Darren Jones

E: 

Date: 9 September 2022 

Ms A Mutch  
HM Senior Coroner 
Coroner’s Court  
1 Mount Tabor  Street  
Stockport  
SK1 3AG 

Dear Ms Mutch 

Re: Regulation 28 Report to Prevent Future Deaths – Darren Jones 22/10/21 

Thank you for your Regulation 28 Report dated 17/07/22 concerning the sad death of Darren Jones on 
22/10/21. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by 
offering our sincere condolences to Mr. Jones family for their loss. 

Thank you for highlighting your concerns during Mr. Jones Inquest which concluded on 6 June 2022. On 
behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it 
is also very important to ensure we make the necessary improvements to the quality and safety of future 
services.   

The inquest concluded that Darren’s death was a result of 1a) Sepsis; 1b) Urinary Tract Infection on a 
background of long-term catheterisation; II) Chronic bladder outflow obstruction, Chronic Kidney 
Disease. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there 
is a risk future deaths will occur unless action is taken. 

I hope the response below demonstrates to you and Mr. Jones family that NHS GM has taken the 
concerns you have raised seriously and will learn from this as a whole system.  

This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning 
from this case. 

The evidence was that the District Nursing Teams were under significant pressure which impacted 
the support and care they could deliver  
The key issues in this case were in relation to nursing practice, specifically documentation and the failure 
to direct the patient to the most appropriate setting within the hospital.    

Documentation 
It  was  identified that documentation standards  were not  achieved in this  case;  Emis  (clinical  system) 
entries were not made following the second attendance and clinical observations were not recorded prior 
to the decision to refer Mr. Jones to the hospital. 

The team has been reminded of the importance of accurate and timely completion of all patient records 
and  there is  now  a  monthly  review of 10  sets  of  notes to  ensure that  standards  are  achieved  and 
maintained.   

4th Floor, Piccadilly Place, Manchester  M1 3BN   

 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 The locality has confirmed that 1:1 feedback has been given to all of the nurses involved with the expected 
standards of documentation shared across the Stockport District Nursing Service during daily huddles, 
team meetings, ‘message of the week’ and the divisional lessons learnt newsletter.    

Referral into hospital  
In circumstance where a patient is transferred to Stockport NHS Foundation Trust (Stepping Hill Hospital) 
due to failed catheter insertion, the correct pathway is for the patient to be admitted and reviewed within 
the Surgical Assessment Unit (SAU) as opposed to the Emergency Department.  In this case  Mr. Jones 
was referred into the Emergency Department which was not the appropriate pathway for him.    

The team has been reminded of the appropriate pathway and management of a patient needing admission 
due to failed catheter insertion. 

In response to the general question of pressures within the District Nursing Service, there are pressures 
across the system including district nursing services.  However, the findings in this case were identified to 
be around individual practice and awareness as opposed to being due to pressures.  That said, it can be 
realistically accepted that wider pressures may have had an impact.   

The Action Plan  resulting from this case  has  been reviewed and the locality is satisfied that a  detailed 
review of the case has taken place and that the necessary actions have been taken to reduce the likelihood 
of a similar situation arising in the future.   

Mr. Jones had significant learning difficulties which were not recognised at the hospital to ensure 
that he was provided with support and to ensure that an IMCA was put in place to ensure his best 
interests 
In circumstances where a  patient with significant learning difficulties is admitted to hospital, there is  a 
robust process of referral to the safeguarding team for support and guidance; this is to ensure that the 
patient is supported and appropriate services, including the involvement of an IMCA made available to the 
patient. In this case, regrettably, the team were not contacted / alerted to the admission.   

In  response to  this  omission, arrangements  were made  for safeguarding supervision for the specific 
purpose of learning from this episode of care and to ensure improvement across the team.  The learnings 
here have been fed back to the whole of the Victoria Nursing Team. 

We are satisfied that there is a robust process in place for the support of patients with learning difficulties 
but acknowledge that the process failed on this occasion which is highly regrettable. Appropriate steps 
have been taken to ensure wider team awareness for the benefit of future patients.    

The inquest heard that there was a dispute between two local authorities in relation to training re 
catheter care and that this impacted on the provision of respite care and the health and wellbeing 
of Mr. Jones  
This is a  matter for the local authorities involved to address; what can   be confirmed is that the District 
Nursing Team are trained in catheter care 

No LeDeR Report appeared to have been commissioned in relation to Mr. Jones  
A LeDeR notification had been made to the system in respect of Mr. Darren Jones. The review was put on 
'hold' as per national and regional guidance as the case was being heard at inquest.  

Previous instructions were  that  in  circumstances where a  Coroner requests a  review be  completed, 
localities would be informed directly by the Coroner’s Office.  Such a request was not received in this case.   

4th Floor, Piccadilly Place, Manchester  M1 3BN   

 
  
 
 
 
 
 
 
 
 
 
 
 
 A copy of the overall Action Plan resulting from this case is attached which I hope will offer reassurance.  

Actions taken or being taken to share learning across Greater Manchester.  

1.  Learning to be presented/shared with the Greater Manchester System Quality Group.  This 
meeting is attended by commissioners, including commissioners of specialist services, 
regulators, Healthwatch and NICE. 

2.  Shared learning from this and similar cases at Greater Manchester and borough level will be 

cascaded to professionals through relevant governance and learning forums. 

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded 
within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.  

I hope this response demonstrates to you and Mr Jones family that NHS GM has taken the concerns you 
have raised seriously and is committed to work together as a system including our service users, carers  
and families to improve the care provided.  

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. 

Yours sincerely 

Gill Gibson 
Interim Chief Nurse 
GM Integrated Care 

4th Floor, Piccadilly Place, Manchester  M1 3BN