Mary Nwanonyiri

PRIVATE  & CONFIDENTIAL  

Ms N Persaud  
HM Coroner 
East London Coroners Service 
Walthamstow Coroner's Court  
Queens Road 
Walthamstow 
E17 8QP  

Acting Chief Executive 
Trust Head Office 
West Wing 
CEME Centre 
Rainham 
Essex 
RM13 8GQ 

13 January 2023 

Dear Madam 

Re: Inquest touching upon the death of Mary NWANONYIRI 

I refer to your letter dated 01 December 2022 and the enclosed Regulation 28 report, 
issued in respect of your concerns regarding the risk of future deaths.  

Concerns  

At  the  conclusion  of  the  hearing  into  the  death  of  Mary  Nwanonyiri,  you  expressed 
concern regarding the matters below: 

1.  Senior nursing staff who gave evidence at the Inquest did not appear to appreciate 
the  importance  of  an  agreed  comprehensive  care  plan  in  which  the  multi-
disciplinary ward team, patient and relatives are involved. The nursing staff did not 
acknowledge the value of a holistic care plan which incorporates the consideration 
of the many ways in which patients can be supported to engage in their recovery. 
Such  a  care  plan  could  also  incorporate  assessments  of  capacity  to  refuse 
physical  observations.  There  was  no  clear  evidence  of  assessment  of  Mary’s 
capacity to refuse physical observations. 

2.  A  number  of  nurses  failed  to  recognise  the  acute  clinical  severity  of  Mary’s 
condition on the morning of the 19th April 2021. They did not respond to her very 
concerning clinical state with the necessary urgency. 

I have provided a summary of the actions we have taken in relation to your concerns. A 
detailed action plan addressing specific aspects of the improvement work is attached. 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
                                     
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 Senior nursing staff who gave evidence at the Inquest did not appear to appreciate 
the  importance  of  an  agreed  comprehensive  care  plan  in  which  the  multi-
disciplinary ward team, patient and relatives are involved. The nursing staff did not 
acknowledge the value of a holistic care plan which incorporates the consideration 
of the many ways in which patients can be supported to engage in their recovery. 
Such  a  care  plan  could  also  incorporate  assessments  of  capacity  to  refuse 
physical  observations.  There  was  no  clear  evidence  of  assessment  of  Mary’s 
capacity to refuse physical observations. 

The Executive Team currently have oversight of care planning compliance Trust wide. 
Compliance with care planning is monitored regularly through the 3 C’s app on our Power 
BI  performance  platform  and  reviewed  by  the  monthly  Acute  and  Rehabilitation 
Directorate (ARD) Quality Leadership Team. Exceptions are escalated to the Executive 
Director and presented at the Quality and Safety Committee for assurance to the Board. 
ARD compliance is currently 100% and the expectation is that it will remain at this level.  

All patients will have a named nurse and an associate nurse to deputise in their absence. 
The  Named  Nurse/Health  Professional  Standard  Operating  Procedure  (SOP)  will  be 
amended  to  make  this  explicit  as  it  currently  states:  ‘In  most  cases  the  named 
nurse/professional will have an associate who will deputise in his/her absence’. 

With regard to the quality of care planning, nursing leadership have further reviewed our 
processes.  The admitting nurse will write an initial care plan and the expectation is that 
the named nurse, or associate nurse in their absence, will review the care plan within 72 
hours  and  weekly  thereafter.  This  will  ensure  timely  completion  of  a  multidisciplinary 
(MDT) care  plan  for each  patient,  which  will  be  co-produced  with patients  and  carers, 
with patients’ consent.  

Clinical leads will ensure capacity assessments are completed for all patients regarding 
their care and treatment, including patients who have declined to participate in their care 
planning  or  are  non-compliant  with  their  care  plan.    Multidisciplinary  decisions  will  be 
made in the best interest of patients who lack capacity in consultation with their carer and 
the respective stakeholders.  

The quality of care planning is monitored through the bi-weekly peer care planning audit. 
Audit  questions  include  multi-disciplinary  team  input,  physical  health,  patients’  views, 
carers’ views and capacity in relation to treatment decisions. Results and actions taken 
to address findings will be monitored through the monthly Respect Approach meeting, 
and  any  concerns  identified  will  be  escalated  to  the  Quality  Leadership  Team.  The 
January 2023 Respect Approach Meeting will have a specific focus on care planning and 
the care planning audit tool. This has recently been reviewed by a task and finish group, 
including  our  Clinical  Effectiveness  Team  and  Audit  Team  to  ensure  it  remains  fit  for 
purpose.   

As indicated in the attached action plan, the Trust has piloted a non-contact vital signs 
monitoring  medical  device  (Oxevision)  on  one  of  our  in-patient  wards.  The  device  is 
currently being installed in single bedrooms across our wards to complement routine vital 
signs checks by nurses, particularly where the service user is uncooperative with  their 
physical health care plan, or it is unsafe to approach them for physical health checks due 
to aggression or violence towards staff. 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Focus groups will be held with Matrons and Ward Managers to look at existing care 
plans  and  emphasise  the  importance  of  person-centred  care  planning  to  the 
patient,  carer  and  staff  involved  in  delivering  care.  The  focus  groups  will  also 
involve patients and carers. 

The Regulation 28 findings will be shared at the ARD quarterly Serious Incident Learning 
Event, with a specific focus on the importance of care planning. 

A  number  of  nurses  failed  to  recognise  the  acute  clinical  severity  of  Mary’s 
condition on the morning of the 19th April 2021. They did not respond to her very 
concerning clinical state with the necessary urgency. 

As previously stated, the Oxevision device is currently being installed in single bedrooms 
across our wards to complement routine vital signs checks by nurses, particularly where 
the service user is uncooperative with their physical health care plan.  

Resuscitation drills have been increased from every 2 months to monthly for every ward. 
A program of resuscitation drill training/refresher training is being progressed which now 
includes all ward managers as well as matrons. 16 managers and matrons have been 
recently  trained,  with  8  outstanding  to  be  trained  in  January  2023.    Resuscitation  drill 
action plan monitoring is now a standing agenda item on the Quality Leadership Team 
Meeting as is Intermediate Life Support training compliance.  

A  business  case  will  be  submitted  to  the  Executive  Management  Team  for  increased 
capacity for Resuscitation Officers, including a dedicated Resuscitation Officer for ARD. 
Funding is approved for a band 6 general nurse to support the physical health needs of 
patients  on  Picasso  Ward  and  to  provide  training  to  staff,  and  recruitment  is  being 
progressed.  

The process for auditing the content of our emergency equipment resuscitation trolleys 
on our wards has been reviewed and is now inputted via the ‘my kit check’ app. Non-
compliance  with  daily  and  monthly  equipment  checks  is  automatically  emailed  to 
matrons, managers and the resuscitation officer. The system also automatically re-orders 
items that are nearing their expiry date. The app includes a visual display of each item of 
equipment being checked.   

An emergency response SOP is in place. A new SAS Alarm system with a display panel 
indicating the location of an incident has been installed in all clinical areas to expedite 
the  attendance  of  the  Emergency  Response  Team  (ERT)  in  the  event  of  a  medical 
emergency.  Furthermore,  to  enhance  current  emergency  response  process,  each 
cardiac  arrest/CPR  emergency  call  is  followed  by  a  direct  radio  message  by  the  lead 
Incident Coordinator (IC) to alert the ERT to medical emergencies as distinct from calls 
for support with the management of incidents of violence and aggression. A guidance 
process is being developed, clearly outlining expectations for all staff involved in incident 
response  and  detailing  actions  that  will  be  taken  for  staff  who  do  not  respond 
appropriately to medical and other emergencies.  

I would like to take this opportunity to thank you for raising your concerns as part of this 
inquest. We find learning from inquests extremely valuable and are very grateful for your 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 comprehensive investigation, which benefits not only the families of the deceased, but 
also the Trust and its service users. 

I trust that the above and the attached action plan will reassure you that the Trust has taken 
this tragic death very seriously indeed, and that it reflects our commitment to improve care 
quality and patient safety.  

If I can further assist, please do contact my office

Yours sincerely  

Acting Chief Executive 

 Enc:  Action Plan  

www.nelft.nhs.uk