Marion Nickson

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

www.cqc.org.uk 

HM Senior Coroner 
Manchester South 
Coroner’s Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG 

29 September 2023 

Care Quality Commission 

Dear HM Senior Coroner 

Prevention of future death report following inquest into the death of Marion 
Nickson 

Thank you for sending the Care Quality Commission (CQC) a copy of the 
prevention of future death report issued following the death of Marion Nickson. 

This response seeks to address the concerns raised in your report. 

“The inquest heard evidence that to deal with the risk of falls in patients 
deemed to be high risk the concept of observable bay nursing had been 
introduced at both Trusts. At both Trusts Mrs Nickson fell whilst 
unobserved due to the challenges of maintaining the bays as observed 
bays…. The evidence was clear that if observable bays could not function 
as intended then across the NHS there would continue to be avoidable 
falls and consequential deaths. If bay nursing could not effectively 
delivered due to resourcing then other options to keep patients safe 
needed to be explored by Acute Trusts” 

In accordance with CQC’s regulatory remit in the context of this registered 
provider CQC highlights to Trusts identified breaches of the relevant regulations, 
and in particular under the Health and Social Care 2008 (Regulated Activities) 
Regulations 2014 (‘Regulated Activities Regulations’). We also require 
compliance where those breaches have been identified and take civil (and/or 
criminal) enforcement action in line with CQC’s published Enforcement Policy 
where it is appropriate to do so. However, while the fundamental standards 
contained in the Regulated Activities Regulations set out the relevant standards 
that registered providers must meet, they do not prescribe how exactly and what 

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 exactly registered providers must do to meet them; those are things that the 
registered provider, and the Trust in this context, must determine in order to meet 
the standards and duties set out in the Regulated Activities Regulations. It is 
therefore not for CQC to include or prescribe detailed standards and expectations 
about each specific condition and potential need in our regulatory framework. 
The CQC through its website signposts Trusts to relevant guidance on how they 
can meet relevant regulations, including the fundamental standards under the 
Regulated Activities Regulations. However, under CQC’s regulatory model it is 
for registered providers, including Trusts, to determine how it will meet and 
implement good practice standards, including in consultation with third-party 
expert organisations, as required who produce national guidance and may 
consult on local guidance. Such organisations include, for example, NHS 
England, Department of Health, Royal College of Nursing, National Institute for 
Health and Care Excellence and the General Medical Council. 

As part of our inspections of Trusts, staffing forms part of the assessment we 
make when we ask our key question “Is the service Safe?” There are a number 
of Key Lines of Enquiry in our inspection assessment framework that ask: 

•  How are staffing levels and skill mix planned and reviewed so that people 

receive safe care and treatment at all times and staff do not work 
excessive hours? 

•  How do actual staffing levels and skill mix compare with the planned 

levels? Is cover provided for staff absence? 

•  Do arrangements for using bank, agency and locum staff keep people safe 

at all times? 

•  How do arrangements for handovers and shift changes ensure that people 

are safe? 

•  Are comprehensive risk assessments carried out for people who use 
services and risk management plans developed in line with national 
guidance? Are risks managed positively? 

•  How do staff identify and respond appropriately to changing risks to 

people, including deteriorating health and wellbeing, medical emergencies 
or behaviour that challenges? Are staff able to seek support from senior 
staff in these situations? 

•  How is the impact on safety assessed and monitored when carrying out 

changes to the service or the staff? 

Inspectors explore staffing and how this is managed to ensure people receive 
safe care and treatment by enough staff who have the qualifications, 

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 competence, skills and experience to do so safely. Our assessment would 
identify where staffing levels do not support appropriate standards of care, for 
example, for patients to be appropriately observed to prevent falls.      

CQC have not identified bay nursing as a national issue because it is not a 
patient safety issue in and of itself.  However, we do identify workforce pressures 
and staffing levels as a national issue as this is a cause of patient safety risks. 
When staffing levels fall below acceptable standards any clinical intervention 
becomes a safety issue, we would indicate our findings on this.  We highlight this 
in our reports and ratings demonstrating the level of risk, and appropriate 
regulatory action taken in response.    

In addition to our inspection activity, inspectors regularly monitor the National 
Reporting and Learning System (NRLS) and Strategic Executive Information 
System (StEIS), reviewing a Trust’s National Patient Safety Incident Reports and 
Serious Incident investigations data. Currently these data sources are going 
through a significant transformation, as NHS England implements the new Learn 
from Patient Safety Events system, which limits CQC’s ability to carry out further 
national analysis until this has completed. We recognise there are currently some 
challenges for CQC in being able to analysis large qualitative datasets, but we 
are looking at developing methodologies to deal with this, albeit recognising that 
consistency of information reported by Trusts may be a challenge CQC will need 
to consider in seeking to make those improvements. 

CQC has contacted Stockport NHS Foundation Trust and East Cheshire NHS 
Trust to request written confirmation and evidence of the action they have taken 
to date following this death and any additional action they intend to take in 
response to the prevention of future death report.  

We will consider the response of Stockport NHS Foundation Trust and East 
Cheshire NHS Trust to our request as part of our monitoring function in respect of 
this registered provider and specifically whether and to what extent their 
response gives rise to any further regulatory actions. 

We also note the legal requirement upon NHS England to respond to your report 
within 56 days. We will review NHS England’s response to your Regulation 28 
report to consider whether and what further discussion or action may be required 
to seek to address the concerns identified in your Regulation 28 report.  
As you may be aware from 1 April 2015 CQC is the lead enforcement body for 
health and safety incidents in the health and social care sector. Following the 
Inquest, we are reviewing the facts and evidence in relation to Ms. Nickson’s sad 
death to determine whether there are grounds to suspect that a criminal offence 
may have been committed, and whether a formal criminal investigation will be 
undertaken by the CQC. 

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 Please do not hesitate to contact me if you require any further information.   

Yours sincerely 

Deputy Director of Operations 
Network North 

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Ms Alison Mutch 
Senior Coroner  
Greater Manchester South Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG  

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

20 September 2023  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Marion Nickson who died 
on 14 February 2023.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 July 
2023  concerning  the  death  of  Marion  Nickson  on  21  July  2023.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Marion’s family and loved ones. NHS England are keen to assure 
the family and the coroner that the concerns raised about  Marion’s care have been 
listened to and reflected upon.  

In your Report you raised concerns around inpatient falls and the use of observable 
bay nursing practices.  

NHS England commissions the National Audit of Inpatient Falls (NAIF) as part of the 
Falls and Fragility Fracture Audit Programme via the Healthcare Quality Improvement 
Partnership UK (HQUIP) which is delivered by the Royal College of Physicians (RCP). 
NHS England’s Patient Safety  Team are significantly involved in this programme at 
advisory,  audit  design  &  delivery  level.  The  RCP  has  and  continues  to  produce  a 
significant number of quality improvement resources using audit learning to support 
providers with the care offered to people at risk of, or who have, fallen and sustained 
injury in hospital. The NAIF 2023 Annual Report is due to be published in November. 
This will include further recommendations around preventing inpatient falls and post-
fall checks.  

The  topic  of  observation  is  covered  in  the  e-learning  training  module  ‘FallSafe’ 
produced by the RCP and NHS England. The module is freely available and is widely 
publicised and used across the NHS and covers the knowledge needed to identify and 
reduce patient and environmental risk factors to assist with reducing inpatient falls as 
well as post fall management.  

Regarding  the  management  of  head/brain  injury  following  an  inpatient  fall,  NHS 
England  has  also  recently  worked  with  the  RCP  to  inform  their  successful  re-
application to the audit tender, the scope of which will now be widened to include such 
injuries. We  anticipate  that  future  learning  from  the audit  results  will support further 
quality improvement initiatives and resources to support providers. 

You also raised the issue of appropriate levels of resourcing within observable nursing 
bays. In June this year, the NHS published its Long Term Workforce Plan, setting out 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 how we will ensure that staffing is put on a sustainable footing over the next fifteen 
years  to  improve  patient  care.  The  plan  sets  out  three  core  priorities;  to  improve 
training and education, ensure that we retain more staff, and to reform. The plan is 
underpinned by the biggest recruitment drive in NHS history.  

NHS  England  has  also  engaged  with  the  Greater  Manchester  Integrated  Care 
Partnership on the concerns raised in your report and they have advised that Stockport 
NHS Foundation Trust have taken learnings and actions from Marion’s fall and their 
subsequent internal investigation. The Trust have made recommendations to include 
ensuring that staff have a refresher on the protocols and assessments available and 
that  there  are  divisional  leadership  walk  rounds  with  a  focus  on  bay  nursing, 
adherence to policy and the wearing of tabards.  

The Trust have also shared the learnings from Marion’s death via various forums, such 
as  ward  meetings,  the  Respiratory  Clinical  Group  Meeting,  the  Ward  Managers 
Governance Meeting and the Division of Medicine and Urgent Care Quality Group. 

I would also like to provide further assurances on national NHS England 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 preventable deaths are shared across the NHS at both 
a national and regional level and helps us 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