Kenneth Rippon

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

www.cqc.org.uk 

Assistant Coroner 
Janine Richards 
H.M. Coroners Office 
P.O. Box 282 
Bishop Auckland 
Co. Durham 
DL14 4FY 

23 October 2023 

Care Quality Commission 

Dear HM Coroner Janine Richards, 

CQC response to prevention of future death report following inquest into the 
death of Kenneth Rippon. 

Thank you for naming the Care Quality Commission (CQC) as a respondent in the 
prevention of future death report issued following the death of Mr. Kenneth Rippon 
on 5th May 2022 and for the extension of time to respond to the same. Thank you 
for agreeing an extension to our timeframe for response this was to allow us time 
to  respond  to  factual  accuracy  comments  from  the  trust.  Our  report  has  been 
finalised and will be published on 25 October 2023. We are happy to send you a 
copy after publication.  

In this case the CQC has reviewed the trust’s serious incident investigation report 
and the inquest bundle and has concluded that there is currently no evidence to 
suggest  that  there  has  been  a  failure  by  the  Registered  Person,  Tees  Esk  and 
Wear Valleys NHS Foundation Trust to provide Mr Rippon safe care and treatment 
causing Mr Rippon avoidable harm or exposing him to significant risk of such harm 
occurring.  CQC  does  not  have  the  power  to  take  enforcement  action  against 
individuals  who  are  not  Registered  Persons,  except  in  circumstances  where 
individual directors or members may be held individually liable for the commission 
of the offence by a registered provider that is a body corporate or unincorporated 
association, under sections 91 or 92 of the Health and Social Care Act 2008. Those 
circumstances do not arise in this case. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We note that the concerns are as follows: 

1.  The serious incident investigation report in this case was not available 
until  the  24.03.2023,  over  10  months  since  the  death  and  around  8 
months  outside  the  NHS  framework  guidance  of  60  days  for  the 
completion of such, despite repeated requests and a schedule 5 notice 
being issued to attempt to obtain a copy of the draft report to inform 
this investigation, which was not complied with.  

As  well  as  powers  to  prosecute  in  some  cases,  CQC  regulates  NHS 
providers  and  can  require  providers  to  make  improvements.  In  April  and 
May  2023  CQC  completed  inspections  of  six  of  the  trust’s  inpatient  and 
community  mental  health  services  and  an  inspection  of  the  trust’s 
leadership and governance which will be published on 25th October 2023.  

CQC share the concerns of the Coroner. Our own inspection of the trust in 
May  2023  identified  that  the  trust  had  significant  backlog  in  their 
investigation  of  serious  incidents  and  that  this  is  not  in  line  with  NHS 
standards and processes. We also know that the trust was not carrying out 
investigations  in  line  with  the  NHS  serious  incident  framework  because 
investigations  were  not;  open  and  transparent,  preventative,  objective, 
timely and responsive, systems based, proportionate and collaborative and 
because  investigations  had  not  been  undertaken  in  all  cases  beyond  an 
early learning (72 hour) review  

Through the inspection, CQC gathered evidence to assure ourselves that 
the trust has taken action to reduce this backlog and prevent reoccurrence. 
In particular, we have seen that: 

•  The trust had processes in place to address the backlog. The trust’s 
newly  appointed  chief  nurse  was  monitoring  progress  and  had 
introduced  refreshed  analysis  of  each  incident  in  the  backlog  with 
weekly meetings to monitor progress.  

•  The  trust  had  written  to  all  patients  and  families  involved  in  the 

incidents to make apologies for the delay in investigations.  

•  All incidents awaiting to be allocated to a reviewer had been placed 

into 2 cohorts. 

•  The trust had employed a patient safety programme lead to manage 
cohort  1  incidents  via  an  external  agency  and  they  had  also 
appointed a number of external SI reviewers.  

•  The  trust  told  us  that  they  were  assured  that  despite  detailed 
investigations  not  being  completed  for  serious  incidents,  they 
conducted  thorough  72-hour  reviews  into  every  incident  to  ensure 

2 

 
 
 
 
 
 
 
 
 
 
 
 that immediate actions were taken and to reduce the risk of repeated 
incidents.  

To  ensure  the  trust’s progress  in  this matter, CQC have  served  the  trust  with  a 
requirement notice, as an outcome of our inspection processes under Regulation 
17 (1) (2) (a) (b) Good Governance. This states that: 

“The trust must ensure that backlogs in the serious incident review, mortality 
review,  incident  review  and  complaints  are  resolved  with  pace,  and  that 
actions are taken to prevent reoccurrence.”  

CQC will monitor that the trust becomes compliant with this  regulation and take 
action as appropriate and necessary in line with our regulatory functions should 
improvement not be adequate.  

2.  The NHS framework sets out clearly a timescale of 60 working days 
for  the  completion  of  investigation  reports  and  highlights  the 
importance of working in an open, honest, and transparent way. One 
of the key underpinning principles in the management of all serious 
incidents is that they should be timely and responsive. The purpose 
of  the  investigation  is  to  ensure  that  weaknesses  in  a  system  or 
process  are  identified  to  understand  what  went  wrong,  how  it  went 
wrong  and  what  can  be  done  to  prevent  similar  incidents  occurring 
again.  

CQC  share  the  Coroner’s  concerns.  These  were  highlighted  to  the  trust 
during  our  inspection  in  relation  to  the  delays  in  completion  of  reports. 
However,  CQC  have  a  limited  role  in  the  oversight  of  the  quality  of 
investigations beyond our ability to inspect and take action when there are 
delays  and  flaws  in  a  provider’s  system.  The  NHS  Serious  Incident 
Framework (2015) sets out that “Providers are responsible for the safety of 
their  patients,  visitors  and  others  using  their  services,  and  must  ensure 
robust  systems  are  in  place  for  recognising,  reporting,  investigating  and 
responding  to  Serious  Incidents  and  for  arranging  and  resourcing 
investigations.  Commissioners  are  accountable  for  quality  assuring  the 
robustness  of  their  providers’  Serious  Incident  investigations  and  the 
development  and  implementation  of  effective  actions,  by  the  provider,  to 
prevent recurrence of similar incidents.” 

The trust’s commissioners are better placed than CQC to act in improving 
the quality of the trust’s investigation processes. The CQC inspection report 
has  been  shared  with  ICB  and  NHSE  and  we  have  raised  our  concerns 
directly with the trust.  

3.  The delay in the investigation in this case is particularly concerning in 
a number of respects, not least in that it revealed problems in clinical 

3 

 
 
 
 
 
 
 
 
 
 
 
 record  keeping,  risk  assessments  and  the  consideration  of  hospital 
admission,  lack  of  family/carer  involvement,  lack  of  comprehensive 
mental 
capacity, 
safeguarding and social needs and medication review and access to 
services.  

examination/assessment 

including 

state 

As part of CQC’s recent inspections in April and May 2023 we shared our 
concerns in relation to repeated themes arising from serious incidents with 
the trust. The trust was able to reassure CQC that they were taking revised 
approaches to improvements in clinical care. The trust evidenced that: 

• 

•  Following a thematic review of a cohort of serious incidents in July 
2022, the trust was able to identify seven key themes across serious 
incidents  and  programmes  of  work  were  put  into  place  to  improve 
quality  and  safety  in;  risk  assessment  and  management;  multi-
agency  working,  care  planning,  record  keeping,  safeguarding, 
involvement with patients and carers and medication. 
In July 2022 the trust launched an improvement plan to mitigate the 
risk of reoccurrence against these common themes. This included; a 
refreshed electronic patient record system to improve recording and 
support improved care planning and risk assessment, an increased 
number  of  suicide  awareness  trainers,  a  suicide  and  self-harm 
minimisation  group, 
learning  and 
development  enhancements  and  an  improved  training  matrix, 
medical  emergencies  training,  enhanced  learning  opportunities 
including the organisational learning group, safety bulletins, patient 
safety clinical huddles and patient safety rapid (72 hour) reviews. 
•  The trust had also undertaken some thematic work in specific teams 

revised  clinical  guidance, 

where there had been serious incidents in a short time. 

•  The  trust  had  also  used  the  learning  from  identifying  these  key 
themes to refresh their quality assurance programme from January 
2023.  The  trust’s  quality  assurance  programme  included  targeted 
audits and reviews including; self-declaration, modern matron quality 
reviews, practice development reviews, community quality reviews, 
peer reviews, director visits. 

In order to ensure the trust continues to embed these changes and make 
progress, following our inspections in April and May 2023 CQC have served 
requirement  notices  to  the  trust.  We  have  told  the  trust  that  in  order  to 
become  complaint  with  Regulation  12  (1)  (2)  (a)  (b)  Safe  Care  and 
Treatment, they: 

“Must ensure that learning from incidents, deaths and complaints is 
effective  and  embedded  and  that  the  risk  of  repeat  incidents  is 
reduced.  

4 

 
 
 
 
 
 
 
 
 
 CQC  will  monitor  that  the  trust  becomes  compliant  with  this 
regulation and take action as appropriate and necessary in line with 
our regulatory functions should improvement not be adequate.” 

4.  As  a  result  of  the  delay  in  the  serious  incident  Investigation  and 
formulation of an action plan, many of the identified actions required 
to  remedy  these  difficulties  were  still  being  actioned  /completed 
relatively recently.  

At  CQC’s  inspections  in  April  and  May  2023  we  investigated  the  trust’s 
governance procedures and processes. The trust evidenced that they were 
taking revised approaches to governance systems as they recognised and 
shared CQC’s concerns that the trust have not always completed actions 
with the required pace to improve safety to patients. In order to ensure the 
trust continues to embed these changes and make progress, following our 
inspections in April and May 2023 CQC have served requirement notices to 
the  trust.  We  have  told  the  trust  that  in  order  to  become  complaint  with 
Regulation 17 (1) (2) (a) (b) good governance they: 

"Must  ensure 
that  governance  systems  and  processes  are 
established, embedded and operated effectively to assess, monitor 
and improve the quality and safety of the services. Using accurate 
and clear information to make improvements to the safety and quality 
of services.” 

CQC will monitor that the trust becomes compliant with this regulation and 
take  action  as  appropriate  and  necessary  in  line  with  our  regulatory 
functions should improvement not be adequate.  

5.  Further one of the actions upon identification of a serious incident is 
to obtain, secure and preserve all relevant evidence. In this case the 
memory capture forms identified as being required in the immediate 
aftermath of the incident were not taken promptly and were seemingly 
only  taken  after  I  requested  sight  of  them,  several  months  after  the 
incident and therefore when memories had already begun to fade. This 
was concerning given the identified problem of clinical record keeping 
at the time of these events.  

CQC share the Coroner’s concerns in relation to the delays in completion 
of  reports.  We  shared  these  concerns  with  the  trust  during  out  recent 
inspection and these are contained within the published inspection report. 
The  report  has  been  shared  with  ICB  and  NHSE  colleagues  for  their 
consideration.  However,  CQC  have  a  limited  role  in  the  oversight  of  the 
quality of investigations beyond our ability to inspect and take action when 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 there are delays and flaws in a provider’s system. The NHS Serious Incident 
Framework (2015) sets out that.  

“Providers are responsible for the safety of their patients, visitors and 
others using their services, and must ensure robust systems are in 
place  for  recognising,  reporting,  investigating  and  responding  to 
Serious  Incidents  and  for  arranging  and  resourcing  investigations. 
Commissioners are accountable for quality assuring the robustness 
the 
of 
development  and  implementation  of  effective  actions,  by  the 
provider, to prevent recurrence of similar incidents.” 

their  providers’  Serious 

investigations  and 

Incident 

The trust’s commissioners are better placed than CQC to act in improving 
the quality of the trust’s investigation processes. 

6.  I  am  concerned  that  the  extensive  and  continuing  delays  in 
investigating serious incidents may lead to further deaths, as lessons 
cannot be learnt and improvements made in a timely manner. I am also 
concerned that the quality of such investigations is compromised by 
the failure to complete memory capture forms and the passage of time 
before important evidence is secured. 

Due to the concerns relating to the backlog of serious incidents, CQC and 
other  stakeholders  have  continued  to  monitor  the  trust’s  progress  with 
reducing this backlog and preventing reoccurrence of this issue.  

In August 2023, the trust provided CQC with information which showed that 
the backlog had reduced, and a trajectory is in place with a target date of 
December 2023 for completion of all historical investigation reports. There 
is a revised process in place to prevent reoccurrence of this backlog.  

To ensure improvements, CQC will continue to monitor the trust’s progress 
with  removing  this  backlog  via  the  current  quality  board  which  meets 
monthly  and  is  overseen  by  NHS  England  due  to  the  trust’s  ongoing 
performance  issues  and  its  placement  in  ‘system  oversight  framework 
segment 3’. This means that: 

“For  trusts  and  ICBs  in  segment  3,  NHS  England  and  NHS 
Improvement  regional  teams  will  work  collaboratively  with  them  to 
undertake  a  diagnostic  stocktake  to  identify  the  key  drivers  of  the 
concerns  that  need  to  be  resolved.  Through  this,  we  aim  to  better 
understand their support needs and agree improvement actions.” 

Our inspection report of our findings from our recent inspections will be published 
on our website on 25 October 2023. CQC are happy to share this with HM Coroner 
should you wish. 

6 

 
 
 
 
 
 
 
 
 
 
 
 
 I hope this satisfies HM Coroner that CQC continue closely monitor the progress 
the trust are making in this respect. Should CQC find improvement does not occur 
CQC would review the risks associated with this in conjunction with our partners, 
and in the event of breaches of regulation, we would use our powers to take further 
action.  

Yours sincerely 

Deputy Director, Network North.  

7

Office of the Chief Executive 
West Park Hospital 
Edward Pease Way 
Darlington 
Co Durham 
DL2 2TS 

20 October 2023 

Private & Confidential 
Ms J Richards 
HM Assistant Coroner  
for County Durham and Darlington 
H M Coroners Office 
PO Box 282 
Bishop Auckland 
Co Durham  
DL14 4FY 

Dear Ms Richards, 

Re: Report to Prevent Further Deaths issued on 19 July 2023 in relation  

to Mr Kenneth Rippon 

Just a short note at this stage to 
acknowledge receipt of your 
letter dated XXXX  2017 bringing 
I am writing to you in response to your direction in the prevention of future deaths notice 
to my attention concerns raised 
served to Tees, Esk and Wear Valleys NHS FT on 19 July 2023 regarding the death of Mr 
Kenneth Rippon  to provide in writing further information on what the Trust is doing to ensure 
by your above named constituent 
Serious Incident reviews are completed within a timely manner as well as an update on the 
in respect of XXXXXXX 
estimated time of arrival for each outstanding review.  

I have asked for an investigation 
I am responding in the same format and with similar information to that in the response letter 
to be carried out into the 
sent September 2023, I hope this consistency will be helpful in enabling you and your team 
concerns raised by XXXXX 
to see the clear evidence of the progress we are making towards providing timely serious 
following which I will send a 
incident reviews. I have continued to have direct oversight of how we are performing as I am 
detailed reply to you. 
concerned that we improve our position as soon as possible. Our Board share this concern 
and therefore I  have asked the Chief Nurse to keep our Quality Assurance Committee and 
our Board fully briefed.  

With kind regards 

The following action has been taken: 

Yours sincerely 

1)  We have contracted in additional expert capacity in incident reviews to actively address 
the  reviews  that  are  delayed.  Since,  my  previous  update  we  have  contracted  / 
employed further reviewers and to date we have allocated 41 of these reviews which 
is an increase of 16 since my previous letter to you. 

2)  We have continued to increase our internal capacity to review incidents, our clinical 
and leaders are engaged across services in completing incident reviews in order that 
Colin Martin 
we can review incoming incidents and avoid further delays developing.  
Chief Executive 
3)  We have reviewed all incidents to ensure we have met Duty of Candour, that families 
have received notification of a review and have a named contact person and that we 
Date 
have  a  clear  term  of  reference  for  each  review.  We  report  weekly  to  the  Executive 
Directors on our compliance with Duty of Candour to ensure there are no delays. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4)  An external company specialising in incident management has reviewed our historical 
incident data so that we can address the potential risks of missing issues and learning 
due to a delay with some reviews.  

5)  We have adapted processes to facilitate much earlier identification of the type of review 
required (concise or full) – this now takes place at the daily patient safety huddle, and 
we  follow  the  national,  soon  to  be  Patient  Safety  Incident  Response  Framework 
(PSIRF), guidance for this. It is anticipated that we will increase the number of concise 
reviews, where appropriate, in line with this national guidance. 

6)  We have also adapted our processes to ensure they identify immediate / early learning 
for each incident and that we take immediate improvement action where appropriate. 
We  never  wait  for  a  full  investigation  before  implementing  any  immediate  action 
necessary  to  reduce  the  risk  to  other  patients  and  service  users.  While  a  full 
investigation will often have a broad scope and capture learning which is not directly 
relevant  to  a  death,  immediate  learning  is  designed  to  eliminate  or  reduce  any 
identified  patient  safety  issues.  We  have  examples  of  Trust  wide  patient  safety 
briefings we have developed following immediate learning. 

7)  We have in place weekly sitrep / report out meetings to ensure we are sighted on the 
progress of each review and can provide any additional support to reviewers that may 
be  needed.  We  will  be  monitoring  our  performance  against  the  trajectory  we  have 
developed, and this is being reported to executive directors on a weekly and monthly 
basis. 

8)  We are reporting to our regulators and regional leaders via the mandated Quality Board 

our progress and have demonstrated progress. 

9)  We have modified our documentation, reviewed our report templates and are utilising 

standard operating procedures to support efficient working and flow. 

10) We have increased our internal Serious Incident Review Panel capacity to ensure we 
can be efficient in our internal quality assurance in order that this does not delay the 
release of reviews to families once completed. 

11) We have increased our Family Liaison Capacity so that we can better support families 
and ensure that they are enabled to ask questions about their loved one’s care as a 
part of the review process. 

12) We  will  continue  to  expand  our  range  of  subject  matter  expert  categories  to  lead 

specific types of reviews. 

13) The Associate Director of Patient Safety commenced in post as planned from 19 July 
23 and is being supported by the Deputy Chief Nurse who commenced at TEWV 3 
July 2023. Together they are ensuring that reviews are of the right standard and that 
reviewers have the right support and supervision to complete high quality reviews. 

Since we last wrote to you we have made steady and consistent progress with allocating and 
completing incident reviews and at the beginning of this week we reported only 13 reviews 
outstanding for allocation across the whole of TEWV services, we also reported this to our 
Quality Board which is chaired by our regional Chief Nurse. This is a significant improvement. 

I hope that the progress list and the actions outlined above will provide some assurance that 
we share your concern about the delays in serious incident reviews and that we are focussed 
on eradicating the delays. 

Finally,  I wish to restate that I would welcome an opportunity to meet and discuss these issues 
as would our Executive Medical Director and Chief Nurse.  

 
 Yours Sincerely  

Chief Executive

Tarncroft 
Lanchester Road Hospital 
Lanchester Road 
Durham 
DH1 5RD 

13 September 2023 

Private & Confidential 
Ms J Richards 
HM Assistant Coroner  
for County Durham and Darlington 
H M Coroners Office 
PO Box 282 
Bishop Auckland 
Co Durham  
DL14 4FY 

Dear Ms Richards, 

Re: Report to Prevent Further Deaths issued on 19 July 2023 in relation  

to Mr Kenneth Rippon 

I am writing to you in response to your direction in the prevention of future deaths notice served 
to Tees, Esk and Wear Valleys NHS FT on 19 July 2023 regarding the death of Mr Kenneth 
Rippon. 

On the 3 July 2023 I wrote to 
 proactively to articulate the actions we are taking 
to ensure we review care in accordance with the standards required in the NHS framework. I 
confirmed at this time that I have written personally to each of the families where a review was 
overdue and apologised sincerely for the further distress we may have caused. I speak on 
behalf of the TEWV Board in saying we fully recognise that this is not acceptable, and we will 
make improvement. 

In responding to this PFD, I will reiterate the steps we have taken, the additional steps since 
3 July 2023 and a summary of the progress we are making. 

The following action has been taken: 

1)  We have contracted in additional expert capacity in incident reviews to actively address 
the  reviews  that  are  delayed.  Since,  my  previous  update  we  have  contracted  / 
employed further reviewers and to date we have allocated 41 of these reviews which 
is an increase of 16 since my previous letter to you. 

2)  We have continued to increase our internal capacity to review incidents, our clinical 
and leaders are engaged across services in completing incident reviews in order that 
we can review incoming incidents and avoid further delays developing.  

3)  We have reviewed all incidents to ensure we have met Duty of Candour, that families 
have received notification of a review and have a named contact person and that we 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 have  a  clear  term  of  reference  for  each  review.  We  report  weekly  to  the  Executive 
Directors on our compliance with Duty of Candour to ensure there are no delays. 

4)  An external company specialising in incident management has reviewed our historical 
incident data so that we can address the potential risks of missing issues and learning 
due to a delay with some reviews.  

5)  We have adapted processes to facilitate much earlier identification of the type of review 
required (concise or full) – this now takes place at the daily patient safety huddle, and 
we  follow  the  national,  soon  to  be  Patient  Safety  Incident  Response  Framework 
(PSIRF), guidance for this. It is anticipated that we will increase the number of concise 
reviews, where appropriate, in line with this national guidance. 

6)  We have also adapted our processes to ensure they identify immediate / early learning 
for each incident and that we take immediate improvement action where appropriate. 
We  never  wait  for  a  full  investigation  before  implementing  any  immediate  action 
necessary  to  reduce  the  risk  to  other  patients  and  service  users.  While  a  full 
investigation will often have a broad scope and capture learning which is not directly 
relevant  to  a  death,  immediate  learning  is  designed  to  eliminate  or  reduce  any 
identified  patient  safety  issues.  We  have  examples  of  Trust  wide  patient  safety 
briefings we have developed following immediate learning. 

7)  We have in place weekly sitrep / report out meetings to ensure we are sighted on the 
progress of each review and can provide any additional support to reviewers that may 
be  needed.  We  will  be  monitoring  our  performance  against  the  trajectory  we  have 
developed, and this is being reported to executive directors on a weekly and monthly 
basis. 

8)  We are reporting to our regulators and regional leaders via the mandated Quality Board 

our progress and have demonstrated progress. 

9)  We have modified our documentation, reviewed our report templates and are utilising 

standard operating procedures to support efficient working and flow. 

10) We have increased our internal Serious Incident Review Panel capacity to ensure we 
can be efficient in our internal quality assurance in order that this does not delay the 
release of reviews to families once completed. 

11) We have increased our Family Liaison Capacity so that we can better support families 
and ensure that they are enabled to ask questions about their loved one’s care as a 
part of the review process. 

12) We  will  continue  to  expand  our  range  of  subject  matter  expert  categories  to  lead 

specific types of reviews. 

13) The Associate Director of Patient Safety commenced in post as planned from 19 July 
23 and is being supported by the Deputy Chief Nurse who commenced at TEWV 3 
July 2023. Together they are ensuring that reviews are of the right standard and that 
reviewers have the right support and supervision to complete high quality reviews. 

Since I last wrote to you, we have allocated a further 16 serious incident reviews, we have 
completed a further 10, there are 8 reviews in the final stages of quality assurance and / or 
proof reading prior to submission and there has been a further 5 deaths of people who we 
understand  will  have  a  hearing  within  your  jurisdiction.  This  means  that  apart  from  which 
review which requires an external review due to the nature of the incident all serious incident 
reviews are underway, this is a significant improvement. 

I  have  taken the  opportunity  to  share  an  updated  version  of  the  list  of  the  serious  incident 
reviews that I have previously shared with you to be open and transparent and to demonstrate 
progress. You will see from this list that of the reviews that are not yet complete the majority 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 are  working  to  a  clear  timeline  for  internal  quality  assurance  which  is  also  a  significant 
improvement.   I hope that the progress list and the actions outlined above will provide some 
assurance that we share your concern about the delays in serious incident reviews and that 
we are focussed on eradicating the delays. 

Finally, whilst the purpose of this letter is to articulate how we are meeting your direction, I 
wish to re state that the driver for me and my colleagues is the recognition that these delays 
potentially have an impact on people who have lost someone dear to them. It is not acceptable, 
and we are committed to working with the people who come into contact with our services in 
a proactive and compassionate way.  

Yours sincerely, 

Chief Nurse 

Encs. 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS