Derek Holmes

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Tameside and Glossop 
Integrated  Care 
NHS  Foundation Trust 

Tameside and  Glossop Integrated Care NHSFT  · 

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Fountain Street 
Ashton  Under Lyne 
Tameside 
OL69RW 

Integrated Governance Unit 
Silver Springs 
Tameside and  Glossop Integrated Care  NHSFT 
Ashton  Under Lyne 
OL6  9RW 

11 th  August 2022 

Private and  confidential 
To  be  opened by the addressee only 
HM  Coroner,  Mr Chris Morris 
Via  Email 

Dear Mr Morris 

I am writing  further to  the  inque!st touching  upon the death of Derek Holmes (who died  on 2nd 
December 2021) which concluded on 20th  June 2022 and the subsequent Regulation 28 Notice 
issued to the Trust.  I hope to be able to build  upon the issued raises within your report,  and set 
out be.low my respbnse.  I have outlined these  in  order of the concerns raised. 

Concern 1:-
Prior to  the  inquest the Trust acknowledged  and  shared  with  Mr Holmes' family and  with Her 
Majesty's Coroner that the root cause analysis contained  errors,  which  had  been  identified as 
part of the inquest preparation. As an  immediate response to this,  an addendum was added to 
the  investigation  report  and  a  written  explanation  and  apology  to  Mr  Holmes'  family  was 
provided. 

In  response to the concerns raised, the Trust instigated an  immediate strategy meeting with all 
the  Divisional Directors to collaborate,  assess and  understand the actions required to address 
the  issues  raised.  As  a result,  a number of key actions  have  been taken  and  are  planned  to 
strengthen and improve the root cause analysis investigation and quality assurance processes. 
These are listed -here  as two core themes; Training and  Policy and  process. 

Training 

Whilst  basic training  has  been  provided  for Trust  members  of staff  in  incident  management 
over the  last  two  years  and  support  has  been  offered,  and  comprehensive,  individual  and 
bespoke  support  has  been  provided  to  individuals  completing  investigations,  the  delivery  of 
largescale comprehensive investigation training  has  been  challenging  in  the context of Covid 
and the Covid  response. The reasons for this are twofold;  both in terms of the redeployment of 
key  members of the  corporate governance team to  support clinical  areas,  and  in  terms of the 
ability of staff to  attend, when the training is not mandatory. 

The  Trust  recognise  the  importance  of comprehensive  investigation  training  to  underpin  the 
Q)  methodology ~md  rigor that must be  applied  to  this process.  As such,  the Trust are  providing
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root cause analysis investigation training days which commence in  September 2022, and
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are also scheduled to run  in October and  November..  Following these initial sessions, these are 
planned to  continue through  2023.  Each training sessions runs over the course of one full day 
with  availability for key staff to attend each session. 

This training will  provide  Root Cause Analysis training  in  line with  national  requirements.  The 
course will offer a practical guide to investigations with a foc;;us on systems-based patient safety 
investigation  as  proposed  by  the  forthcoming  Natio'nal  Patient  Safety  Incident  Response 
Framework which emphasises the requirement for investigations to be led  by those with safety 
investigation  training  and  expertise,  and  with  dedicated  time  and  resource  to  complete  the 
work.  The  course  will  provide  staff with  the  key  skills  and  knowledge that they will  require to 
conduct an  investigation effectively and  accurately. 

· 

The training day contents will support staff through the seven-key stages to conducting a high-
quality investigations and  it includes;  planning and  managing investigations,  interviewing staff, 
mapping  and 
to  establish 
contributory factors to  ensure that comprehensive  and  accurate  reports  and  action  plans are 
produced. 

information,  using  appropriate  analysis 

triangulating 

tools 

· 

The  training  has  been  targeted  initially to  key  members  of clinical  and  corporate teams who 
are  likely to  undertake  root  cause  analysis  or complaints  investigations  as  part  of their role. 
Once  undertaken the  Integrated  Governance Team  will  hold  a  live  register of staff who  have 
completed  root  cc;3use  analysis 
investigation  training.  This  is  to  ensure  that  on  the 
commissioning of any new investigation, at least one member of the team have: completed this 
training. 

The Trust has used the case of Mr Holmes and subsequent learning to develop a seven minute 
briefing  which  has  been  shared  widely  across  the  Trust,  to  reemphasise  the  importance  of 
triangulation and accuracy of data used within any investigations including root cause analysis 
and  complaints. 

Overseen by the Head of Investigations, Learning and Audit a resource tool kit for investigators 
has  been. reviewed  an  updated  to  include  guidance  on  triangulation,  factual  accuracy  and  a 
data  mapping  tool  which  should  be  included  as  part of the  investigation  process.  The tool  kit 
will  be  provided  to  each  investigation  team  on  the  commencement  of a  root  cause  analysi~ 
investigation. 

Process and  Policy 

In regard to the errors identified within the ro.ot cause analysis, steps have been taken following 
the inquest of Mr Holmes to  strengthen the process in which these documents are checked for 
quality  and  factual  accuracy,  with  increased  divisional  ownership  and  oversight.  The  Safer 
Care  Assurance  Process  has  been  revised  to  explicitly  include  the  expectation  for  all 
investigations of this form to be reviewed  and approved as. an  accurate account of the incident 
and  learning  by an  appropriate  Matron.  Although  it  is  not possible to  completely  remove  the 
human  factors  which  can  affect  this  process,  it  is  anticipated  that  this  should  reduce  the
opportunity for errors such  as those identified  in  the  root cause analysis document presented 
in  relation to  Mr. Holmes.

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In  addition to  this,  the Safer Care Assurance  Process also  includes a caveat that the  request 
for root cause analysis is reviewed  by the Head of Nursing and Assistant Director of Integrated 
Governance should the patient die during the investigation process. This is intended to provide 
an  opportunity  to  stop  and  reassess  whether  continuation  of  the  enquiries  is  tt")e  most 
appropriate  cause  of  action,  or  whether  an  additional  or  more  comprehensive  form  of 
investigation is  required. 

Prior to  the  inquest of Mr Holmes,  I had  instructed  a  review of the Trust's  Incident Reporting 
and  Incident and  Complaints Investigation Policy.  This was  in  the  context of Patient Safety 2, 
as  information  and  resources  become  available  to  inform  the  Trust  approach.  The  learning 
from  this  inquest has further informed  the  quality assurance  process. The  review and  update 
to the Policy has been undertaken by the Head of Investigations, Learning and Audit and Head 
of Nursing  for  Professional  Standards  and  Assurance,  overseen  by the  Assistant  Director of 
Integrated  Governance. 

The  policy builds  of the  principles of good  compliant handling  that have  been  recommended 
by  the  Parliamentary  Health  Service  Ombudsman.  This  includes  the  Trust's  approach  to 
managing the complaints,  responding to complainants and  keeping people informed about the 
concerns that  they  raise.  As  part  of this  approach,  learning  will  be  disseminated  across the 
organisation  regarding  the  required  methodology  and  how we  respond  and  support  people 
when they raise concerns,  Ongoing monitoring of the policy will take place through  local audits 
of  informal  concerns  and  formal  investigations.  This  will  support  the  completion  of  other 
investigations su'ch  as  root cause  analysis  and  use  the same  principles  so  that these  can  be 
communicated across the organisation, alongside learning from investigations. 

As  stated  above,  the  Incident  Reporting,  and  Incident  and  Complaint  Investigation  Policy  is 
currently being reviewed  alongside the NHS England Patient Safety Framework to ensure that 
this aligns. The Policy will outline the process for identifying, reporting, managing, investigating 
and  learning  from  patient  safety  incidents,  including  Serious  Incidents  (Sis),  Never  Events, 
incidents  which  are  notifiable  under  the  Trust's  Being  Open  Policy  that  supports  Duty  of 
Candour.  The  purpose of this  review of policy is to  support a systematic,  compassionate and 
effectiv~  response  to  patient  safety  incidents;  with  a  clear focus  on  learning  and  continuous 
improvement.  This work will  ensure  accountability,  compassion,  openness and  ownership of 
improvement  and  will  provide  a  basis  for  local  training  and  development.  This  policy  will 
describe in  detail the  approach  in  place to  ensure that the Trust is  prepared for patient safety 
incidents so  that staff understand  what to  do  and  how to  behave when  an  incident happens. 
This will also include the Trust, Divisional and  Directorate governance arrangements (including 
key organisational roles· and  responsibilitie~) to ensure an  effective response. 

The  management  and  oversight  of  investigations,  complaints  and  incidents,  including  time 
taken  to  conclude  is  undertaken  in  our  Service  Quality  and  Assurance  Group,  chaired  by 
myself.  As the operational forum for discussions regarding  governance,  effectiveness of and 
adherence to this policy will continue to be undertaken through this group, providing assurance 
through  to  our Quality and  Governance  Committee,  led  by  Non-Executive  Director members 
and  to Trust Board. 

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Concern 2:-
The  Trust acknowledge  that the  root  cause  analysis  investigation for Mr Holmes  missed  the 
opportunity to  include the wider factors present during his care and treatment at Tameside and 
Glossop  Integrated  Care  Foundation  Trust.  We ·also  acknowledge  that  although  this  was 
included  within  the  complaints  investigations which  had  been  completed  and  shared  with  Mr 
Holmes' family,  these had  not been  disclosed to  Her Majesty's Coroner prior to or during the 
inquest. 

Following the inquest I commissioned an external review of the complaint investigation relating 
to  Mr  He>lmes,  to  provide  an  independent  lens  upon  the  findings  and  learning  from  the 
investigations completed  by the Trust.  The  independent review concluded  that the Trust had 
"answered in  detail all the concerns raised by the family in  the letters they have submitted and 
has  responded  to  them  ia  a  timely  manner".  They  also  noted  that  "that  where  the  ICFT 
(Integrated  Care  Foundation  Trust)  have  identified  lapses  in  care  during  their investigations 
they have clearly apologised to  the  family and articulated the  steps they have  taken  to  share 
the  learning with  the  teams involved and wi<;ler across the  ICFT". 

May. I take  this  opportunity to  apologise  that these  documents were  not disclosed  to  you  as 
they  should  have  been  and  that  as  such,  opportunities  were  missed  to  provide  you  with  a 
complete pictu're of the steps taken and information provided to Mr Holmes's family. This should  · 
not have happened and  I am  aware that the team have reflected  upon this oversight outside of 
this  process.  I hope that the  inclusion  of this information from  our third  party review provides 
you  with  assurance.  Further  response  to  this  concern  has  been  organised  into  two  themes; 
oversight and  learning. 

. 

Oversight 
Although the Trust review all  cases of newly commissioned  root cause analysis investigations 
to  understand  other investigatory processes which  may be  underway for the  patient,  this  has 
been  strength~ned  to  include  triangulation  between  the  Head  of  Investigations,  Audit  and 
Learning and  Head of Nursing for Professional Standards and Assurance. As part of this, a list 
of  all  new investigations  commissioned  as  part  of a  complaints  or  patient  safety  process  is 
shared with the Head of Nursing for Professional Standards· and Assurance on a weekly basis 
for cross reference against ongoing root cause analysis which  might be ongoing as part of our 
safer  care  processes.  This  should  also  support  the  identification  of  any  patient  deaths, 
prompting a case review as outlined earlier in this letter. While this process is in its early stages, 
this  is  supported  by an  automated  report  produced  by the  Ulysses  Safeguard  system  which 
indicates patients who might have simultaneous processes ongoing. 

The Trust has also introduced a bimonthly oversight meeting for triangulation of scheduled and 
new  inquests  with  existing  or  newly  instructed  investigatory  processes,  with  Head  of 
Investigations, Audit and Learning,  Head of Assurance, Compliance and Governance, Head of 
Nursing  for  Professional  Standards and  Assurance  and  Legal  Services  Manager,  chaired  by 
the  Assistant  Director  of  Integrated  Governance.  This  process  has  sought  to  ensure  the 
improved triangulation of cu~rent- investigations and support early identification of any changes 
in  status  to  the  patient  (such  as  their  death)  or  delays  in  conclusion.  Patient  tracking  li_st 
methodology will be used to inform this process and ensure that there is oversight of all learning 
activity associated with  investigations and  inquests. 

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The development of a clinical  review process is ongoing at the time of preparing this response 
to  ensure that  all  incident investigations,  inquest statements  and  reviews  undertaken -as  part 
of  our  learning  from  deaths  process  are  assessed  and  considered  cohesively  before  an 
inquest. This aims to  ensure consistency across all  streams of investigatio'n  and  learning and 
will  help  provide  an  additional  clinical  check  to  ensure  that  any  potential  discrepancies  are 
responded to,  enhancing our approach to learning. 

The documentation of oversight and  Divisional  approval  of investigations  has  been  amended 
and  strengthened  following  the  learning  from  Mr  Holmes'  inquest.  The  root  cause  analysis 
template has been  updated to  include evidence of review and  approval  by senior members of 
the  Divisional  operational,  nursing  and  clinical  leadership teams.  It is  proposed  that  any root 
cause  analysis  document  will  not  be  accepted  for  review  at  an  assurance  panel  if  this 
information  is  not  completed.  A  process  has  also  been  introduced  to  undertake  a  quality 
assessment  of  investigations  undertaken  as  part  of  our  falls  pathway.  In  this  process,  a 
member of the  Safer Care Team  will  review the  completed  root cause  analysis for accurc;icy 
against the  clinical  and  nursing  records  prior to  assurance  panel.  This  is  registered  with  the 
Trust  clinical  audit  team  and  this  will  be  identified  at  the  point  that  the  investigation  is 
commenced. 

Learning 
The  Trust  has  held  a  learning  from  complaints  stakeholder  event  with  senior  leadership 
colleagues from  across t_he  organisation  to  review  current  processes for learning.  This  event 
reviewed the learning that had been identified in relation to complaints investigations and what 
was  needed  to  strengthen  and  support  the  completion  of  investigations  resulting  from 
complaints.  The  Complaints  and  Concerns  policy  was  reviewed  and  a  11umber of additional 
actions  were  agreed  such  as  updating 
training  on  complaint 
investigations  and  writing  a  role  description  to  support  investigators.  This  includes  ensuring 
that evidence reviewed  as part of the investigation process is clearly referenced to ensure that 
there  is oversight of this· when  completing  responses. 

learning  and 

informal 

The  Trust are  currently undertaking  a comprehensive  improvement project focused  upon the 
Ulysses Safeguard system, which is the electronic risk management system used by the Trust 
.It is a system which allows for web-based  reporting  of incidents and  safeguarding concerns, 
alongside  system  based  operational  management of complaints,  incidents,  claims,  inquests, 
safeguarding and  risk.  It is also a platform which has the facility to recognise and acknowledge 
good  professional  practice known  as  'Excellence reporting'.  The  improvement project aims to 
increase utility of this system, with standardisation of use and  increased reporting functionality. 
This  is  intended  to  support  teams  in  the  Integrated  Governance  Unit,  but  also  divisional 
colleagues in  providing a single version of standardised  reports and  increasing ownership and 
understanding of processes which can be complex and  running concurrently. 

This  project  is  ongoing  and  updates  are  provided  on  a  monthly  basis  to  the  Service 
Improvement  Group,  chaired  by  the  Deputy  Chief  Executive.  One  of the  success~s  of the 
project is use of the web-based management of complaints, which allows divisional colleagues 
coordinating and  undertaking complaints investigations to document their progress and  record 
their findings  or identified  areas  for  learning  in  real  time.  This  supports  our ambition  for the 
PALS  and  Complaints Team to  provide timely and  useful  updates·to  complainants about the 
progress of an  investigation as outlined  earlier in this letter. 

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Part of this  project is focused  on  the  alignment of the  different modu.les  used  and  knowledge 
and  skills  of staff using  the  system.  This has led  to  the development of the  automated  report 
which  links  ongoing  investigatory processes for  individual  patients  as  referenced  previously.  · 
This  shows  at  a  glance  listed  inquests  for  which· a  patient  may  also  have  open  incident 
investigations,  a  complaint  or  safeguarding  concern.  This  should  support  triangulation  and 
minimise the  risk of duplication or silo  working.  Alongside this,  the Trust is  also  working  with 
Ulysses to understand the potential benefits of accessing supplementary modules which would 
support learning and the coordination of theme or issue specific action plans or workplans. 

Beyond  this,  to  further  strengthen  internal  processes,  the  Trust  are  undertaking  training  to 
support the development of staff.  Witness statement training  is  being  implemented Trust wide 
to  help support those who  have been approached to  prepare statements.  Clinical and  nursing 
staff understand that they may be  asked to  provide a written  report about their involvement in 
a patient's care. The training will accentuate that the statement is to focus on the facts relevant 
to  death  and  is  to  be  detailed  and  accurate.  In  order to  maintain  consistency.,  templates  are 
being drafted to ensure structure is  provided. 

In  relation to the issue raised  relating  to  patient call  bells,  a safety checklist has  been  revised 
with  an  accompanying  standard  operating  procedure  intended  to  support the  regular testing 
and  checks of emergency equipment within  all  inpatient areas. This includes a daily check by 
operational staff of the call  bell,  oxygen and  suction  located  at each bedside. This is overseen 
by a weekly assessment,  recorded  within the safety checklist. This is then auditable as part of 
assessments completed  by members of the'Safer Care Team for each  area and  reviewed  as 
part of the Ward accreditation process. As this is a new process, this has been socialised with 
the  divisional  leadership  teams  to  ensure  their  views  and  comments  are  considered  in  the 
implementation of this. 

Finally,  in  response to your concerns regarding the referral  process to  another NHS Trust and 
the oversight of this. Enquiries have been undertaken and I understand that our current process 
is  for the Trauma  Coordinators to  be  copied  into  all  referrals to  an  external  or tertiary  centre 
such  as Wrightington, Wigan and  Leigh NHS Foundation Trust by the clinical team.  If a patient 
is accepted  by the Acute  Hip Team at Wrightington, Wigan  and  Leigh  NHS  Foundation Trust, 
a response to. indicate this is provided along with a patient referral booklet, which is completed 
by the Middle Grade Doctor. This is returned and a copy is retained by the Trauma Coordinator 
until the patient is either transferred or treated  locally. 

Following  consideration of the  information provided,  a response  is provided  by email from the 
Acute  Hip  Team  with  the  plan  to  treat  locally or transfer.  If ithe  plan  is  for transfer,  then  the 
Trauma Coordinator will commence the appropriate preparations required such as blood tests, 
an  Echocardiogram  or ECHO  (  if needed),  Covid  and  MRSA swabs, and  anaesthetic  review, 
sharing this information with the  receiving organisation. 

This process is recorded using a database and is pursued manually by the Trauma Coordiators 
on  a  daily  basis  for  confirmation  of an  available  bed  and  allocation  of a  theatre  date.  I am 
advised th?t as centres such as Wrightington, Wigan and  Leigh NHS Foundation Trust receive 
referrals from across Greater Manchester, any changes or developments to this process would 
be  led  by them.  However,  it is considered that there is an opportunity for the Trust to f~rther

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develop  and  automate  the  electronic  system  used  here,  with  the  ability  for  the  system  to 
generate reports and  notifcations based  on  days waited or pre-agreed  markers. · 

Development  of a·  system  such  as  this  is  currently  being  discussed  with  our  Chief  Clinical 
Information Officer, who  has developed our interactive Ward White Boards, to  understand the 
possibilities of this  and  the  scope for intgratioin with  other existing  systems used  at the Trust 
to  improve efficiency and  patient outcomes.  While this  remains  in  its formative  stages,  I hope 
that  this  provides  you  with  assurance  of  the  Trust's  commitment  to 
innovation  and 
development,  while  acknowledging  that  some  improvement  programmes  require  time  and 
investment. 

· 

Concern 3:-
Your final  concern was that the Trust did  not revisit the  level  of harm following  completion  of 
the Root Cause Analysis Investigation.  As you  know, there may be occasions where the initial 
harm  level for a patient following  a safety. incident is  not fully known  or understood at the time 
of  completion  of  an  investigation,  such  was  the  case -for  Mr  Holmes.  However,  the  Trust 
acknowledge that in  cases such  as this there is a need to  strengthen the  processes to ensure· 
that this is  considered when final sign off of an investigation takes place. I hope that the steps 
introduced  or reinvigorated  to  triangulate  our processes  has  provided  you  with  assurance of 
our commitment to improve. 

To  provide  an  additional  safety  net  in  this  process,  the Trust has also taken  steps to  amend 
and  improve the triage system for newly listed  inquests.  In  the  context of the  recent letter HM 
Senior Coroner received from  Mr Richard_Jolly of Weightmans LLP , in relation to the provision 
of our  inhouse  legal  team,  processes  have  been  reinvigorated  to  ensure  triage,  review  and 
instruction sent out to clinicians within seven days of the initial inquest request. 

As  part  of  the  new  process,  a  clinical  review  of  the  case  and  a  review  of  any  previous 
investigations is also performed at the outset where we are able,  in order to  identify any linked 
actions. This  process would  allow for the revisiting  of levels of harm for individual  incidents to 
ensure that this is appropriate, with advice from the specialist teams. There is also t~e addition 
of  a  full  time  clinical  member  of  staff to  support  this  process  moving  forward,  and  a  more 
rigorous  review  system  to  capture  potential  delays.  The  Trust  has  started  to  implement this 
process ensuring communication is maintained with  HM  Coroner throughout. 

It is acknowledged that all comprehensive investigations for which there is an  inquest listed by 
HM  Coroner remain in  draft until the conclusion of this process in which the definitive cause of 
death is established. In this instance, the original incident may also remain open. This has been 
the  Trust  prc~ctice  for many years  as  you  may  be  aware,  acknowledging  that  evidence  from 
third  parties  or external  partners  may impact on  the  information  understood  on  conclusion  of 
the Trust investigation. This may in turn  result in  a reassessment of the harm grading. 

I hope that this response has provided assurance that the Trust has taken your comments and 
concerns seriously and taken action to minimise the risk of such event occurring again. Should 

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· 

you  require  any further  information,  please  do  not hesitate  to  contact  me  through  the  Legal 
Services Team on 

Executive Director of Nursing and  Integrated Governance 

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