Philip Taylor

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, 
Llanelwy, LL17 0JG 

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Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Dyddiad / Date: 20 March 2024 

Kate Robertson 
HM Assistant Coroner 
North Wales (East and Central) 
Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin LL15 1YN 

Dear Ms Robertson, 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Philip David Taylor 

I  write  in  response  to  the  Regulation  28  Report  to  Prevent  Future  Deaths  dated  02 
February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following 
the inquest into the death of Phillip David Taylor.  

I would like to begin by offering my deepest condolences to the family and friends of Mr 
Taylor, and to apologise to them for the failures that were  identified during the inquest 
that led to your notice. 

In the notice, you highlighted your concerns about the management of patients placed 
Out of Area by the Health Board for acute care when there are no available beds within 
North Wales. You specifically noted a lack of sharing of information, joined up planning 
meetings,  the  timely  sharing  of  key  documentation  and  lack  of  a  standard  operating 
procedure  defining  the  standard  requirements  and  expectations  between  the  Health 
Board and independent providers. 

The Health Board recognises that the use of out of area acute beds is a necessity in the 
current climate and is a nationally recognised issue for all NHS providers. However, the 
Health Board is committed to ensuring that the safety and experience of those patients 
is not compromised. 

In  response  to  the  Notice,  I  requested  our  Mental  Health  and  Learning  Disabilities 
Division (MHLD) to consider your concerns and provide details of their plans to make our 
services as safe as possible, taking into account the learning from the inquest. 

After  the  inquest  a  memorandum/alert  was  shared  with  MHLD  staff  as  an  immediate 
“make safe” notice. This memorandum reinforced the requirements for the monitoring of 
out of area patients and key responsibilities for roles and wider teams. This memorandum 
was presented in each area of mental health through the established daily safety huddles, 
ensuring  all  staff  understood  the  context  of  the  communication,  responsibilities  and 
action. This was disseminated on 08 February 2024 and I can confirm that mental health 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office 
Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

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 services in East, Centre and West are directly overseeing acute out of area patients within 
their services. 

All areas have stood up a formal weekly out of area monitoring meeting. The purpose of 
this meeting is to promote timely repatriation where possible, assurance that key clinical 
activity and  standards are being met and  that  discharge  plans  are being implemented 
and actioned. These meetings are underpinned by terms of reference, agenda, minutes 
and a log of actions to be completed. Membership includes the multidisciplinary team, 
including  Health  and  Social  Care,  Consultant  and  Medical  staffing,  Occupational 
Therapy, Home Treatment Team and Care Coordinators. Outcomes from the meetings 
are provided to Divisional Putting Things Right meetings and the weekly Divisional Senior 
Leadership meeting to ensure appropriate escalation arrangements can be put in place 
where required. 

The  learning  from  the  inquest  of  Mr  Taylor  has  identified  that  a  standard  operating 
procedure is required (SoP) and  must include the requirements for sharing information, 
joined up planning for repatriation and/or discharge and standards for the development 
and sharing of key documentation. 

A multi-disciplinary task and finish group has been established, chaired by the Head of 
Integrated strategy and development, who is leading on the development of the SoP in 
collaboration with both operational and clinical teams. Progress will be overseen by the 
MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will 
oversee the launch and implementation of the SoP and compliance with the SoP will be 
monitored through established local and divisional Putting Things Right Meetings. I am 
advised that the SoP will be fully ratified by the end of August 2024. 

For out of area acute placements, the health board uses providers’ identifed as part of 
the  All  Wales  Commissioning  Care  Assurance  and  Performance 
framework, 
commissioned by the National Collaborative Commissioning Unit. These providers have 
qualified to be on the framework by undergoing a robust due diligence process including 
provision of evidence to demonstrate they are meeting required quality standards with 
regard to patient safety, quality and experience. The Health board currently uses 3 of the 
identified providers, including Elysium. 

Implementation of the fully ratified SoP, will provide clear direction for health board staff 
and  providers  on  the  framework  and  will  ensure  a  coordinated  approach  to  the 
management of out of area placement and optimise communication between all parties. 

I share your disappointment that the action plan presented at the inquest of Mr Taylor did 
not identify the need for stronger governance in relation to the management of acute out 
of area patients and I would like to advise you that the Health Board is currently reviewing 
completed proportionate reviews and action plans to identify and address issues such as 
this. We expect this review to be fully completed towards the latter end of summer 2024. 

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 I hope this letter sets out for you the actions we have taken to ensure the concerns raised 
by yourself are being addressed. 

We would  be  happy  to  meet  with  you further  and  discuss  our  plans  in more  detail,  or 
provide further information and assurance should that be helpful. 

Once again, I offer my deepest condolences to the family and friends of Mr Taylor for 
their  loss  and  I  reiterate  my  sincere  apologies  to  them  for  the  concerns  identified  at 
inquest. 

Yours sincerely 

Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro 
Executive Medical Director / Acting Deputy Chief Executive 

cc 

, Divisional Director for Mental Health and Learning Disabilities 

, Deputy Director of Quality 

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Elysium Healthcare Limited 
2 Imperial Place 
Maxwell Road 
Borehamwood 
WD6 1JN 

25 March 2024 

Ms R Robertson  
Assistant Coroner for North Wales (East and Central) 
HM Coroners Office 
County Hall 
Wynnstay Road 
Ruthin  
Wales 
LL15 1YN 

Dear Madam 

Report for the Prevention of Future Deaths (PFD)  
Inquest of Philip David Taylor  

I refer to the letter from Mr Gittins, HM Senior Coroner for North Wales (East and Central) 
enclosing your Regulation 28 report dated 2 February 2024.   

This letter comprises the response on behalf of Elysium Healthcare Limited, which operates 
Ty Grosvenor Hospital, Wrexham where Mr Taylor was an informal patient (that is, he was 
not detained under the Mental Health Act (MHA) (and his status is of particular relevance 
here)).   

Elysium takes inquests very seriously. These are managed by our in-house legal team (with 
assistance  from  external  solicitors  where  appropriate)  to  ensure  courts  have  all  the 
documentation and evidence requested, and families therefore have the closure of an inquest 
that is as full and effective as possible. Further, we support our staff attending as witnesses 
and  send  legal  representation  whenever  this  is  required.  Unfortunately,  I  regret,  for  the 
reasons set out below, that something seems to have gone wrong in this particular instance 
as the inference behind and basis upon which the report has been issued does not properly 
reflect the factual position. For some reason, none of our staff were called to attend the  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 inquest,  or  asked  in  advance  about  these  matters,  and  thus  we  were  not  given  the 
opportunity to address the issues to which the PFD report refers.     

I am sorry that it has thus appeared necessary to address a report to Elysium but I will deal 
with the matters of concern that you have raised as follows: 

Not sharing information except a few telephone calls 
That is not a fair reflection of the factual position.  The reality is:- 

1.  There were three ward rounds during Mr Taylor’s stay at the hospital on 31 July, 7 August and 
14 August 2023.  Betsi Cadwaladr University Health Board (“Betsi”) were invited to all of them 
(via a Teams invitation) but did not attend any.   

Under  the  terms  of  the  NHS  Wales  Framework  Agreement  (see  further  below),  to  which 
Elysium is a party, Elysium enters ward round details through the informatics system in use by 
NHS  Wales  (the  Commissioning  Care  Assurance  and  Performance  System  or  “CCAPS”)  live 
during  a  ward  round  but  Betsi  do  not  avail  themselves  of  this  facility  (unlike  other  Welsh 
Commissioners) because  they do not  enter their patients  into that electronic system.  NHS 
Wales are frustrated by this and have apparently provided training to Betsi but, as they failed 
to register Mr Taylor, their lack of use of the system meant they did not have that ward round 
information live.  

2.  The third ward round took place on 14 August.  Mr Taylor wished to leave.  He was an informal 
patient.  He did not meet the criteria for detention under the MHA.  Nor did he lack capacity 
so  a  deprivation  of  liberty  under  the  Mental  Capacity  Act  was  not  available.  He  had  to  be 
discharged as there was accordingly no  lawful basis to refuse this.  It was agreed that to enable 
this to take place in an orderly fashion he would leave the next day.  Elysium had no alternative 
but to proceed with this. 

3.  On  15  August,  before  Mr  Taylor  left  the  hospital,  Elysium’s  charge  nurse  at  Ty  Grosvenor 
phoned the Betsi home treatment team (HTT) to inform them of the discharge. They said they 
would not be seeing Mr Taylor until the following day, so on the next day the hospital followed 
up by emailing to the HTT the requisite risk matrix and care notes.  These documents would 
serve to provide a full brief to the HTT. No request for additional information was forthcoming 
from the HTT. 

4.  On 17 August Elysium received a telephone call from Betsi who stated they were assessing Mr 
Taylor at 11 o’clock that day (not the previous day as they had previously assured Elysium they 
would be doing).  The documents referred to above had not been received so these were  re-
sent immediately.   

5.  This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of 
future deaths in relation to the role of Elysium.  Mr Taylor was an informal patient and was 
assessed as low risk.  His details were already well known to Betsi who had summarised his 
position when referring him to Elysium in the first place.  They had been informed by  

 
 
 
 
 
 
 
 
 
 
 
 
 telephone of the discharge and provided with the information set out above before their post-
discharge visit.  There was ample time for an assessment and any intervention to take place 
based on the information circulated prior to the date of Mr Taylor’s sad death on 23 August.   

There was no joint discharge meeting.   

That is factually correct but the context is important because:- 

i. 

ii. 

Betsi  did  not  attend  the  multi-disciplinary  team  (MDT)  meetings  to  which  they  were 
invited 
Betsi did not have the live ward round information because of their failure to register the 
patient through CCAPS 

iv. 

iii.  Mr Taylor was a voluntary patient who wanted to leave. There was no legal basis to detain 
him, and therefore no basis to delay that discharge to seek to arrange a joint discharge 
meeting 
This is not a case where the facts indicate that the lack of a discharge meeting gives rise 
to a risk of future deaths because relevant information was passed on to Betsi, Mr Taylor 
was assessed as a low risk informal patient who had the right to leave anyway, and the 
Betsi  HTT  had  ample  time  to  intervene  (if  indeed  that  was  necessary,  foreseeable  or 
reasonable) prior to his death.   

The  prescription,  pre-admission  and  admission  paperwork  was  only  sent  to  Betsi 
after the death  
and 
The discharge letter was only sent after the death 
This is also factually correct.  However, as is apparent from what is set out above, Mr 
Taylor was a voluntary patient who wished to leave.  There was no legal basis to detain 
him and his departure therefore took place quickly.  There was no legal framework to 
insist to the contrary.  Information was sent to Betsi by email and telephone as set out 
above.   
The discharge letter was not sent at the point of discharge as this is almost always not 
possible except with a long-planned discharge or transfer.  Discharge letters have to 
be  prepared,  typed  and checked  carefully  before  they  can  be  sent  and  that  almost 
invariably  takes  at  least  48-72  hours.    The  Elysium  internal  policy  is  to  ensure  the 
relevant information is given to home teams so that they can follow up within 72 hours 
(as was done here). In case it is of assistance to put the issue in context, the contract 
we have with Surrey requires that information only within 5 days of discharge. 

It was Mr Taylor’s wife who informed the HTT of discharge. 
This is factually incorrect.  As is apparent from the information above, the HTT were 
informed  of  the  discharge  by  telephone  on  15  August  before  Mr  Taylor  left  the 
hospital.   

 
 
 
 
 
 
 
 
 
 
 
 In  addition,  it  should  be  noted  that  Mr  Taylor  was  discharged  with  two  weeks  of 
medication to take out.   
There  is  no  standard  operating  procedure  or  agreement  regarding  sharing 
information.   
This is incorrect.  Following a formal procurement exercise, a framework agreement 
of  138  pages  was  put  in  place  with  Elysium  for  Welsh  NHS  patients  by  Velindre 
University NHS Trust dated 1 April 2022.  Betsi is one of several Welsh Authorities that 
expressly have the benefit of this Framework Agreement.  The agreement sets out at 
length  at  paragraph  14  and  schedule  6  the  information  sharing  requirements.    It 
should be noted that despite the careful procurement exercise by the qualified NHS 
professionals who led this, there is no contractual requirement for discharge letters 
to be sent concurrently with the discharge of the patient.   
It  should  also  be  noted  that  schedule  2  of  the  contract  has  a  detailed  service 
specification.    At  paragraph  1.4  this  provides  that  all  professionals  involved  in  a 
patient’s  care  should  attend  the  MDT.    Sadly,  as  is  apparent  from  what  is  set  out 
above, Betsi did not attend the three MDT meetings for Mr Taylor.   

I hope that this information provides helpful background evidence to this matter which I infer 
was not available at the inquest. As I have indicated above, given what is set out in this letter, 
as  far  as  Elysium  is  concerned,   there  is  no  risk of  future deaths  created  by the  processes 
outlined above if they are properly followed.  

Yours faithfully  

Chief Executive Officer 
For and on behalf of Elysium Healthcare