Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0457, written 17 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2023 |
|---|---|
| Reference | 2023-0457 |
| Deceased | Raymond Eggleton |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive The Great Western Hospital Marlborough Road Swindon SN3 6BB Ms. Victoria Atkins MP Secretary of State for Health and Social Care Department of Health and Social Care 39 Victoria Street London SW1H 0EU CORONER I am David Ridley, Senior Coroner for Wiltshire and Swindon 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. http://www.legislation .gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation .gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On the 13th February 2023 I commenced an investigation into the death of Raymond Lionel Eggleton and I opened an Inquest into his death on the same date. On the 14th November 2023 I concluded Ray's Inquest. I found the medical cause of death was as follows: 1a. Aspiration Pneumonia 1 b. Dysphagia 1c. Hospital Acquired Delirium and Immobility due to Osteoporotic Right Fractured Neck of Femur (Operated 19/01/2023) and Acute On-Chronic Subdural Haemorrhage and Subarachnoid Haemorrhage following a Fall on Ward II. Falls due to Orthostatic Hypotension and Frailty of Old Age By way of a conclusion, I recorded not only the short form conclusion of Accident but also a Narrative Conclusion to explain when, where and how (by what means Ray came by his death). That Narrative Conclusion was as follows: - "Raymond died on the afternoon of 25 January 2023 at the Great Western Hospital in Swindon having developed an aspiration pneumonia attributable to swallowing issues (dysphagia), having developed hospital acquired delirium and immobility following a fall on the Linnet Acute Medical Unit during the early hours on 18 January 2023. As a result of the fall Raymond sustained an osteoporotic right fractured neck of femur (repaired 19 January 2023) and an acute on chronic subdural haemorrhage and subarachnoid haemorrhage. Raymond was admitted to hospital the day before with a history of recent falls attributable to orthostatic hypotension and was frail by virtue of his age. The falls risk assessment, prior to the fall on the ward, did not accurately take into account this history and as a consequence there was no assessment in respect of his additional care needs which more likely than not should have resulted in 1:1 care which Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPI IDP probably would have avoided the severity of the injury by managing the fall when he needed to urinate or avoided him having to get out of bed in the first place. 4 CIRCUMSTANCES OF THE DEATH Having considered the evidence, I found the following facts in relation to the circumstances of Ray's death. Ray arrived late evening on the 16th January 2023 at the Emergency Department of the Great Western Hospital in Swindon. He had a history of 3 falls in the previous few days which following an examination was considered to be attributable to a condition called postural hypotension. This condition results in a sudden drop of blood pressure when somebody stands up and can cause dizziness even temporary unconsciousness. The treating clinicians view, in respect of which I agreed, was that the postural hypotension and general frailty likely caused Ray's falls noted over the previous few days. Ray was admitted the following day onto the Linnett Acute Medical Unit (LAMU) and a CT scan undertaken revealed evidence of chronic subdural haematomas, indicative of previous head trauma more likely than not attributable to earlier falls, not necessarily those falls in the last few In keeping with the hospital's falls policy, following his arrival on LAMU, Charge Nurse days. , who was starting the night shift, carried out a falls risk assessment amongst other assessments . Relying on information that was passed to him verbally at the shift handover before 8 o'clock that evening, he was however only told and therefore recorded as part of that falls risk assessment that Ray had had 1 fall in the last 12 months. Whilst recognising that there was a risk of a fall the assessment did not trigger any of the higher levels of monitoring over and above 1 hourly care rounding such as ensuring that Ray was within line of sight or more importantly was within arm's reach of a care worker. Whilst the plan was for hourly care rounding I noted that no such checks were made on Ray from 20:50 on 17th January 2023 until just after midnight on 18th January 2023, although it was not material in my view to the events that followed but was indicative as regards the working pressures faced by nursing staff on that shift. At 00:45 on 18th January 2023, Nurse was called by another patient in the same bay as Ray and saw him stood next to his bed passing urine into a bottle. She recalls the night light was on and she could see him clearly. She observed him suddenly falling to the right not putting his hands out to break his fall and he fell hitting his head on the chair leg as he collapsed to the floor. Due to the postural hypotension Ray was being given IV fluids and this equipment was connected to his arm. I was not of the view that the equipment contributed to the fall and found as a fact that the fall more likely than not was attributable to Ray's postural hypotension . As a consequence of the fall, Ray was found to have suffered head trauma and in addition had fractured his right neck of femur in respect of which it was noted more likely than not it was an osteoporotic fracture. The fracture was repaired the following day on the 19th January 2023, however, Ray as a result of immobility and trauma sustained deteriorated and he began to develop swallowing issues. He also became generally more confused and ultimately, he developed an aspiration pneumonia from which sadly he died in The Great Western Hospital on the 25th January 2023. During the Inquest hearing I heard live evidence from Charge Nurse who came across as a conscientious and caring Nurse. That having been said I did ask probing questions as regards the discrepancy between Ray's pre-admission history and of Charge Nurse what was actually recorded as part of the falls risk assessment. By way of background, I was told that LAMU consisted of a ward with 36 beds. Back in January 2023 those beds were occupied by elderly patients. I was told following the arrival of a new Chief Nurse there had been improvements in relation to staffing levels and at the time of Ray's fall Charge Nurse told me that there was 1 Senior Nursing Sister in charge, 5 Registered Nurses of which he was one, 4 Health Care Assistants and 2 enhanced Care Workers. There were no shortages in terms of their allotted numbers. Charge Nurse was assigned 8 patients of which Ray was one of those patients and they were split between 2 bays on the ward . As previously stated, Ray's bed was not in direct eyesight of the nursing station . When asked why Charge Nurse did not check the medical records where there were at least 4 entries referrinq to a number of previous Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPI IDP indicated that he relied on the verbal falls and postural hypotension, Charge Nurse handover and that due to the volume of work he did not check either the electronic or paper Initially when I challenged Charge Nurse records when completing the falls risk assessment. as to whether or not Ray would have been a candidate for 1:1 supervision/arm's length supervision the response was that Ray would have had to have had a fall on ward before that I rejected that argument as of course in this particular instance it would have been considered. would have made no difference here and sometimes it only takes a single fall to be causative in relation to an individual's death. My view and my finding was that the previous falls history and the presence of postural hypotension made Ray a prime candidate for arm's length supervision and had that been in place then more likely than not his injuries as a result of the fall would have been avoided and given that his intention at the time was to pass urine, the need for him to get out of bed at all more likely than not could have been avoided. I asked all the witnesses who gave live evidence in relation to the challenges as regards getting 1:1 supervision and I noted in particular that the answers were consistent that it was very difficult to secure 1:1 supervision during a night shift. There was no pool of people available. I also noted the comments from a senior member of the nursing team, as regards the dynamic changes that can affect LAMU over a very short period of time in terms of the acuity of patients on the ward . LAMU is an assessment ward and therefore its patients are ultimately either transferred to another ward or other hospital or discharged into the community such that the patient constitution on the ward can change quite dramatically during a shift. From being Senior Coroner for a number of years now I am acutely aware that in dealing with elderly patients it not only presents challenges in relation to addressing physical needs but often the elderly have additional mental health issues that only add to the level of the challenge to care for them. By that I mean conditions such as dementia, depression and Alzheimer's and as a consequence I was told whilst on paper the ward may appear to be adequately staffed, the reality is that does not necessarily translate, as I was of the view here, as was the case on the evening of the 17th and the morning of the 18th of January 2023, that there were not enough staff to meet the needs of the patients all of whom were vulnerable and to ensure that they were appropriately safeguarded . The inability to carry out hourly intentional rounding in relation to was clear evidence to me of the Ray combined with the evidence from Charge Nurse extreme pressure that the nursing team faced in managing the needs of 36 patients on that shift. 5 CORONER'S CONCERNS Falls in the hospital environment do happen and I am not saying that all can be avoided. That having been said what I have noted of late when dealing with these cases is an increase in the instances where as a result of my investigation, in relation to cases that I have been directly involved in, that I am making findings that more likely than not the falls could have been prevented and the injuries that were causative in relation to that individuals death, avoided. Ray was a 96 year old gentleman who would have died had it not been for the fall at some point in the future . That may have been in a matter of weeks, months or even a few years but had it not been for the fall on the night of the 17118th January 2023 he would not have died as he did, in the circumstances that he did, on the 25th January 2023. During the course of the Inquest, I also heard evidence from Sister Jones and in addition to the challenge of getting the staffing levels commensurate to the patients needs and safeguarding patients there does appear to be an issue that causes me a concern as regards the ability to dynamically respond to a need for enhanced supervision especially entering into night shifts . Sister Jones when questioned was open and extremely candid in her answer that at those times nursing staff could not always support those additional needs in the short term because of the challenge to get additional personnel at short notice in circumstances where the nursing team were under pressure due to the complexities and demands of patient's needs. There is in my view no flexibility and resilience within the system to dynamically adapt and respond to changing patients enhanced needs exacerbated by the fact that especially during the winter months these It is easier during day shifts to respond but there beds are mainly occupied by the elderly. clearly appears to be an issue especially going into night shifts. There were 2 issues here, firstly the initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray's supervision needs . His fall was observed by another member of the Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl l DP nursing staff and therefore my view was that only arm's length supervision would have avoided the fall and that there were sufficient indicators to warrant this prior to the event occurring. The failure here in relation to the initial assessment was down to the volume of work and not in my view laziness or anything of that nature on the part of nursing staff. Flowing from the first issue a further issue relates to the resilience and the ability to respond dynamically with changing patients on the ward so as to ensure that vulnerable patients with a high degree of risk of falling, like Ray, are properly safeguarded. in her evidence talked about an ongoing programme, the Enhanced Care Toolkit Framework, which I acknowledge is work in progress, in respect of which not only the family but also I am interested in hearing what steps the Trust intends to take to mitigate against a risk of further incidents occurring such as the fall that Ray had on the night of 17th/18th of January. This report is also being sent to The Secretary of State for the Department of Health and Social Care and the reason I have sent this to The Secretary of State is to highlight the issue and my concerns. Often when Regulation 28 Reports are submitted responses often come back from Government Departments as regards the increase in the amount of money that they are injecting into that particular public service. Coroners cannot make recommendations but as we advance in time into yet another winter period, which will undoubtedly be challenging for frontline NHS personnel, combined with an ever-increasing elderly population whose care needs both physical and mental are more complicated and demanding, it is essential that when these vulnerable I cannot see this people come into the care of the state, that they are effectively safeguarded. winter being much different from last winter and at the moment and my concern is that potentially it could be worse. Whilst the focus of this report relates to a hospital environment, the challenges created by an increasing elderly population in terms of NHS and social care response affects those in the community as well. I do not believe that there is an easy fix for these issues when resources and budgets are stretched. The problem here undoubtedly is multi factorial but any solution here is one in respect of which the Government undoubtedly has a crucial role to play, and I hope The Secretary of State understands why she is a recipient to this Regulation 28 Report. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 12th January 2024. 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 Person, Family of Mr Eggleton, Chief Executive at Salisbury District Hospital, Care Quality Commission I am also under a duty to send the Chief Coroner a copy of your response . 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 time of your response, about the release or the publication of your response by the Chief Coroner. 9 . Dated 17th November 2023 Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP
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 the Rt Hon Andrew Stephenson CBE MP Minister of State for Health and Secondary Care 39 Victoria Street London SW1H 0EU HM Coroner David Ridley Wiltshire and Swindon Coroner’s Office 26 Endless Street Salisbury Wiltshire SP1 1DP 9 May 2024 Dear Mr Ridley, Thank you for the Regulation 28 report to prevent future deaths of 17 November 2023 about the death of Raymond Eggleton. I am replying as Minister with responsibility for health and secondary care, and the NHS workforce. Firstly, I would like to say how saddened I was to read of the circumstances of Raymond Eggleton’s death, 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 delay in responding to this matter. The report raises concerns over the lack of resilience in the system to adapt dynamically to changing patient needs due to the challenges in getting commensurate staffing levels to safeguard patients, particularly where there are short notice changes in patient circumstances. It also raises concerns about the initial falls risk assessments which did not take advantage of all the available information which led to an incorrect assessment of Mr Eggleton’s supervision needs. Safe staffing Responsibility for staffing levels remains with clinical and other leaders at a local level, responding to local needs, supported by evidence-based guidelines by national and professional bodies and overseen and regulated in England by the CQC. Reaching the right staff numbers and mix should depend on an evidence-based approach and the exercise of real-time, risk-assessed, professional judgements by day-to-day leadership and a multi- professional approach. The CQC checks for compliance with regulations1 that require regulated providers to ensure there are enough suitably qualified, competent, skilled and experienced people, who are supported, to provide safe care and treatment to patients. Where staffing is having an impact 1 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 18 on patient outcomes, whether due to a lack of staff or an incorrect mix, the CQC can take enforcement action. It means that regulated providers should have a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service and keep them safe at all times, in accordance with the legislation and reflecting guidance where it is available. NHS Workforce The NHS Long Term Workforce Plan (LTWP), published by NHS England in June 2023 sets out the steps the NHS and its partners need to take to deliver an NHS workforce that meets the changing needs of the population over the next 15 years. The plan outlines the action needed to ensure we train and retain more staff, and reform medical education and training to put the NHS workforce on a sustainable footing for the future. By significantly expanding domestic education, training and recruitment, we will have more healthcare professionals working in the NHS. This will include more nurses and doctors alongside an expansion in a range of other professions, including more staff working in new roles. The LTWP sets out the aim to increase adult nursing training places by 92%, taking the number of total places up to nearly 38,000 by 2031/32. To support this ambition, we will increase training places to nearly 28,000 in 2028/29. This forms part of our ambition to increase the number of nursing and midwifery training places to around 58,000 by 2031/32. We will work towards achieving this by increasing places to over 44,000 by 2028/29, with 20% of registered nurses qualifying through apprenticeship routes compared to just 9% now. Managing the risk of falls in hospitals You have raised concerns about managing the risk of falls and sustaining injuries in hospitals. Falls are common and occur in 30% of adults aged over 65 years annually. The ageing of the population has meant that the incidence of traumatic injury in older people is rising in both absolute numbers and as a percentage of national trauma admissions annually. Trauma services for older people, and especially older people living with frailty, are organised depending on the structure of local services. There are 22 Adult Major Trauma Centres in England predominantly in Teaching Hospitals. District General Hospitals have Trauma Units most commonly in a surgical ward of the hospital. Care for each patient should be bespoke, dependent on nature and severity of injury and co-morbidities including frailty. NHS England advise that the risk of falls is an ongoing priority for providers and continues to be an active area of developing research and evidence. The current NICE guidelines Falls in older people: assessing risk and prevention. Clinical guideline [CG161] describes evidenced based practice. This guideline is currently being updated and due to be published in March 2025. The Royal College of Physicians also provides evidenced based guidance on preventing falls and serious injury in Falls in hospital. Further, the British Geriatrics Society was included in the international membership that has developed guidelines on falls prevention and management: World guidelines for falls prevention and management for older adults: a global initiative. The report contains a section specifically on falls in hospital. I know that Great Western Hospitals NHS Foundation Trust have already responded to your report setting out what they are doing to improve recruitment and retention of nursing staff, a review of enhanced supervision procedures, falls improvement work and additional training on the falls risk assessment. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE FOR HEALTH AND SECONDARY CARE
Private and confidential David Ridley, Esq His Majesty’s Area Coroner for Wiltshire Marlborough Road Swindon SN3 6BB 10 January 2024 Dear Mr Ridley Re: Coroner’s Regulation 28 Report Thank you for your letter dated 17th November 2023 in regard to the Regulation 28 Prevention of Future Death Report, raising concerns about the circumstances which led to the death of the late Mr Ray Eggleton. I was very sorry that the fall Mr Eggleton suffered in hospital contributed to his death and would like to again pass on our sincere condolences to his family and reassure you that we have taken the learning from this incident very seriously. This letter is to respond to the concerns raised in the Regulation 28 and the actions the Trust is undertaking to address them in regard to safe staffing and enhanced care/ supervision. Safe Staffing for Nursing Staff The Trust has significantly invested in safe staffing levels over the last 2 years, this has ensured that all acute ward areas are now working to a 1:8 nurse to patient ratio for health care support workers and registered nursing staff. This is in line with national guidance. Year 1 (2021/2) there was investment in health care support workers and Year 2 (2022/3) there has been investment in the registered nurse staffing. This investment has come to a total of £7.1 million. Alongside this there has been robust work on recruitment and retention, the Trust has moved from over 70wte Health Care Support Worker vacancies in January 2022 to zero vacancies in December 2023. There will continue to be fluctuation and change in specific areas and so continues to remain an area of focus and attention. The Trust has robust safe staffing processes which are in line with national guidance and evidence based. This includes a 6 monthly safe staffing report to Trust Board which includes details of the Chief Nurses yearly establishment reviews with the ward managers. Nurse to patient ratios, benchmarking data, patient acuity, quality metrics and enhanced care data are reviewed as part of the Chief Nurse yearly establishment reviews. 1 The Trust’s daily safe staffing process includes a three times a day safe staffing meeting, chaired by a divisional director of nursing, where any staffing concerns are highlighted and staff moved accordingly to support patient care. There is also improved senior nurse support out of hours, with a duty Matron working till 20:00 pm and at weekends from 08:00 – 16:00 pm. This role supports the dynamic response required to adjust staffing levels or redeploy staff to accommodate the needs of patients that are at risk of falling or requiring enhanced supervision. Overnight there is a senior nurse ‘site manager’ who will support staffing and patient safety. The Trust uses the national Safe Care Acuity and Dependency Tool in the three times a day safer staffing meetings. This is a tool that measures the acuity and dependency of patients on a ward and then applies a multiplier to calculate how many staff are required to care for that patient care mix. This, along with professional judgement, can help inform decisions on the best deployment of nursing staff across the Trust. If wards identify patient with additional needs, the patients are assessed using the enhanced care assessment and then staff are either moved from another area based on the Safe Care Acuity / dependency data or by requesting through the nurse bank or agency. There will be a further review of the Acute Medical Assessment Unit staffing using the national Safer Nursing Care Tool and the results will be used to inform future staffing models. I hope this reassures you that the actions the Trust is taking in regard to safer staffing and how areas are supported to respond to differing patient needs. Enhanced supervision Enhanced care or enhanced supervision is when a patient has additional care needs that require support to keep them safe. Patients requiring enhanced care will often have some degree of cognitive impairment such as dementia or delirium or are at high risk of falls. The Trust has had an enhanced care policy in place for several years. The Deputy Divisional Directors of Nursing are working with the Falls Team and undertaking a review of the current policy, paperwork and teaching. This work has an emphasis on the correct assessment and clear definitions of levels of supervision e.g. line of sight and within arm’s reach. This is supported by a ‘Stay in the bay’ approach when health care support workers are providing enhanced care. This mandates that before the designated staff leaves, this duty has to be handed over to another member of staff. This new approach is currently being trialled on 3 wards that frequently care for higher-than-average numbers of patients requiring enhanced care. During the enhanced care trial, the Falls Lead is reviewing daily to ensure that the enhanced care assessments reflect the patient care needs appropriately and then address any gaps in care and education. Once this trial has been completed a plan for roll out and engagement with all wards will be implemented and informed by the learning outputs from the trial. The Trust is also updating the ‘care rounding’ document and process and aiming to roll out the improvements once the trial is completed successfully. Care rounding is the proactive approach to meeting care needs such as toileting and prompting over hydration particularly in those patients who have a degree of cognitive impairment whose awareness of their own needs might be impaired. 2 Falls improvement work The falls team review all inpatient falls to identify areas for learning and improvement as well as delivering an ongoing education programme. Some of this learning has identified that the point of transfer from one clinical area to another is a time of increased risk of falling. To address this the Trust is working hard to reduce the number of patients that move out of hours as well as highlighting this risk to increase staffs’ awareness and ensure that falls prevention strategies are put in place immediately on transfer. The other area of focus is to improve the handover process on the patient’s risk of falling and a new handover tool is being developed which will highlight the falls risk in more detail. There is also Trust wide improvement work on identifying and managing postural hypotension as a significant contributor to falls risk. A Clinical Fellow (non- trainee doctor with a proportion of employment set aside for research/Quality Improvement) will be working alongside the Falls Team to develop strategies to improve identification and response to this promoter of falls. This has also been shared in a safety brief that was shared Trust wide for learning. Falls Risk assessment The Falls team will be providing additional training in the Acute Medical Unit on Multifactorial falls assessment, this training will include the essential components and sources of information required to support a personalised assessment, identifying key risks and level of supervision. To support this work the Trust has recently recruited a number of Clinical Practice Educators to support the wards and assessment units, part of their remit is to support training around enhanced care supported by the Falls team. The first round of training is planned for March 2024. Falls investigation The circumstances of Mr Eggleton’s fall was investigated immediately at the time and a 72-hour investigation report was completed on the 27 January 2023. The falls report was reviewed at the Divisional Falls round table as an MDT approach on the 01/03/23 led by the Deputy Medical Director to ensure a robust investigation and identify any learning outcomes. Other contributors were the Ward Manager and Matron for the area, the Falls team, Radiology and the Governance team. The report was signed off by the Division on 20 March 2023 and presented at the Trust’s Incident Review meeting (IRM) on 27 March 2023. There was a delay reporting this as a Serious Incident and it was uploaded on STEIS (Strategic Executive Information System). The investigation outcome was presented to Serious Incident review meeting on 12 December 2023. The Trust is reviewing how falls with harm are investigated and reported to ensure there is no delays going forward. Falling and the harm from falling is one of the quality indictors the Trust monitors closely and is reported through the Integrated Performance Report to Trust Board. Falls and the falls prevention actions are part of the regular nursing audit programme and this helps ensure the effectiveness of actions are monitored. The overall trend of falls is reducing however there has been a theme of falls with harm or patients having multiple falls. Therefore it has been agreed that falls is one of the top 5 quality improvement 3 priorities under the Patient Safety Incident Response Framework and will therefore continue to have focus and support for improvement. Conclusion I hope this letter reassures you that we are taking the learning from this sad case very seriously and will ensure that we continue to develop our approach to enhanced care to support patients that require additional support. Finally, I would like to reiterate my sincerest condolences to Mr Eggleton’s family and apologise for the distress this process may have caused. Yours sincerely Acting Chief Executive CC: CQC 4
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