Asher Sinclair

Lydia Brown 
Acting Senior Coroner 
West London Coroner’s Service 
25 Bagley’s Lane 
Fulham 
London  
SW6 2QA 

Dear Ms Brown 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

02 December 2022  

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  Asher  William  Robert 
Sinclair who died on 08 October 2019   

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 July 
2022  concerning  the  death  of  Asher  Sinclair  on  8  October  2019.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deepest condolences to  Asher’s family and loved ones and I am very sorry to hear 
about the tragic circumstances of Asher’s death. NHS England are keen to assure the 
family and the Coroner that the concerns raised about Asher’s care have been listened 
to  and  reflected  upon,  in  the  hope  that  an  incident  such  as  this  one  never  occurs 
again.  

I am grateful for the further time granted to respond to your Report, and I apologise to 
the family for the delay, as I appreciate this will have been an incredibly difficult time 
for them.  

Following the inquest, you raised concerns in your Report regarding:  

1)  The care package was not appropriately reviewed and there was no mandatory 
system of quality checks or formal review when there was a significant change 
in  family  circumstances.  Quarterly  reviews  were  not  carried  out,  without 
explanation. 

2)  Concerns  raised  by  the  parents  were  not  taken  for  discussion  to  case 
conference or professional’s meetings and were not followed up at all, leaving 
the situation in the house dangerous. 

3)  There was a lack of scrutiny or reconciliation of Asher’s care package, which 

could have identified gaps that needed to be addressed. 

4)  Training  for  the  staff  involved  was  unclear  and  seemingly  not  in  place  or 
inadequate. The high turnover of staff reported should have highlighted a need 
for increased training and scrutiny. 

The National Tracheostomy Safety Project (NTSP) exists to provide a wide range of 
resources  and  materials  to  support  those  providing  care  to  these  patients,  both  in 
hospital and in the community. This also extends to children with permanent/long term 
tracheostomies where it is recognised that care requires significant skill, knowledge 
and training. The NTSP has a bespoke and comprehensive paediatric section relevant 
to this. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 I  understand  that  the  incident  described  in  your  Report  occurred  in  October  2019. 
Additional  work  has  been  done  since  then  to  further  improve  tracheostomy  care, 
including  the  2020  Safer  Tracheostomy  Care  program,  which  was  delivered  via  a 
Safety Improvement Programme through NHS England (NHSE). 

As well as this, the child health outcome programme, commissioned by the Healthcare 
Quality  Improvement  Partnership  (HQIP),  on  behalf  of  NHSE,  looked  at  long-term 
ventilation in children and young people aged 0-25 years and published their findings 
in 
https://www.hqip.org.uk/resource/child-health-long-term-
ventilation/#.Yys6bnbMKUk. The recommendations in the report included the need for 
emergency healthcare plans and planning/commissioning integrated care.  

February 

2020: 

I have had sight of  NHS North West London’s (NWL’s) response dated 27 October 
2022, which addresses training and supervision, as well as the planning and oversight 
of care packages. I understand that the NWL children’s continuing care team still work 
within  the  Department  of  Health’s  National  Framework  for  Children  and  Young 
People’s Continuing Care, published in January 2016. In addition, NWL confirm that a 
parental  agreement  has  been  developed  which  sets  out  expectations  and 
responsibilities  in  respect  of  parental  responsibility,  and  how  parents  can  escalate 
concerns regarding the care of their child. 

NWL’s  response  also  explains  the  position  regarding  the  dissolution  of  clinical 
commissioning  groups  (CCGs)  into  new  structures  called  integrated  care  boards 
(ICBs), which took place in July 2022, and how commissioning responsibilities are now 
delivered. I have therefore not addressed this further in NHSE’s response. 

I  would  like  to  provide  further  assurances  on  the  national  NHSE  work  taking  place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around events, such as the sad death of Asher, are shared across the 
NHS at both a national and regional level, and helps us to pay close attention to any 
emerging trends that may require further review and action. 

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, 

National Medical Director 
NHS England

Ms Lydia Brown 
HM Acting Senior Coroner 

Ref: 313438 

Dear Ms Brown, 

Chief Nursing Officer 
15 Marylebone Road 
London  
NW1 5JD 

27th October 2022 

Re. Response to regulation 28 report to prevent future deaths, following your investigation into the 
death of Asher William Robert Sinclair. 

NHS  North  West  London  have  reviewed  your  findings  in  relation  to  the  sad  death  of  Asher  William 
Robert Sinclair on 8 October 2019.  We are committed to ensure that we learn from Asher’s death, to 
prevent future deaths under these circumstances.   

At the time of Asher’s death, the children’s continuing care service was delivered by borough based 
teams, covering North West London’s eight local authorities.  Each team had developed its own local 
processes for managing children’s continuing care.  This led to varying levels of service delivery being 
in  place.    Since  Asher’s  death,  the  national  dissolution  of  clinical  commissioning  groups  (CCGs)  into 
integrated  care  boards  (ICBs)  has  resulted  in  a  number  of  changes  being  made  in  the  way  previous 
commissioning responsibilities are delivered.    

There is now one North West London children’s continuing care team in place that is responsible for 
providing a consistent, safe, effective and equitable service.   

The  Team  comprises  of  registered  nurses,  experienced  in  the  management  of  children’s  continuing 
care,  including  assessment  and  on-going  case  management.  Each  case  manager  has  a  designated 
caseload and is overseen by a senior experienced manager.  All members of the team receive monthly 
supervision and regular caseload review. 

The  Team  continue  to  work  within  the  national  children’s  continuing  care  framework  (2016).    A 
standard operating procedure has been put in place and a clear process for referral, assessment and 
delivery of a package of care has been developed. 

In accordance with the national framework, reviews are undertaken of all children’s packages of care, 
initially at three months from a new package of care commencing and then on an annual basis or more 
frequently  where  there  is  a  need/change  of  circumstance  identified  by  the  family,  care  provider  or 
health/social  care  professional.    All  reviews  are  now  undertaken  with  the  family  and  the 
multidisciplinary team involved in the child’s care. Reviews are now recorded and discussed formally 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
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within  a  multi-disciplinary  panel.      The  responsibility  for  the  performance  monitoring  of  reviews  is 
undertaken by senior managers within the team. 

The children’s continuing care case managers now meet at quarterly intervals with the clinical leads for 
the provider commissioned to provide a children’s care package, within this meeting, the appropriate 
lead  professional  for  the  child  is  also  involved,  to  identify  any  clinical  concerns  and  monitor  the 
provision of the package of care, as well as identifying and ensuring that the child’s clinical needs are 
being safely and appropriately met. 

When commencing a package of care, an NHS standard contract is issued to all providers commissioned 
by NHS North West London which sets out specific key performance indicators, including; 

the requirement to return monthly reports on provision of care 

  quality checks required 
 
  staff competencies assurance required to safely meet the health needs of the child 
 

risk assessments, associated with the provision of the care package  

Senior Managers responsible for children’s continuing care and our care brokerage officer meet with 
commissioned care providers on a quarterly basis to monitor the care packages. 

In addition, an individual care contract is issued for each separate children’s package of care, setting 
out individual requirements, for example:   

the need for 2:1 support and who provides this 

 
  what elements of care are delivered as support to the family as opposed to respite periods? 

Benchmarking  of  care  is  now  undertaken  to  identify  hours  of  support  to  meet  assessed  children’s 
clinical  needs.    This  is  also  peer  reviewed,  to  ensure  safe,  fair  and  consistent  packages  of  care  are 
provided. 

A parental agreement has been developed which sets out expectations and responsibilities in regard to 
parental responsibility.   Where parents feel that they are unable to maintain parental responsibility for 
the  care  of  their  child,  parents  can  escalate  their  concerns  initially  via  their  names  case  manager, 
continuing healthcare senior manager or via NHS North West London’s complaints team.  During the 
initial continuing care assessment and planning stage, all families are now informed of this process for 
raising concerns, in addition to further information provided both in a paper based information leaflet, 
as well as within NHS North West London’s website.   

In my new role as the Chief Nursing Officer for NHS North West London, I am currently meeting along 
with our Director of Nursing, responsible for all age continuing care, with the local Borough Directors 
of Children’s services.  One of the outcomes of these meetings is to ensure that joint care is seamless 
between the NHS and local authority.  NHS North West London acknowledge that this is essential for 
children  with  complex  health  needs,  where  families  have  siblings  that  require  support  from  local 
authority partners, to facilitate parental responsibility for their child’s health needs.   

The NHS procures care packages for children with increasingly challenging complex clinical care needs.  
Supporting children and families to allow care to be provided outside of the hospital setting, continues 
to present risks for care providers and the NHS.  The ability to reduce these risks will continue to be the 
responsibility  of  NHS  North  West  London  and  I  hope  that  the  steps  that  we  have  taken  since  Asha 
Sinclair’s  death  will  assure  you  of  our  commitment  to  provide  children  and  their  families  with  safe, 
effective and consistent care. 

 
 
 
 
 
 
 
 
 
 
 
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Yours sincerely 

Chief Nursing Officer  
NHS North West London