Robert Kelly

Executive Office 

10 January 2023 

Mr Tom Osborne 
Senior Coroner for Milton Keynes 
HM Coroner’s Office 
Civic Offices 
1 Saxon Gate East 
Central Milton Keynes 
MK9 3EJ 

Dear Mr Osborne, 

Re: Regulation 28: Report to prevent future deaths 

Thank you for your Regulation 28 report dated 15 November 2022 following the 
inquest into the death of Mr Ronald Kelly.  I am writing to provide Central and North 
West London NHS Foundation Trust (CNWL)’s response to the concerns that you 
raised in that report. 

Firstly, we would very much like to extend our condolences to Mr Kelly’s family and 
friends. 

We note that Trust witnesses were not required to provide written evidence or to 
attend the inquest to give oral evidence.  However, in response to your officer’s 
request, the Trust did provide Mr Kelly’s medical records before the inquest. 

You raised three matters of concern: 

1. That a 91-year-old man was discharged from the hospital following surgery, having 
refused to wait over the weekend for a care package to be put in place and there was 
no follow-up arranged to either assist him with his care or to ensure that he was coping. 

2. That when the GP practice made a subsequent referral for a visit and assessment 
by the district nurse, it was rejected on the basis that the appropriate referral was to 
“home first“. The GP forwarded the referral but nothing was actioned. 

3. There does not appear to be any system to ensure that a patient discharged home 
possibly needing support and care are automatically followed up. 

Trust Headquarters, 350 Euston Road, London NW1 3AX 
Telephone: 020 3214 5700 
www.cnwl.nhs.uk 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 In response to your first point, we did not receive a referral for Mr Kelly either before 
or at the point of discharge and were not involved in his care whilst he was an 
inpatient at MKUH.  We note that MKUH have provided a full response in relation to 
the discharge process, which they kindly shared with us. 

We continue to work closely with MKUH to discuss the inpatient-to-community 
interface to improve the patient journey, avoid prolonged admissions and enhance 
the care provided in the community. 

On your second point, on 7 September 2022, a referral was received by the CNWL 
District Nursing Single Point of Access (SPA) service from Mr Kelly’s GP. The 
referral was screened and responded to on the same day, advising that Home First 
(the reablement service provided by MK Council)  would have been more 
appropriate. The team also requested further information about whether Mr Kelly had 
any nursing needs or was housebound and did not hear back from the GP. 

Since Mr Kelly’s death, the service has undertaken a review session with staff to 
identify learning about our referral process. We will amend the Standard Operating 
Procedure to ensure that we instigate tighter follow up when we request additional 
information on referrals. 

Thank you for bringing your concerns to our attention. I hope that this response 
provides some reassurance to both you and Mr Kelly’s family that the Trust takes the 
concerns raised seriously. Should you have any further questions, please do not 
hesitate to contact me. 

Yours sincerely, 

Chief Executive

Mr Tom Osborne 
HM Senior Coroner  
Milton Keynes Council 

29 November 2022 

Dear Mr Osborne 

Regulation 28 Report following an Inquest into the death of Mr Ronald Kelly 

I am writing following receipt of a Regulation 28 Report dated 15 November, following 
on from the Inquest you held on 10 November. I was saddened to hear of the death of 
Mr Kelly and the very sad circumstances around it which you describe as follows: 

The deceased was found hanging 
from hospital and was struggling to cope.  

… He had recently been discharged 

I  was  surprised  to  receive  a  Regulation  28  report  given  that  the  Hospital  was  not 
represented at the Inquest, nor were we asked to provide statements in relation to the 
issues  that  caused  you  concern.  The  concern  which  you  specifically  raise  for  the 
hospital is as follows:  

That  a  91-year-old  man  was  discharged  from  hospital  following  surgery,  having 
refused to wait over the weekend for a care package to be put in place and there was 
no follow-up arranged to either assist him with his care or to ensure that he was coping.  

Since receipt of your Regulation 28 Report, we have reviewed records in respect of 
Mr Kelly and his recent admission.  

Mr Kelly attended the Emergency Department (ED) via his General Practitioner on 31 
August. He was admitted with an incarcerated hernia and surgery was planned. 

Mr Kelly went to theatre on 01 September and had an open right inguinal hernia repair. 
A  urinary catheter was  placed.  His post-operative  recovery was uneventful.    On 02 
September, the Consultant reviewed him in the morning and stated that he might be 
suitable for discharge if he managed following a trial without his urinary catheter.  At 
noon, one of the hospital’s Discharge Officers discussed Mr Kelly’s home and social 

 
 
  
 
 
 
 
 
 
 
 
 
 
 history with him. Mr Kelly advised that he had no package of care, he had a partner 
who supported him, and he felt they could manage. He consented to the Discharge 
Officer contacting his partner to confirm that no further support was needed. 

The Discharge Officer contacted Mr Kelly’s partner who advised that she was happy 
for him to  come  home  and  could  support him  provided he  was able  to  walk  up  the 
stairs. She also advised that there was no equipment at home, and she did sometimes 
have difficulty in showering / bathing Mr Kelly. The Discharge Officer advised that the 
therapy  team  would  be  asked  to  review  Mr Kelly,  and  they  would update  her when 
there was further information. 

The  Discharge  Officer  asked  a  Registered  Nurse  to  complete  a  referral  for 
Physiotherapy.  In  the  mid-afternoon,  the  physiotherapist  assessed  Mr  Kelly:  he 
managed  a  ‘stairs  assessment’,  was  independent  with  bed mobility,  transfers  (from 
bed  to  chair,  chair  to  standing  etc…)  and  was  walking  independently  without  any 
mobility aids.  Mr Kelly was given a ‘useful numbers contact list’ if he felt he needed 
any  support  following discharge.  He  was  not  felt  to have  any  equipment needs.  Mr 
Kelly was not judged to require a support / care package and nor did he seek such.  

Shortly  after  5pm,  Mr  Kelly’s  nurse  documented  a  successful  trial  without  urinary 
catheter. Bloods had been requested for the following morning (to review inflammatory 
markers, CRP) and the potential for discharge the next day was noted (depending on 
blood results). Of note, this was a day later than the Consultant’s earlier suggestion.  

On Saturday 03 September, a consultant reviewed Mr Kelly, noted a satisfactory CRP, 
and a plan was made for discharge that day assuming no specific home / social issues. 
A Discharge Officer contacted the Mr Kelly’s partner once again, updated her on the 
outcome of the therapy assessment and advised that he could go home that day. She 
agreed to collect him when he was ready and did so shortly after 4pm.  

The nursing records note that Mr Kelly was alert and orientated, independent and self-
caring.  He  was  given  the  useful  numbers  list  if  he  felt  he  needed  support  post 
discharge.  

While it is impossible not to be affected by the circumstances of Mr Kelly’s death over 
two weeks later, we have not identified anything that we would seek to do differently 
in similar circumstances. An elderly gentleman received prompt surgical treatment and 
his  discharge  needs  were  subsequently  explored  with  him  and  his  family  by 

 
 
 
  
  
  
 
 
 appropriate  members  of  staff.  Mr  Kelly’s  functional  ability  was,  with  his  agreement, 
assessed by a qualified therapist. The professional opinion was that no formal support 
was required. Signposting information as provided to Mr Kelly such that he would know 
where to go for support should his situation change.  

Mr Kelly was judged to have mental capacity throughout his admission (from providing 
informed consent for surgical intervention, through to discharge planning).  His self-
autonomy was respected in line with his mental capacity. Importantly, Mr Kelly did not 
‘refuse to wait over the weekend for a care package’: he was not judged to require a 
care package, nor did he or his partner seek one.  

From  the  information  that  we  have  subsequently  received,  it  seems  that  Mr  Kelly’s 
partner having a fall four days after his discharge may have been a key event: this 
could not have been predicted or averted by the hospital. The medical information that 
we hold at the hospital, in the round, did not point to significant psychiatric illness: the 
only  pertinent  entry  was  made  in  the  Emergency  Department  some  months  prior 
where there is passing reference to Mr Kelly having started and quickly stopped an 
anti-depressant in the community.  

I  am  conscious  that  discharge  from  hospital  can  be  a  challenging  area,  with 
widespread  concern  nationally  around  the  availability  of  domiciliary  support  and 
funding of the same. On this occasion, I consider that hospital procedures functioned 
well and could not reasonably have foreseen subsequent events. It is unfortunate that 
a  Regulation  28  Report  was  felt  to  be  the  appropriate  route  for  us  to  share  this 
information.      

Yours sincerely, 

Chief Executive