Jade Hart

Doncaster Royal Infirmary 
Armthorpe Road, Doncaster 
South Yorkshire, DN2 5LT 

www.dbth.nhs.uk 

13 September 2022 

Dr E A Didcock 
HM Assistant Coroner 
Coroner’s Office, Nottingham City Council 
The Council House 
Old Market Square 
Nottingham 
NG1 2DT 

Dear Dr Didcock 

Jade Hart - Regulation 28 Report to Prevent Future Deaths 

, Chief Executive, 
Thank you for your correspondence of the 26 July 2022 addressed to me, 
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust enclosing the Regulation 28 (Report 
to Prevent Future Deaths) which was issued to the Trust, following the conclusion of the inquest into the 
death of Jade Michelle Hart on the 1st June 2022.   

This is a tragic case and in the first instance, may I repeat my sincere condolences to Mrs Hart’s family for 
her very sad death.  I have met with the relevant teams at the Trust to discuss the issues which have been 
identified in relation to the care provided to Mrs Hart and the investigation which followed her death.  I 
have set out below information in response to the Regulation 28 report, which I trust will provide you 
with  assurance  as  to  the  learning  which  has  already  taken  place  at  the Trust and  indeed  the  ongoing 
improvements. 

Accordingly, I can respond to the matters of concern you have raised as follows: 

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 1.  Conduct of the Trust Serious Incident Investigation 

▪  Outstanding  concerns  as  to  the  methodology,  findings  and  conclusions  and  concern  that  the 
investigation was flawed as it was taken without including, nor giving due  weight to, the family 
evidence, in the analysis and conclusions of the report 

We apologise for the lack of due weight given to the evidence of the family in the drafting of the report.  
In view of the particular circumstances of this case, the investigation was taken out of our usual Trust 
processes  in  order  to  facilitate  as  supportive  an  approach  as  possible.    A  senior  member  of  staff  was 
appointed to facilitate the investigation and act as family liaison officer with the intention of making the 
process  more  personal  and  inclusive.    Unfortunately,  unforeseen  changes  in  Trust  personnel,  and  the 
complexity of the investigation meant our contact with the family became inconsistent, resulting in an 
inevitable loss of confidence and a failure to fully incorporate the family’s concerns within the final draft 
of the report.  This clearly compounded the family’s loss significantly and the Trust is deeply sorry for this 
and has learned from the deficiencies in this approach.  

I can assure you that incidents of this kind are no longer investigated by the Trust and are now escalated 
to  the  Healthcare  Safety  Investigation  Branch  (HSIB)  to  carry  out  the  investigation.    As  stated  in  the 
, Executive Medical Director, the Trust did approach HSIB 
evidence provided in the inquest by 
shortly after the incident to request their involvement.  However, they were unable to support us at that 
time, as their northern branch had not been established and they were only operating in the South of 
England. 

Importantly for learning, HSIB now  work with Trusts directly and support Trust investigation teams to 
improve their safety investigations.  They also collate findings from reports nationally to identify themes 
and influence change across the national maternity healthcare system. 

Outside  of  maternity  services,  and  from  a  general  perspective,  investigations  within  the  Trust  have 
changed significantly since 2018 and the improvements made include the following: 

•  we  now  involve  families  more  directly  and  incorporate  comments  from  families  within 
investigation reports.  A family’s recollection of events along with the clinicians’ recollection of 
events  are  both  included  to  enable  the  author  to  draw  reasonable  conclusions  based  on  the 
available evidence.  Recollections may differ and reports will display these differences, balance 
any supportive evidence, and draw conclusions over the most likely description of events.  There 
is expected to be evidence included to support the rationale for the conclusion. 

•  The Trust is open and transparent and complies with the Duty of Candour requirements, this is 
monitored via Clinical governance and the monthly Patient Safety Report, which is shared across 
all divisions and discussed at governance meetings. 

▪ 

It was undertaken without any immediate written accounts taken of what had happened, and very 
limited and delayed interviews of key staff involved 

Unfortunately,  due  to  unforeseen  circumstances,  the  senior  member  of  staff  identified  to  lead  the 
investigation left the Trust abruptly and the Medical Director in post at that time, stepped in to maintain 
the personal contact with the family and progress the investigation.  Having initially sought assistance 

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 from HSIB who were unable to help, the Trust then sought support from the Royal College of Obstetrics 
and  Gynaecology,  to  determine  how  the  investigation  should  be  conducted.    This  process  of  seeking 
advice and assistance unfortunately caused a delay in the commencement of the Trust investigation and 
the Trust investigation commenced much later than anticipated, hence the delay in retrieving statements 
from staff. 

The Trust has already sought to improve existing processes at the Trust and backed by NHS England, the 
Trust invited Consequence UK to deliver three one day training courses ‘Introduction to Patient Safety 
Investigations’ in 2019.  The training was very insightful and instructive with approximately 60 members 
of staff attending the events which included the Patient Safety Team, Matrons and Clinical Governance 
Leads.  

In  2021  the  Trust  Patient  Safety  Leads  attended  the  Baby  Lifeline  Healthcare  Incident  Investigation 
Training which provided further updates on specialist training in investigations.    

More recently in 2022, all our investigators and a number of matrons have undertaken further training 
delivered by HSIB.  The Patient Safety Lead will also be attending the HSIB Conference on 21 September 
2022.   

As  a  result  of  the  training  programmes  delivered  across  the  Trust,  many  aspects  of  our  approach  to 
investigations changed.  Families have always been contacted by the investigators; however we now fully 
reference their view and recollections in the reports. These programmes have ensured our investigating 
team remain up to date on current investigation techniques and refresh their knowledge.   

Furthermore, the Trust recognises how vital it is to document factual accounts of events at the earliest 
opportunity and that this should be done without delay.  When an incident occurs within the organisation, 
this is immediately scoped which includes requesting a recollection of the event from all staff involved in 
the incident.  To support this process, a memory capture document (please see attached) was developed 
and is accessible on the Trust’s  Incident Reporting System (DATIX) for ease of access and is utilised in 
addition to undertaking initial interviews and obtaining factual accounts in the form of written statements. 

The  memory  capture  document  was  shared  widely  with  teams  for  awareness  at  the  time  of  its 
development and re-introduced at the time of the Consequence UK training event.  Further awareness 
and  education  of  the  memory  capture  document  has  been  shared  again  recently  within  the  Trust,  to 
ensure staff use the document at the time of events and the Maternity Team maintain evidence of its 
usage. 

▪  The Trust commissioned an expert to assist with the Investigation.  This was provided by a well- 
respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, 
simply because there were aspects of the expert report that the Trust did not accept 

The Trust took the decision to seek an early external opinion for this case to ensure the investigation was 
both  robust  and  comprehensive.    We  initially  approached  the  Royal  College  of  Obstetricians  and 
Gynaecologists to ask them to conduct a review.  They declined to do so, but were able to suggest the 
.    We  therefore 
names  of  people  who  could  assist  and  review  the  case,  including 
 who was provided with copies of the clinical records.  We are mindful that 
approached 
clinical opinions can vary significantly, however the conclusion of 
 report was at odds with 
the emerging evidence that we were subsequently gathering through the interviews and statements of 

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 staff who were present at the time of the incident. The Trust provided further evidence to 
but at the point the investigation report was completed, the Trust formed a view that 
opinion, was not as informed as those directly involved in the incident and the investigation. 

, 

We note that differing opinion in clinical matters may well be present in cases and fully acknowledge that 
a reference to 
 invited opinion should have been included within the investigation report, 
with a rationale as to why this opinion was not used within the conclusion.  

▪  All  of  these  omissions  in  the  Investigation  process,  led  to  serious  omissions  in  the  analysis, 

conclusions, recommendations and actions that following in the report, in my view 

We  accept  that  the  Trust’s  best  intentions  of  taking  the  investigation  outside  of  the  usual  process  to 
provide more comprehensive support for the family has unfortunately resulted in a number of gaps that 
otherwise would have been addressed had we followed our systems and processes in place at the time.  
The  Trust  now  ensures  that  investigations  are  not  taken  outside  of  the  established  process,  and  we 
acknowledge that there were omissions in the investigation process which included a delay in obtaining 
factual accounts from staff; a failure to fully incorporate the family’s concerns; and a failure to reference 
the instruction of 
 and provide a rationale as to why her opinion was not relied upon within 
the report.   

As HMAC will be aware, the processes and procedures for investigating patient safety incidents occurring 
within the NHS are subject to significant change.   The national NHS Patient Safety Strategy was published 
in 2019 and sets out the Patient Safety Incident Response Framework (PSIRF) which replaces the Serious 
Incident Framework.  This is considered as a learning and improvement framework with the emphasis 
placed on the system and culture that support continuous improvement in patient safety through how 
we respond to patient safety incidents. 

One of the underpinning principles of PSIRF is to improve the quality of investigations by taking the time 
to conduct systems-based investigations by people that have been trained to undertake them.  Of note is 
that the accountability for Patient Safety Investigations will no longer sit with the Clinical Commissioning 
Groups but with the local Board of Directors.  The Trust has 3 Patient Safety Specialists, who are leading 
on the implementation of the PSIRF. 

The Trust has also reviewed 3 years of data in order to design the Patient Safety Incident Response Plan 
(PSIRP), which identifies the key priorities for the Trust.  This in turn has led to the formation of specific 
committees, which lead on the delivery of the work to meet these key priorities. 

Furthermore, the NHS-wide Patient Safety Syllabus is now live and has been added to the Electronic Staff 
Record (ESR) for all staff to enable them to access the level 1 training. The NHS Patient Safety Syllabus is 
a Health Education England initiative with the aim of helping to save lives and protect patients by outlining 
a new approach to patient safety emphasising a proactive approach to identifying risks to safe care while 
also including systems thinking and human factors.  

The syllabus is multi-professional. It is intended to cover all the patient safety training and educational 
needs of people currently working in the NHS or those in training to work in the NHS. This includes both 
clinical and non-clinical staff and covers the voluntary sector and social care. Level 1 of the syllabus is for 
all NHS staff. The Trust is currently devising a strategy as to which staff cohorts will access the other levels 
of training as they are released nationally. Communication about the Patient Safety Syllabus has also been 

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 shared with divisional governance leads for further dissemination and communication to their teams and 
has been included in the Trustwide newsletter. 

The Patient Safety Team and others involved in investigations within the Trust access relevant training as 
available, for ongoing development, including Consequence UK, HSIB, the Patient Safety Syllabus etc. 

▪  Also, the Trust, on the evidence of 

, Executive Medical Director likely did not share with 
either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that 
they had not included, nor referred to in the final investigation report 

It is very difficult to evidence at what point the report had or had not been shared with the CCG, or CQC 
as the Medical Director at the time has now retired.  We are aware that there was open dialogue with 
both organisations during the course of the investigation of this case and NHS England representatives 
were present at meetings with the CCG.  We have therefore also improved our documentation to ensure 
that a clear record of correspondence with stakeholders is maintained on DATIX.  

As noted above, where an expert opinion is sought for the purposes of a Serious Investigation, it will now 
always be referenced within the report.  Where the authors of the investigation report determine that 
the expert opinion  provided  cannot  be  reconciled  with  the  evidence  obtained through  interviews  and 
within statements, then the rationale for that determination will be included within the report. 

▪  At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that 
the  inadequacies  of  the  report  had  caused  huge  distress  to  the  family,  and  more  importantly 
insufficient learning 

Unfortunately, from the point of the incident to the point of the investigation report being released to the 
family, the movement of senior staff members was considerable and had a significant impact on this case.  
However,  an  overview  of  the  situation  was  clearly  lacking  and  the  Trust  acknowledges  that  had  the 
investigation not been taken out of the usual process, the investigation would not have been affected by 
workforce  matters.    Then  and  now  the  investigation  would  have  been  progressed  and  monitored 
differently.  It is with sincere regret that what was initially intended to be a more supportive measure for 
the family, actually resulted in considerable delays in the investigation process and the production of an 
investigation report of poorer quality than we would expect.  Furthermore, we acknowledge the omissions 
in the investigation process as referenced above. 

The Trust has learned from this incident and regrets the inadequacies in the report and the distress that 
this has caused Mrs Hart’s family. 

▪ 

If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is 
there  that  there  will  be  sufficient  learning  by  the  Trust  in  the  future.    In  my  mind  this  poses  a 
continuing risk of similar deaths occurring in the future if the investigation process does not change 

As referenced, the investigation of this case was not to the standard we would have wanted nor expected 
in 2018.  Since then, there have been many changes and improvements in how we structure our patient 
safety team, how we train our investigators, how we conduct investigations and analyses and how we 
track and monitor appropriate progress and how we engage with families and incorporate their concerns.  

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 As referenced above, as a Trust we are currently preparing for the full implementation of the PSIRF which 
will govern patient safety investigations moving forward.   

Nationally the Ockenden report produced a list of improvements for maternity services across the NHS.  
At the Trust the maternity service is continuing to implement the 7 immediate and essential actions (IEA) 
from  the  first  Ockenden report.      An  assurance  visit  undertaken  by  the  regional  midwifery,  and  local 
maternity and  neonatal  team on  29  April 2022  assessed  good  progress  against  these  actions.  Work  is 
ongoing with continued progress.  

The service has undertaken a gap analysis against the further 15 IEA in the final Ockenden report. An 
action plan has been developed and work is ongoing. The action plans and progress are monitored by the 
internal governance meetings, Trust board and the Local Maternity and Neonatal System (LMNS).  

2. 

Insufficient support for newly appointed Obstetric Consultants 

We accept that support for staff working at any level in the Trust will be required at times and this applies 
to the consultants we employ, at any stage after their appointment.  We have two main receiving sites in 
the  Trust  and  run  two  integrated  services  with  linked,  but  separately  staffed,  maternity  services  at 
Doncaster Royal Infirmary and at Bassetlaw Hospital in Worksop.  Each site has a consultant obstetrician 
available 24 hours a day.  It is now embedded in obstetric practice that when a consultant on call on either 
site requires advice and support, they will contact the on-call consultant on the other site.  This is normally 
to discuss a patient and is often for ethical advice over a hysterectomy in a young woman, as in this case.  
If physical presence is required, the consultants’ on-call liaise and agree on the best way to proceed and 
then contact the other consultants for assistance.   

The Trust does offer and actively encourages mentoring to newly appointed Consultants, and others, this 
is referenced in our job descriptions and mentoring is available for as long as it is required.  The Trust 
offers induction to all new consultants.  The specialty holds regular consultant meetings where discussions 
take place and working relationships are maintained.   

We are also in the process of setting up a Trust wide “new Consultants” group for helping staff to establish 
wider  linkages  into  the  organisation  and offer  more  generic support  for  newly  appointed consultants, 
should it be necessary.  As part of this initiative, a new consultant’s forum is being developed. This will be 
held every 4 or 6 months depending on the number of new starters.  

Further,  as  part  of  the  forward  planning  agenda  for  the  Trust’s  Medical  Advisory  Committee,  newly 
appointed Consultants have the opportunity to present to the committee to provide their observations 
following  their  first  few  months  in  post.  This  provides  valuable  feedback  to  the  committee  and  helps 
identify what further support and direction newly appointed Consultants may require in the future.  

Conclusion 

The Trust  acknowledges and regrets the failings in terms of the investigation process adopted for this 
case. We acknowledge that this created unnecessary additional distress for the family of Mrs Hart and for 
that we sincerely apologise.  Immediate actions were implemented to address deficiencies in the process 
used and other cases were not investigated in this manner.  Moving forward further robustness will be 
provided with the implementation of national Patient Safety Incident Response Framework. 

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 I trust that this letter has addressed the concerns raised, but please do contact me if I can be of further 
assistance. 

Yours sincerely 

Chief Executive 
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust 

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 MEMORY CAPTURE DOCUMENT  

The purpose of this form: It is for the member of staff to recall the events of an incident as they 
remember them from the start of their involvement to the end. Ideally this will accomplished as soon as 
possible after the event but at least within 72 hours of an incident occurring. 
A memory capture document is not a statement. Its purpose is as its title suggests - to preserve your 
memory. Therefore, it is a protective factor, and allows the widest appreciation of the situation at the time 
the incident occurred.  
What is required: 
You may find it helpful to write your memory capture in two parts: 
1: What I can recall about the care and treatment I was giving to the patient, before during and after the 
incident  

2: What I can recall of the shift – what it was like from when I came to work, to when I went home.  No 
patient receives their care in a vacuum. There are always other activities going on. It is important that ‘this 
incident’ is considered with a good understanding of what else was happening.  This type of information 
can (and does) enable effective team working, exceptional leadership under difficult circumstances etc to 
be recognised. It also enables wider areas for improvement to be identified and acted on that may have 
no bearing on the outcome for the patient.  

Confidentiality: It is important to understand that this document, as with all statements, reflective diaries 
etc are disclosable and can be requested by the Coroner, and representatives of the patient. This should 
not deter you from giving a complete account of your involvement in the patient management, or your 
experience of the environment, team working etc on the day. It should however remind you to write 
correctly, so that what you write is not misinterpreted or misconstrued.  

Your memory recall:  

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