Donna Levy

From Helen Whately MP 
Minister of State for Social Care 

39 Victoria Street 
London 
SW1H 0EU 

16 May 2024 

Mr. Graeme Irvine 
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 31/08/23 about the 
death of Donna Rose Lydia Levy.  I am replying as Minister with responsibility for adult social 
care and safeguarding. 

Firstly, I would like to say how saddened I was to read of the circumstances of  Ms. Levy’s 
death and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are very 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. 

The report raises concerns about the level of care provided by community services, including 
no formal  referral being  made  to  mental  health  services.  You  also  raise  concerns  that  the 
North  East  London  Foundation  Trust  responsible  for  community  care  did  not  undertake  a 
Serious Investigation Review. 

The Department wants to see a focused and effective safeguarding system, where harm or 
risk of harm is identified, acted upon effectively and ultimately prevented. 

In preparing this response, Departmental officials have made enquiries with NHS England and 
the Care Quality Commission.  

I understand the Trust responded to your report on 09/11/23 with actions it will take to improve 
patient safety and quality of care. These include: increasing nursing capacity; holding weekly 
multidisciplinary  Complex  Case  discussion  meetings;  updating  the  risk  escalation  process; 
devising standardised operating procedure relating to how district nurses conduct their daily 
handovers; providing relevant training for health and social care staff; making the completion 
of mental capacity assessments in complex cases mandatory; undertaking risk assessments 
to identify  anxiety  and depression  scores;  increasing  frequency  of  high  risk  cases reviews; 
ensuring incident reports incorporate concerns across integrated services; and introducing a 
new Patient Safety Incident Response Framework.  

In  addition,  CQC  reviewed  the  incident  in  line  with  their  specific  incident  guidance  and 
assessed  that  it  does  not  meet  the  threshold  for  CQC  to  consider  using  its  criminal 

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 enforcement powers. However, they are keeping the incident under review with the Trust and 
will  be  asking  for  an  update  on  their  action  plan  in  relation  to  this  incident  at  their  next 
engagement meeting. 

Local authorities have a statutory duty to investigate safeguarding concerns under the Care 
Act 2014.  A new duty on the CQC to assess local authorities’ delivery of their adult social care 
duties under Part 1 of the Care Act 2014 came into effect on 1 April 2023. Linked to this new 
duty is a power for the Secretary of State to intervene where, following assessment under the 
new duty, it is considered that a local authority is failing to meet their duties. The Department 
are  awaiting  CQC’s  findings  from  five  pilot  assessments  that  took  place  between  July  and 
early September 2023 and their proposed assessment framework. 

Furthermore, on 12 June 2023 the Safe Care at Home Review was published. This is a joint 
review led by the Home Office and DHSC into the protections and support for adults abused, 
or at risk of abuse, in their own home by people providing their care.  This includes those who 
are unable to make safe decisions in  their own best interests and the review considers the 
balance between choice and safety when dealing with someone who self-neglects. The Home 
Office  and  DHSC  are  making  progress  on  implementing  recommendations  made  by  the 
review.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

Yours, 

HELEN WHATELY

PRIVATE  & CONFIDENTIAL  

Mr G Irvine 
HM Coroner 
East London Coroners Service 
124 Queens Road 
Walthamstow 
London 
E17 8QP 

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

        9th November 2023 

Dear Sir, 

Re: Inquest touching upon the death of Ms Donna Levy 

I refer to your letter dated 31 August 2023 and the Regulation 28 report detailing your concerns 
about the risk of future deaths in light of the findings of the Inquest.  

I should like to extend my sincere condolences to the family of Ms Donna Levy. This must have 
been  an  extremely  difficult  time  and  I  hope  that  my  response  provides  them,  and  you,  with 
assurances that the North East London Foundation Trust is taking action to address the issues 
set out in your report. 

At the conclusion of the Hearing into the death of Ms Donna Levy, you expressed the following 
concerns in respect of the care provided by NELFT: 

1.  In the two months prior to her final admission into hospital Ms Levy was being regularly 
assessed  by  district  nurses,  the  community  matron  and  her  GP.  Despite  the  obvious 
nature of her deteriorating health, no meaningful steps were taken to escalate the care 
she received to mitigate the risks of her self-neglect. 

2.  The inquest heard that as Ms. Levy was believed to have capacity throughout this period, 
and consequently it was determined that there were no practical steps that could have 
been taken to improve the provision of care to her. 

3.  No formal Mental Capacity Act assessment was ever undertaken or considered. 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
                                     
 
 
 
  
 
 
   
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 4.  No formal referral was made to mental health services regarding Ms Levy’s reluctance to 

take advantage of offered care. 

5.  The Trust responsible for community care did not undertake a Serious Investigation. The 
decision  was  justified  on  the  basis  that  Ms  Levy’s  pressure  sore  was  insufficiently 
significant to justify further inquiry. The decision was, in the view of the court flawed as 
evidence  heard  indicated  that  the  pressure  sore  was  in  fact  far  more  serious  than 
appreciated at the time of community treatment. Further, restricting the scope of a serious 
incident  report  to  the  extent  of  a  single  pressure  sore,  neglected  to  take  in  the  wider 
physical health problems suffered by Ms Levy that were obvious at that time. 

In respect of the specific concerns, expressed by you at the Hearing and within the Regulation 
28  Report,  the  Trust  has  put  actions  in  place  that  aim  to  address  these  specific  areas  for 
improvement in order to strengthen the safety of our services further. Please note that we have 
put together a joint Action Plan with London Brough of Redbridge which sets out these actions 
and I attach a copy of the same with this letter. 

In order to improve the services provided by the North East London Foundation Trust it will: 

•  Engage  will  the  London  Borough  of  Redbridge  in  weekly  Complex  Case  Discussion 
meetings involving all 5 Health and Social Services localities and areas of responsibility. 

• 

Introduce two new and full-time senior band 8a nurses. 

•  Review, revise and disseminate the risk escalation process with health and social care 

staff. 

•  Devise a standardised operating procedure relating to how District Nurses conduct their 

daily handovers. 

•  Provide Professional Curiosity training for health and social care staff. 

•  Provide legal training on Court of Protection referrals for health and social care staff. 

•  Request  and  encourage  GP  involvement  in  discussions  of  complex  cases  and 

professional meetings. 

•  Provide mental capacity assessment training for all health and social care staff. 

•  Complete mental capacity assessments in complex cases. 

•  Undertake risk assessments to identify anxiety / depression scores. 

•  The Multi-disciplinary Leadership Team will increase the review of cases escalated via 

High Level Risk Reporting from twice a month to once a week. 

•  Undertake a review of this case at the Pressure Ulcer Assurance Group to identify any 

further gaps in care and learning. 

•  Ensure incident reports include concerns across integrated services. 

•  Ensure  that  the  new  NELFT  Pressure  Ulcer  incidents  management  approach  is 

embedded. 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (cid:120)  Establish staff learning events for health and social care staff. 

NELFT did not conduct a Serious Investigation into this matter because, as detailed on the 72-
hour Report, it was understood that the incident had occurred within a hospital setting rather than 
a community setting.  It was also understood that whilst Ms Levy was under the care of NELFT 
community services, the severity of her pressure ulcer had not met the threshold for a serious 
incident investigation under the previous serious incident framework.  Unfortunately, too, we were 
not engaged in the Serious Incident Investigation that was carried out by the Barking, Havering 
and Redbridge University Hospitals Trust (BHRUT).  

With  the  introduction  of  the  new  Patient  Safety  Incident  Response  Framework,  this  has  now 
changed.  This framework includes new processes such as the Patient Safety Incident Report 
Group  Forum  (PSIG)  that  provides  for  greater  and  more  detailed  review  of  whether  an 
investigation is needed and what form that will take.  The PSIG is a NELFT wide meeting headed 
by  the  Executive  Chief  Nursing  Officer  and  attended  by,  but  not  limited  to,  representatives  at 
various levels from the different Directorates, Directors, Assistant Directors, Operational Leads, 
the Legal Team and the Patient Safety Team.  

As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis  
will  be  investigated  via  a  full  Patient  Safety  Incident  Investigation  (PSII)  by  the  patient  safety 
incident  team.    The  revised  process  in  place  in  relation  to  pressure  ulcers  also  ensures 
Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure 
ulcers,  as  well  as  unstageable  and  deep  tissue  injuries.    In  support  of  this,  we  are  also 
establishing multidisciplinary review panels to address key themes in relation to pressure ulcer 
care,  with  thematic  learning  being  reviewed  through  the  PSIG  and  through  the  the  Trust’s 
pressure ulcer assurance group for wider learning. 

I hope that I have provided you with some assurance that North East London Foundation Trust 
is taking steps to address the concerns expressed in your report and that we are continuing to 
take action to improve patient safety and quality of care. 

Thank  you for raising this matter  with  North  East  London  Foundation  Trust. If I  can  be  of  any 
further assistance or if you would like a further update on the progress made to address your 
concerns, I would be happy to provide a further update. 

I look forward to hearing from you. 

Yours sincerely  

Chief Executive Officer 

Enc:   Regulation 28 Action Plan

www.nelft.nhs.uk