not communicate easily with each other. 

Each  Chief Constable  is  the  Data  Controller for their force  and  has  ultimate  responsibility  for the 

management and  use of data and information as  defined by the Data  Protection Act 2018. 

The  policing Digital,  Data  and Technology Strategy  2020-2030 sets  out ambitions and  priorities that 

are pertinent to this matter in 'addressing harm' and  'embedding a whole system approach' to deliver 

enablers such as  'Data', 'Modernised Core Technology', and  'Connected Technology'. 

The concern documented within viii outlines the need for police to be able to access  NHS systems. 

The difficulties of achieving this across  policing alone have been  highlighted above and  until we  have 

this capability internally, we would not be  able to link all the NHS  and  policing systems quickly.  That 

said,  some  forces  have  tried  to  bridge  the  data  gap  between  the  police  and  NHS  through  the 

introduction of medical teams into their control rooms. These  NHS staff members have  direct access 

to NHS and  police systems, and they review incidents where mental health,  harm  and vulnerabilities 

are highlighted. Even though this is not fully automated through system integration, this demonstrates 

police  are  trying  to  bridge  that  gap  and  it  allows  officers  access  to  real-time  information  and 

intelligence  to  aid  informed  decision  making.  For  those  vulnerable  individuals  already  known  to 

policing,  the  Multi  Agency  Safeguarding  Hubs  are  a  useful  conduit  for sharing  information  across 

partner agencies, albeit this is  a local function. 

The  national  policing ambition is  to deliver what is  described  in  2)  ii; an  ability 'for information held 

on all Police Systems to be shared to assist in the management and assessment of individuals and the 

risk  they  pose  to  themselves  or  others'  as  well  as  a  process  by  which  Police  Forces  can  access 

information re  health and  wellbeing.  Unfortunately, the complexity involved  in  this  and  the need  to 

unpick legacy databases and systems means that to deliver this ambition will take significant time and 

investment  and  some  thought  would  need  to  be  given  to  the  ethics  and  governance  of  such  an 

approach. The  National  law  Enforcement  Data  Programme  (NLEDP)  was  launched  in  2016  by  the 

Home  Office,  with  the  initial  intention  of  providing  a  platform  that  replaced  and  enhanced  the 

capabilities of the Police  National Computer (PNC)  and the Police  National Database (PND).  This  was 

to be the platform that will enable this greater sharing of information. To  illustrate the complexities, 

this programme was due to be completed in  2020 but is  not yet in a position to deliver the expected 

 services.  PND  replacement is  not currently part of the scope  of the programme,  but a 5-year plan  is 

being  implemented  by  the  Home  Office  to commence  the  work shortly.  This  programme  of work 

includes a review of what data is  held  locally and what should  be  held on the national system. 

The  Police Digital Service (PDS)  was  created  in  April  2021,  with the ambition of delivering the Digital, 

Data and Technology Strategy 2020-2030. Part of the PDS is the creation of a new NPCC National Data 

Office and  proposed Data  Strategy (LEARN),  that will look at the opportunities for better use  of data 

including that of other agencies. Work has already commenced to try to address data issues to enable 

sharing of each forces RMS  data across policing. 

The suggestion of a health & well-being database shared between the NHS trusts and policing is quite 

a significant task,  technically,  lawfully and  ethically,  and  until policing has  achieved  its  own strategic 

data  aims,  this  is  unachievable  without  a  significant  national  investment  and  a  comprehensive 

programme of work being commissioned  across  all  partners.  The  work being carried  out to achieve 

the strategy should go some way to demonstrate the importance that policing places its responsibility 

to enable more effective data sharing between forces. 

This  is  a complex issue  and  I hope  that the  information that has  been  provided  goes  some  way to 

reassure  you  that  the  matters  of concern  you  have  raised  are  being  considered  and  that  we  are 

working  with our Home  Office  and  emergency services  colleagues  to deliver on  the  improvements 

that have been  highlighted. 

Yours sincerely, 

Chief Constable,  Durham Constabulary 

National Policing Lead for the Information Management & Operational Requirements 

Coordination Committee (IMORCC) 

 
 ly\ Yeovil  Hospital
\-.!  •1 

lthcore 

20 January 2022 

Ms R Griffin 
Senior Coroner 
The  Coroner's Office for the County of Dorset, 
Bournemouth Town  Hall, 
Bournemouth, 
BH26DY 

Yeovil  District Hospital 
Higher Kingston 
Yeovil 
Somerset 
BA21  4AT 

Telephone: 

Email: 

email: 

Dear Ms  Griffin, 

Re  : Felicity Jane Clough 

I am  writing  in  response to the Coroner's report to prevent future deaths following  from  the 
inquest into the death of Felicity Jane Clough. 

I can  confirm that the Emergency Department at Yeovil  District Hospital has put measures in 
place that will mitigate the risk of staff not accessing pre-hospital information for those patients 
that attend the department and  in  particular those brought in  by ambulance.  I have included a 
copy of the action log regarding this issue with  this correspondence. 

In  summary, whilst we would  aspire to having a fully automated system allowing access to the 
ambulance records and  other pre-hospital information through the hospital's Electronic Health 
Care Record (Trakcare ),  this  is not yet possible.  However, we have been able to identify and 
put in  place an  interim measure which  gives the same outcome in terms of making the pre-
hospital information available to all  staff in  an  electronic format stored within  our existing system. 

The immediate measure of converting the pre-hospital information available on  other 
organisations' electronic systems into a PDF document and saving within  our Trakcare system 
was introduced within the  Emergency Department on  6 January 2022.  This allows easy access 
to important information.  We have shared the  patient story and  learning from this tragic incident 
with the Emergency Department team, together with  the expectation of considering  ambulance 
records as part of their initial assessment.  Along with  ongoing education, this will  help to 
improve patient safety by ensuring our clinicians access all of the relevant clinical details 
required to  effectively treat their patients. 

I hope that this has assured you that appropriate actions have been taken  in  respect of the 
issues raised  in  your regulation  28 report.  Please let me know if you  require  any further 
information. 

Yours sincerely 

Chief Executive 

Enclosures: 
Action  Log 

Chair: 

Yeovil Hospital  •  Higher Kingston•  Yeovil  •  Somerset  BA21  4AT 

Chief Executive: