Claire Twinn

Trust Executive Office 
Ground Floor 
Pathology and Pharmacy Building 
The Royal London Hospital 
80 Newark Street 
London E1 2ES 

Group Chief Medical Officer 

www.bartshealth.nhs.uk 

12 December 2023 

Mr Graeme Irvine 
Area Coroner – East London 
Walthamstow Coroner’s Court 
Queen’s Road 
London 
E17 8QP 

Dear Mr Irvine 

Re:  Regulation 28 Report to Prevent Future Deaths 

I write regarding your letter of 16 October 2023 regarding your concerns relating to the death of 
Claire Twinn at Newham University Hospital.  I hope this letter will provide assurance to you of 
the steps that we are taking to address the concerns you have outlined. 

1. Ms Twinn’s disability played a role in the provision of sub-optimal care, reasonable 
adjustment was not made for; her inability to communicate clearly and her impaired 
respiratory function when arriving at clinical decisions. 

2.  Neither the trust decision to discharge Ms Twinn and not admit for continued 
monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice 
to carers was recorded in the clinical record. 

3. Ms Twinn’s treatment did not involve any specialised learning disability nursing input to 
facilitate clear communication with Ms Twinn. 

I will respond to these items as a group as they are interlinked.  We have developed a SOP for 
patients with learning disabilities (LD) in the Emergency Department, which has been developed 
in conjunction with the Lead Learning Disabilities Nurse for Barts Health.  This includes the 
instruction that there must be a low threshold for keeping patients with learning disabilities in the 
department overnight and states that any potential issues with this patient group should be 
highlighted at the safety handover.  Furthermore, we are ensuring that discharge letters are 
physically printed as they may be needed by carers. 

For assurance, the LD team will audit the discharge advice given to this patient cohort over a 
period of one month in the first instance. We are also ensuring greater pro-active attendance 

 
 
 
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 by specialist nurses in the department and are making adjustments to particular rooms to make 
them more suitable for this cohort. 

A training package has been put together around communicating with vulnerable patients, which 
includes a case study of a patient with LD in the Emergency Department.  It involves looking at 
factors relating to the clinician, the environment and the patient that might make the situation 
more complex.  Teaching is also taking place on induction and at monthly Consultant meetings. 
Finally, we are procuring specialist equipment in the form of a multi-sensory mobile unit to be 
used when needed alongside smaller items, including communication tools, for use with most 
complex patients. 

4. A radiological report of the chest x-ray taken on 15th  December 2022 was not reported 
until 25th  December 2022. 

The Imaging Department endeavours to report on Emergency Department radiographs within 10 
working days unless a query has been raised by one of the treating physicians or allied health 
care professionals, in which case it is reviewed at the point of query with view to reporting.  The 
chest radiograph was performed on 15/12/2022 (at 18:01, outside normal working hours) and 
was reported on the 10th day (sixth working day). The department attempts to report on ED 
imaging well before this time period, however during this period we were faced with high number 
of plain radiographs due to winter pressures. 

Since the time of the incident, we have increased our reporting radiologists and radiographers to 
near full capacity and are in the process of recruiting further reporters in order to reduce the 
turnaround time. At present, we insource our plain films to all reporters and outsource ones that 
may be reaching the expected time frame. 

Thank you for bringing your concerns to my attention. I trust that you are assured that I 
have taken them seriously and that the hospital has investigated them appropriately and 
is taking appropriate action.  Please let me know if you require clarity on any of the points 
above. 

Yours sincerely 

Chief Medical Officer 

Barts Health NHS Trust

From Maria Caulfield MP  
Parliamentary Under-Secretary of State for  
Mental Health and Women's Health Strategy 
Department of Health and Social Care  

39 Victoria Street  
London  
SW1H 0EU  

Mr Graeme Irvine  
Senior Coroner, for the Coroner Area of East London  
East London Coroner’s Court  
Queens Road 
Walthamstow 
London  
E17 8QP 

13 May 2024  

Dear Mr Irvine,  

Thank you for your Regulation 28 report to prevent future deaths dated 16/10/2023 about the 
death  of  Claire  Twinn.    I  am  replying  as  Minister  with  responsibility  for  Mental  Health  and 
Women’s Health Strategy.       

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Twinn and 
I offer my sincere condolences to their 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 to this 
matter.  

The report raises concerns over the provision of sub-optimal care due to Ms Twinn’s disability, 
incomplete  clinical  record  keeping  regarding  the  decision  to  discharge  Ms  Twinn,  lack  of 
specialised learning disability nurse input and radiology reporting timescales. In preparing this 
response, Departmental officials have made enquiries with NHS England and the Care Quality 
Commission.   

We are aware of the response from Barts Health NHS Trust  which sets out the actions and 
recommendations that the Trust have taken in response to the concerns you set out in your 
report.  This  includes  an  improved  standard  operating  procedure  (SOP)  for  patients  with 
learning  disabilities  in  the  Emergency  Department,  developed  in  conjunction  with  the  Lead 
Learning  Disabilities  Nurse  for  the Trust,  and  improved  discharge  arrangements. The Trust 
have  also  expanded  and  developed  their  staff  training  concerning  patients  with  learning 
disabilities, as well as taken steps to improve environment and access to equipment. The CQC 
have discussed with the Trust how they were going to audit and measure these improvements 
and  will  be  monitoring  their  progress  and  how  they  are  ensuring  learning  is  successfully 
embedded through ongoing engagement with the Trust.  

  
  
  
  
  
  
  
  
   
  
  
  
  
  
  
  
  
  
 Around 76% of acute NHS Trusts have some form of learning disability liaison provision which 
aims  to  support  people  with  a  learning  disability,  and  those  who  care  for  them,  to  access 
hospital services in a way that works for them. The majority of these are available Monday to 
Friday with reduced cover across weekend periods, but this often depends on the size of the 
trust. The input of the liaison team in this case may have been influenced by the time at which 
Ms  Twinn  was  admitted  to  hospital.  NHS  England  are  currently  developing  some  learning 
disability liaison nursing competency standards and workforce guidance for acute trusts.  

The Learning Disability Improvement Standards are intended to help organisations measure 
quality  of  service  and  ensure  consistency  across  the  NHS  in  how  we  approach  and  treat 
people  with  learning  disabilities,  autism  or  both.  In  2018  we  commissioned  the  NHS 
Benchmarking Network to gather baseline information from providers on their compliance with 
the  standards  and  the  views  of  staff  and  people  who  use  NHS  services.  Since  then,  the 
Benchmarking  Network  have  continued  to  undertake  annual  data  collections.  The  Fourth 
Learning Disability Improvement Standards annual report was published in November 2023 
NHSE &NHSI-LD Project documentation & Outputs — NHS Benchmarking Network.  

Every  person  with  a  learning  disability  and  autistic  person  has  the  right  to  safe  and 
compassionate care from wherever they choose to access it. The Government is taking action 
to ensure that people with a learning disability and autistic people are able to communicate 
effectively  and  receive  the  care  and  support  that  is  right  for  them,  to  prevent  instances  of 
suboptimal health care and support such as that experienced by Ms Twinn.  

Under the Equality Act 2010, public sector organisations are already required to make changes 
in their approach or provision to ensure that services are accessible to disabled people as well 
as to everybody else. To make it easier for people with a learning disability and autistic people 
to  use  health  services,  NHS  England  is  working  to  improve  the  use  and  recording  of 
reasonable adjustments to ensure care is tailored appropriately. This includes the development 
of a Reasonable Adjustment Digital Flag, which will enable the recording of key information 
about  a  patient,  including  if  a  person  has  a  learning  disability  and  /  or  is  autistic  and  their 
reasonable adjustment needs, to ensure support can be tailored appropriately across health 
and social care. NHS England published an Information Standards Notice in September 2023 
which mandated use of the Digital Flag by health organisations from April 2024.  

All organisations that provide NHS care or adult social care in England are also required to 
follow  the Accessible  Information  Standard  (AIS). The AIS  aims  to  ensure  that  people  who 
have an impairment or sensory loss are provided with information that they can easily read or 
understand and can communicate effectively with services. NHS England have completed a 
review of the AIS to help ensure that everyone’s communication needs are met in health and 
care provision. NHS England will publish the revised AIS in due course.  

Introducing  mandatory  training  is  an  important  way  in  which  we  can  address  persistent 
disparities in health and care outcomes for people with a learning disability and autistic people 
by ensuring that the health and care workforce have the right knowledge and skills, including 
appropriate communication. That is why, from 1 July 2022, CQC registered service providers 
are required to ensure their staff receive learning disability and autism training appropriate to 
their role, as set out in the Health and Care Act 2022.   

To support this new training requirement, we are rolling out the Oliver McGowan Mandatory 
Training on Learning Disability and Autism. This includes training on how a learning disability 
and autism can affect people, what reasonable adjustments are and how to make them. Part 
one of this training – an e-learning package – is freely available and has been completed by 
over 1.7 million people.   

In addition, NHS England’s ‘Learning from lives and deaths – People with a learning disability 
and  autistic  people’  programme  (LeDeR)  continues  to  build  up  a  detailed  picture  of  key 
improvements needed to ensure people with a learning disability and autistic people are better 
supported and to prevent future deaths from occurring. An online LeDeR Resource Bank has 
been set up which may be of use to health and care professionals supporting people with a 
learning disability or autistic people with their health or care. We recognise that people with 

 
 Down syndrome have unique needs and can have poorer health outcomes compared with the 
general population and other people with a learning disability. We also know that people with 
Down  syndrome  and  their  families  often  find  it  difficult  to  access  the  right  support.  The 
Government is committed to ensuring that people with Down syndrome receive the care and 
support they need, to improve their life outcomes and help them to live longer, healthier and 
happier lives in their communities. We were pleased to support the Down Syndrome Private 
Members Bill, which became law in April 2022.  

The Down Syndrome Act represents a significant opportunity to improve the life outcomes of 
people with Down syndrome, and to raise the understanding and awareness of the specific 
needs of people with Down syndrome. We are using the information received through a  

national  call  for  evidence,  and continued  engagement  with people with lived  experience,  to 
help us to develop guidance for relevant authorities on how they should meet the needs of 
people  with  Down  syndrome.  By  developing  guidance,  we  want  to  raise  awareness  of  the 
unique needs of people with Down syndrome and how they can be met. The guidance will set 
out the actions the relevant authorities should be taking to ensure the support needs of people 
with Down syndrome are met to enable them to live fulfilling lives. We expect to issue the draft 
Down Syndrome Act guidance for consultation as soon as possible this year, and the guidance 
will be published at the earliest opportunity following the public consultation.  

The Government is investing an additional £1 billion this year through the Discharge Fund, to 
support the NHS and local authorities to ensure timely and effective discharge from hospital.  
This  funding  follows  £600  million  last  year  and  £500 million  in  2022/23. The  NHS  and  local 
authorities are using this funding to help provide people with the right care in the right place 
when they are discharged from hospital.    

We have also ensured every acute hospital has access to a care transfer hub. These hubs 
bring together professionals from the NHS and social care to manage discharges for people 
with more complex needs who need extra support with a view to promoting early planning and 
timely discharge.   

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

Best wishes,  

MARIA CAULFIELD MP