Nadia Wyatt

11 March 2024 

Private and Confidential 
Ms Rebecca Mundy   
Assistant Coroner for Essex 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Ms Mundy, 

Ms Nadia Wyatt (RIP)    

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

Tel: 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5,  of  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013, dated 15th January 2024 in respect of the above, which 
was issued following the inquest into the death of Ms Wyatt . 

I would like to begin by extending my deepest condolences to Ms Wyatt’s family. The Trust 
sympathises with their sad loss.  

The  matters  of  concern  as  noted  within  the  Regulation  28  Report  have  been  carefully 
reviewed and noted.  I will now respond in full to these concerns in the hope that this provides 
both  yourself  and  Ms  Wyatt’s  family  with  comprehensive  assurance  of  changes  that  have 
been made at the Trust to address the concerns you have raised, which I will address in turn: 

Concern 1: 
Failure to  update  Nadia’s  records with  the  outcomes  of referrals that were made  and 
whether such referrals were accepted or declined, either for Nadia or her carer. 

Response:  
The Trust has revised line management supervision forms to include quality of record keeping, 
their professional responsibilities, Trust policy and values, and NMC accountability frameworks 
in respect of record keeping.  In addition to discussions during supervision the Crisis Response 
and Home Treatment Service has been reminded of this in their team meetings. 

Bespoke training on the importance of documentation is being arranged for all staff working in 
the urgent care pathway in April 2024. 

In  order  to  ensure  the  assessments  undertaken  by  the  Home  Treatment  Team  are 
comprehensive  and  the findings (including the rationale for  the  decisions  made)  are  clearly 
documented, regular audits on Home Treatment Team assessments will be undertaken and 
the findings shared with the team to continuously improve practice.  

Concern 2:  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 Failure to include within her records considerations and professional opinions reached 
on the prospect, or not, of readmission for in-patient treatment together with the final 
decision and rationale. 

Response:  
As noted in response to Concern 1 bespoke training on the importance of documentation is 
being arranged for all staff working in the urgent care pathway in April 2024. 

The Home Treatment Team complete gate keeping assessments which provide professional 
opinions and rationale, including the ‘purpose of admission’, or a home treatment care plan as 
an  alternative  to  admission.    All  admission  requests  have  oversight  from  the  Purposeful 
Admission Clinical Lead. 

The  Trust  is  currently  commissioning  a  unified  Electronic  Patient  Records  System.    This 
system  will  permit  access  to  all  of the  required  clinical  systems  and  will  also  embed  a  new 
mechanism to ensure robust clinical information sharing.  

Concern 3:  
Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia 
had  begun  to  disengage  and  declined  to  be  involved  in  her  care  planning,  more 
personalised  plans  could  have  been  drafted  taking  into  account  her  personal 
characteristics, needs and past medical history. 

Response:  
The Trust’s Urgent Care and Inpatient Care Unit is implementing a new initiative ‘International 
Fundamentals of Care Framework’, which is a nursing framework that supports transition and 
care  planning  based  on  trusting  therapeutic  relationship,  integration  of  care  and  context  of 
care.  The Home Treatment Team in Mid and South have added the framework principles to 
the Newman’s form that is given to patients to develop and assist with their view and planning 
of their care and treatment needs. The Newman’s form is based on the Newman’s model of 
care, which encourages individuals to be involved and interact with their health needs.   

This  initiative  also  provides  for  in-put  from  family  members  where  consent  is  given  and  is 
appropriate. 

The Admission Checklist in place will also support staff to plan care, escalate required support 
and referrals in a timely way, and reduces risk levels in respect of avoidance of actions being 
missed. 

Concern 4: 
Evidence  of  “cutting  and  pasting”  into  Nadia’s  care  plan  from  another  patient’s  care 
plan. 

Response:  
In order to ensure that clinical notes are individualised, and copy and pasting is not part of the 
team culture, regular audits on Home Treatment Team record keeping will be undertaken and 
the  findings  shared  with  the  team  to  continuously  improve  practice.   The  Home  Treatment 
weekly multi-disciplinary meeting where patients care is reviewed, also provides opportunity 
for notes to be reviewed and any action required to be taken forward. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 5: 
Failing  to  undertake  risk  assessments  at  all  relevant  and  appropriate  stages  and/or 
failure to record that such an assessment had in fact taken place and what the outcome 
was. 

Response: 
Assessments  and  clinical  notes  are  reviewed  with  individuals  during  their  one  to  one 
supervision to focus on the quality of their record keeping including risk assessment.  Storm 
training has commenced with Teams to enhance risk assessment skills.   

Concern 6: 
Failing to provide a “RAG” rating to risk assessments and/or to indicate where required 
that a risk exists. 

Response:  
The Teams discuss all patients including their ‘RAG’ rating during their daily multi-disciplinary 
meeting case reviews and safety huddles to ensure accuracy of records.  

The Trust also randomly audits patients’ records on a monthly basis to identify any concerns 
with RAG rating of risk assessments in order for actions to be taken where discrepancies are 
found. 

Concern 7: 
Failure to include risk management and contingency planning within Nadia’s care plans 
as  well  as  key  elements  of  her  condition  at  that  time,  including  her  recent  inpatient 
admission. 

Response:  
Assessments  and  clinical  notes  are  reviewed  with  individuals  during  their  one  to  one 
supervision  to  focus  on  the  quality  of  their  record  keeping  including  risk  management  and 
contingency planning. 

The Teams discuss all patients during their daily multi-disciplinary meeting case reviews and 
safety  huddles  to  ensure  accuracy  of  records  including  good  team  risk  management  and 
contingency planning in adherence to Trust policy.  

Concern 8: 
The  potential  for  over-reliance  on  Nadia’s  husband,  albeit  he  was  only  too  willing  to 
support  her  and  care  for  her,  and  the  need  to  balance  maintaining  Nadia’s  care  and 
treatment in the community with the need to support her carer as well. 

Response:  

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 All  staff  have  been  reminded  via  Team  meetings  to  ensure  case  discussion  in  the  multi-
disciplinary  team  meetings  document  carer’s  views  and  carer’s  needs.  The  Team  Carer’s 
Leads have been reminded to offer referrals for carers support, and refer on where consent 
given by carer and the importance of documenting carer’s views clearly. 

I hope that I have provided reassurances around the steps that we have taken to address the 
issues of concern contained within your report.  We know there is an acute need to embed 
and  effect  change,  hence  we  will  monitor  the  above  provisions  to  ensure  these  are 
contributing to our overall aim of keeping patents safe and delivering therapeutic care. 

Please do let me know if you require any further information at this stage, including copies of 
any of the documents referred to above.  We will await your direction before sharing a copy 
of this reply with the family.  

Yours sincerely, 

Chief Executive