Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0143, written 28 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Apr 2023 |
|---|---|
| Reference | 2023-0143 |
| Deceased | Winbourne Charles |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Action Plan Title: Regulation 28 Report to Prevent Future Deaths, 1091
Start Date: May 2023
Action Plan Owner:
Target Date: July 2023
Priority: High
Business Unit: Acute and Rehab Directorate
Service/Team:
Directorate: ARD
NELFT Action Plan
Clinical Audit
Source: Complaints
Serious Incident Medicines Management
External Inspection
Summary of the concerns of the Coroner:
Dashboard
Other Regulation 28
External Inspection
Infection Control
Internal Inspection
H&S
QPS
Internal Audit
Serious Case Review
Safeguarding
Safety Thermometer
1. Risk assessment (lack of appropriate consideration of risks) – the Coroner found that poor record keeping and a failure to read electronic records
meant that important information was not considered at a Multi-Disciplinary Team (MDT) ward round on 06 April 2021. The MDT arrived at a conclusion
that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of the self-hard as
high on 31 March 2021 was neither read nor incorporated into the MDT discussion.
2. Risk management (inappropriate care plan) – the Coroner found that a decision to reduce observation frequency made by the MDT on 6 April 2021
was not supported by the Trust Policy guidance which indicated that enhanced observations were appropriate.
3. Risk management (lack of adherence to care plan) – the Coroner found that observations between 16.00 and 17.00 on the day of Mr Charles’ death
were suspended by the ward shift co-ordinator. The decision meant all patients subject to general observation on the ward were ignored.
4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the cardiac arrest
adequately, and that the Trust itself described the emergency response as chaotic, that Trust staff agreed that they “panicked” and did not follow policy;
specific issues include;
a. A ward emergency bell was not sounded.
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination.
d. Duty doctors were not called promptly.
e. Oxygen administration was delayed.
f. An on-site defibrillator was not used by staff.
g. Staff could or would not provide clear and relevant history to paramedics.
Regulation 28 action plan
5. Poor record keeping – the Coroner found that:
a. Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful.
b. Observation records appeared to have been created utilising a “cut and paste” function.
c. Records often inaccurately recorded the prescribed frequency of observation.
d. Factually inaccurate entries were made in the record following Mr Charles’ death. On 11 April 2021 an entry stated that Mr Charles was “Awake
in his bedroom sitting on his bede (sic)” at 07.21. On 12 April 2021 two entries made at 9.48 and 11.40 recorded that Mr Charles was alive and
well. Senior Trust witnesses characterised these entries as dishonest.
6. Lack of learning from the incident – the Coroner found that:
a. A Datix incident report created on the evening of 10 April 2021 by a senior nurse and Modern Matron contained misleading information that
suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention the observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious
and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72-hour report was written by the Modern Matron and was signed-off by an integrated care director on 15 April 2021. This document
also failed to identify or escalate the significant issue of suspension of observation at 16.00 on 10 April 2021.
d. The Trust SI report presented to the inquest failed to address the poor risk assessment or inadequate Datix & 72-hour reports.
Act
ion
no.
1.
Concern raised by
the Coroner
1. Risk assessment
(lack of appropriate
consideration of
risks) – the Coroner
found that poor
Action (short form)
Action
(long form)
Handovers and daily run through to
take place using live RiO
1. Matrons, Ward Managers and
Consultant Psychiatrists to be made
aware that this needs to be in place
2. To be audited to ensure compliance
By Whom
By When
DON/AMD
June 2023
Regulation 28 action plan
2. MDT/Ward Round to use live RiO
1. Matrons, Ward Managers and
DON/AMD
June 2023
Care plans and risk assessments
to be reviewed and updated as a
result of this meeting
Trust to move from current
Assessment of suicide risk in
mental health practice: shifting
from prediction to therapeutic
assessment, formulation, and risk
management
Consultant Psychiatrists to be made
aware that this needs to be in place
2. To be audited to ensure compliance
3. To be audited through above audit
process
Matrons
June 2023
Task and Finish Group including Users
of Service, Carers and Experts by
Experience has been set up
Executive Chief
Nursing Officer
December 2023
3. Observation training to be
1. Observation training available delivered
DON/ADON
June 2023
refreshed to ensure this is explicit
The Safe and Supportive
Observations Policy includes this
already but needs to be more
explicit in training
by DON and ADON
2. At a glance appendix from Safe and
Supportive Observations to be shared
again
3. Ward Managers to discuss in safety
huddles and meetings
4. Medical staff to attend training
Matrons
June 2023
AMD
June 2023
record keeping and a
failure to read
electronic records
meant that important
information was not
considered at a Multi-
Disciplinary Team
(MDT) ward round on
06 April 2021. The
MDT arrived at a
conclusion that Mr
Charles’ risk of self-
harm was “no risk”. A
psychologist’s
assessment on the
clinical record that
assessed Mr Charles
risk of the self-hard
as high on 31 March
2021 was neither
read nor incorporated
into the MDT
discussion.
2. Risk
management
(inappropriate care
plan) – the Coroner
found that a decision
to reduce observation
frequency made by
the MDT on 6 April
2021 was not
supported by the
Trust Policy guidance
which indicated that
Regulation 28 action plan
enhanced
observations were
appropriate.
Following the Inquest an
independent review commissioned
to review the clinical decision made
by the MDT.
Independent Review commissioned by the Chief
Nursing Officer
Chief Nursing
Officer
October 2023
3. Risk
management (lack
of adherence to care
plan) – the Coroner
found that
observations between
16.00 and 17.00 on
the day of Mr Charles’
death were
suspended by the
ward shift co-
ordinator. The
decision meant all
patients subject to
general observation
on the ward were
ignored.3. Risk
management and
record keeping.
4. Risk
management
(shortcomings in
responding to the
emergency) – the
Coroner found that
the Trust did not
respond to the
Regulation 28 action plan
4. The
Safe
Supportive
and
Observations Policy does not allow
for this to happen. However, if this
becomes an issue due to teams
being short staffed then escalation
needs to be clearer
1. Review of Policy to encompass escalation
DON
May 2023
process
2. Professional
accountability,
referrals
made to professional board based on the
new information which came out during
inquest.
3. Refresh of training to make this process
explicit.
DON
DON
May 2023
June 2023
5. Resus drills which include all of
these elements are taking place
monthly.
1. Resus drills to take place monthly
Matrons
May 2023
2. Review of the quality of Resus Drills
3. Review of action plans following Resus
drills
4. Refresh staff on Cardiac checklist as part
of the above
Resus
Officer/DON
DON
July 2023
June 2023
5. Refresh staff as part of the above on
whereabouts of Ligature cutters (2 on
each ward)
6. Coordinator would provide all clinical
details to paramedic on their arrival.
Matrons
Matrons
June 2023
June 2023
Matrons
June 2023
6. The ERT alarm should be sounded
in all ward emergency situations
and the ERT team will respond
1. Roll call which happens daily will pick
this up and remind staff that this includes
medical emergencies
2. To ensure ERT response is robust and
timely
Matrons /Duty
Coordinators
June 2023
7. All bunches of keys have an anti
1. Anti barricade keys to be picked up in
Matrons
June 2023
barricade key on them. Key audits
have taken place in 2023
Resus drills
2. Audits of staff awareness of anti
barricade key function to take place
July 2023
8. There are 2 ligature cutters on
1. Ligature cutter training to be refreshed
every ward, one in a combination
box and one in the grab trolley
2. To be identified as part of the monthly
Resus Drill
DON/Clinical
Effectiveness
Team
Matrons
July 2023
June 2023
9. Duty Dr should be alerted as a
result of the ERT alarm
1. Medical staff to be reminded of response
AMD
June 2023
in relation to the ERT alarm
cardiac arrest
adequately, and that
the Trust itself
described the
emergency response
as chaotic, that Trust
staff agreed that they
“panicked” and did
not follow policy;
specific issues
include;
a. A ward emergency
bell was not sounded.
b. An anti-barricade
key was not used to
open Mr Charles’
door, instead the door
was forced open
causing risk of harm
to Mr Charles.
c. A ligature cutter
could not be used
promptly as it was
secured in a box with
a combination lock –
staff did not know the
combination.
d. Duty doctors were
not called promptly.
Regulation 28 action plan
e. Oxygen
administration was
delayed.
f. An on-site
defibrillator was not
used by staff.
g. Staff could or
would not provide
clear and relevant
history to paramedics.
10. This is already in ILS training which
is mandatory for all ward staff
11. This is already in ILS training which
is mandatory for all ward staff
1. Resus drills to be carried out monthly
Matrons
June 2023
1. To be addressed in Resus drills monthly Matrons
June 2023
12. The use of the SBARD tool is
1. To be addressed in Resus drills monthly Matrons
June 2023
included in ILS training and is a
recognised method of handing over
patients.
The Adult Cardiac Checklist is in all
the grab bags and included in ILS
training and provides another
framework for handing over cardiac
incidents.
5. Poor record keeping – the Coroner found that:
13. Staff involved were exercising their
1. Revisit original evidence provided to the
DON/HR
June 2023
SI report.
2. Review if disciplinary criteria met.
3. Referral to NMC
legal right not to self-incriminate
when answering questions at an
inquest.
In relation to the NMC Code of
Conduct this does not meet the
criteria of Professional and Honest
in relation to the Registered
Nurses.
a. Two Trust
witnesses declined to
answer questions put
to them regarding
whether their
observation records
were truthful.
Regulation 28 action plan
14.
b. Observation
records appeared to
have been created
utilising a “cut and
paste” function.
Cut and paste should not be used
in any part of the EPR
15. Record keeping training is
available and audits take place
1. Observation records to be revisited in
DON/Matron
June 2023
this case and any actions to be reviewed
in relation to staff
2. Observation training to be explicit
3. Review of Electronic Observation
functionality
1. Observation training
2. Audits of records by Matrons
3. To be addressed in supervision
4. Review of Electronic Observation
functionality
DON/Matron
June 2023
16.
1. To be reviewed and action to be taken
DON/HR
June 2023
HR action to be reviewed.
on staff who completed these
2. Disciplinary process
3. Referral to NMC if required
c. Records often
inaccurately recorded
the prescribed
frequency of
observation.
d. Factually
inaccurate entries
were made in the
record following Mr
Charles’ death. On 11
April 2021 an entry
stated that Mr
Charles was “Awake
in his bedroom sitting
on his bede (sic)” at
07.21. On 12 April
2021 two entries
made at 9.48 and
11.40 recorded that
Mr Charles was alive
and well. Senior Trust
witnesses
characterised these
entries as dishonest.
Regulation 28 action plan
6. Lack of learning from the incident – the Coroner found that:
a. A Datix incident
report created on the
evening of 10 April
2021 by a senior
nurse and Modern
Matron contained
misleading
information that
suggested that
emergency response
policies were followed
when in fact they
were not.
b. The Datix failed to
mention the
observations had
been suspended by
the shift coordinator,
a fact that was
understood at that
time. This obvious
and significant piece
of information that
should have been
escalated through the
Trust governance
team for action.
c. The Trust 72-hour
report was written by
the Modern Matron
and was signed-off by
an integrated care
director on 15 April
Regulation 28 action plan
17.
Review of SI report and HR
processes.
1.Revisit original evidence provided to the SI
report.
2.Review if disciplinary criteria met.
3.Referral to NMC if required
SI team
July 2023
DON
May 2023
18. The suspension of safe and
supportive observations is not an
agreed response in any situation.
Where providing observations is
challenged by short staff or other
issues this should be escalated
through line management
structure.
19. The 72 hour report is what is
known about an incident at that
point in time, the investigation
1. Safe and Supportive Observations policy
has been reviewed to make escalation of
this clear, to be shared through
Leadership Team meetings, team
meetings and individual supervision
DON
June 2023
1. Review of SI processes
SI Team
July 2023
SI Team
June 2023
report SI or local is the method of
identifying further learning.
2. Implementation of new PSIRF
framework, all 72hr reports will be
reviewed and signed off by the panel.
20. To be addressed by the SI team
1.Review of SI processes
SI Team
July 2023.
2.Implementation of new PSIRF framework
2021. This document
also failed to identify
or escalate the
significant issue of
suspension of
observation at 16.00
on 10 April 2021.
d. The Trust SI report
presented to the
inquest failed to
address the poor risk
assessment or
inadequate Datix &
72-hour reports.
Regulation 28 action plan
MR G IRVINE
SENIOR CORONER
EAST LONDON
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT 15 BEING SENT TO:
•
Foundation Trust
Acting Chief Executive Officer, North East London
• Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care
1
CORONER
I am Graeme Irvine, senior coroner, for the coroner area of East London
2
CORONER'S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
htt12:LLwww.legislation.gov.ukLuk12gaL2009L25Lschedu1eLSL12aragra12hL7
htt12:LLwww.legislation.gov.ukLuksiL2013L1629L12artL7Lmade
3
INVESTIGATION and INQUEST
On 11 th April 2021 this Court commenced an investigation into the death of Winbourne
Gregory Charles, aged 58. The investigation concluded at the end of the inquest held
before a jury between the 17th and 21 st April 2023. The Court returned a conclusion of:
"Suicide, contributed to by neglect, to which failures in medical intervention contributed
and to which failures to respond to an obvious risk of self-harm contributed."
Mr Charles' medical cause of death was determined as;
1a Suspension
4
CIRCUMSTANCES OF THE DEATH
Winbourne Gregory Charles was a admitted into hospital under section 2 of the Mental
Health Act 1983 in November 2020 following an attempt to take his own life. In
December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms,
Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983.
On 10111 April 2021 Mr Charles was found unresponsive, suspended
on the mental health ward.
5
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. -
1. A failure to adequately assess risk of harm - Poor record keeping and a failure
to read electronic records meant that important information was not considered
at a Multi-Disciplinary Team ("MDT") ward round on 6th April 2021 . The MDT
arrived at a conclusion that Mr Charles' risk of self-harm was "no risk". A
psychologist's assessment on the clinical record that assessed Mr Charles risk
of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT
discussion.
2. A decision to reduce observation frequency made by the MDT on 6/4/21 was not
supported by the Trust Policy guidance which indicated that enhanced
observations were appropriate.
3. A failure to ensure that a treatment plan was followed - observations between
16.00 and 17.00 on the day of Mr Charles' death were suspended by the ward
shift co-ordinator. The decision meant all patients subject to general observation
on the ward were ignored.
4. Failures to respond to an emergency adequately - The Trust described the
emergency response as chaotic . Staff agreed that they "panicked" and did not
follow policy, specific issues include;
a . A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles' door, instead
the door was forced open causing a risk of harm to Mr Charles.
C. A ligature cutter could not be used promptly as it was secured in a box
with a combination lock - staff did not know the combination,
d . Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to
paramedics.
5. The credibility of evidence provided by Trust staff.
a. Two Trust witnesses declined to answer questions put to them
regarding whether their observation records were truthful.
b. Observation records appeared to have been created utilising a "cut and
2
paste" function.
C. Records often inaccurately recorded the prescribed frequency of
observation.
d . Factually inaccurate entries were made in the record following Mr
Charles' death. On 11 th April 2021 an entry stated that Mr Charles was,
"Awake in his bedroom sitting on his bede (sic)" at 07.21 . On 12th April
two entries made at 9.48 and 11 .40 recorded that Mr Charles' was alive
and well. Senior Trust witnesses characterised these entries as
dishonest.
6. Governance process failings.
a . A datix incident report created on the evening of 10th April 2021 by a
senior nurse and Modern Matron contained misleading information that
suggested that emergency response policies were followed when in fact
they were not.
b. The Datix failed to mention that observations had been suspended by
the shift coordinator, a fact that was understood at that time. This
obvious and significant piece of information that should have been
escalated through the Trust governance team for action.
C. The Trust 72 hour report was written by the Modern Matron and was
signed-off by an integrated care director on 15th April 2021. This
document also failed to identify or escalate the significant issue of the
suspension of observation at 16.00 on 10th April 2021 .
d. The Trust SI report presented to the inquest failed to address the poor
risk assessment or inadequate datix & 72 hr reports.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 23/06/2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons, the family of Mr Charles; the Care Quality Commission; The Nursing &
Midwifery Council; the General Medical Council; the Metropolitan Police Service. I have
also sent it to the local Director of Public Health who may find it useful or of interest.
Mr Charles' family .
The Nursing and Midwifery Council
•
• The Care Quality Commission.
•
• The General Medical Council
• The Metropolitan Police Service
• The local Director of Public Health
I am also under a duty to send a coov of your response to the Chief Coroner and all
3
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it
useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest.
You may make representations to me, the coroner, at the tim
the release or the publication of your response.
f your response, about
9
[DA TE] 28/04/2023
[SIGNED BY CORONER]
4
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU 10 May 2024 Mr G Irvine Senior Coroner East London Coroner's Court Queens Road Walthamstow London E17 8QP Dear Mr Irvine, Thank you for your Regulation 28 report to prevent future deaths dated 28 April 2023 about the death of Winbourne Gregory Charles. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Winbourne’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter. Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety. From a national perspective, I would add that we published a new 5-year Suicide Prevention Strategy for England on 11 September with over 130 actions that we believe will make progress towards our ambition to reduce the suicide rate within two and a half years. The strategy is a call to action for national and local government, the health service, the VCSE sector, employers and individuals to work together to help prevent suicides. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
PRIVATE & CONFIDENTIAL
Mr Graeme Irvine
HM Senior Coroner
East London Coroners Court
124 Queens Road
Walthamstow, London
E17 8QP
Acting Chief Executive
Trust Head Office
West Wing
CEME Centre
Rainham
Essex
RM13 8GQ
22 June 2023
Dear Sir
Re: Inquest touching upon the death of Winbourne CHARLES
I refer to your Regulation 28 report dated 28 April 2023, issued in respect of your concerns regarding the
risk of future deaths.
Concerns
At the conclusion of the hearing into the death of Winbourne Charles, you expressed concern regarding
the following matters:
1. A failure to adequately asses risk of harm - Poor record keeping and a failure to read electronic
records meant that important information was not considered at a Multi-Disciplinary Team (MDT)
ward round on 06 April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm
was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles’ risk
of the self-hard as high on 31 March 2021 was neither read nor incorporated into the MDT
discussion
2. A decision to reduce observation frequency made by the MDT on 6 April 2021 was not supported
by the Trust Policy guidance which indicated that enhanced observations were appropriate.
3. A failure to ensure that a treatment plan was followed - observations between 16.00 and 17.00 on
the day of Mr Charles’ death were suspended by the ward shift co-ordinator. The decision meant
all patients subject to general observation on the ward were ignored.
4. Failure to respond to an emergency adequately - The Trust described the emergency response as
chaotic, that Trust staff agreed that they “panicked” and did not follow policy, specific issues
include;
a. A ward emergency bell was not sounded.
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced
open causing risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination
lock – staff did not know the combination.
www.nelft.nhs.uk
d. Duty doctors were not called promptly.
e. Oxygen administration was delayed.
f. An on-site defibrillator was not used by staff.
g. Staff could or would not provide a clear and relevant history to paramedics.
5. The credibility of evidence provided by Trust staff.
a. Two Trust witnesses declined to answer questions put to them regarding whether their
observation records were truthful.
b. Observation records appeared to have been created utilising a “cut and paste” function.
c. Records often inaccurately recorded the prescribed frequency of observation.
d. Factually inaccurate entries were made in the record following Mr Charles’ death. On 11
April 2021 an entry stated that Mr Charles was “Awake in his bedroom sitting on his bede
(sic)” at 07.21. On 12 April 2021 two entries made at 09.48 and 11.40 recorded that Mr
Charles was alive and well. Senior Trust witnesses characterised these entries as
dishonest.
6. Governance process failings.
a. A Datix incident report created on the evening of 10 April 2021 by a senior nurse and
Modern Matron contained misleading information that suggested that emergency
response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator,
a fact that was understood at that time. This obvious and significant piece of information
that should have been escalated through the Trust governance team for action.
c. The Trust 72-hour report was written by the Modern Matron and was signed-off by an
integrated care director on 15 April 2021. This document also failed to identify or escalate
the significant issue of suspension of observation at 16.00 on 10 April 2021.
d. The Trust SI report presented to the inquest failed to address the poor risk assessment or
inadequate Datix & 72-hour reports.
We have carefully considered your Regulation 28 report and by way of response, we attach a detailed
action plan addressing the concerns raised by you.
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 comprehensive investigation,
which benefits not only the families of the deceased, but also the Trust and its service users.
I trust that the attached action plan reassures 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 on
Yours sincerely
Acting Chief Executive
Enc: Regulation 28 action plan
www.nelft.nhs.uk
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