Ethel Reed

HM Coroner 
The Coroners Courts & Office 
The Guildhall 
Alfred Gelder Street 
Kingston upon Hull 
HU1 2AA 

11 April 2024 

Dear HM Coroner (Mrs Sally Robinson, Assistant Coroner) 

Regulation 28 Report following the inquest into the death of Mrs Reed 

We provide the formal response of the Care Quality Commission (CQC) to the 
Regulation 28 Preventing Future Deaths report made by HM Coroner (Mrs Sally 
Robinson, Assistant Coroner) following the inquest into the death of Mrs Reed. (‘the 
Regulation 28 Report’).  

In the Regulation 28 Preventing Future Deaths report  HM Coroner raised the 
following concerns: 

(1) 
H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing 
and spans the full floor. It was opened in response to winter pressures. At that time, in 
January 2023, Hull Royal Infirmary was placed under significant pressure in terms of 
admissions and staffing. The ward been open only a matter of some two weeks by the 
time Mrs Reed was transferred to that ward. Despite being medically fit for discharge 
upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns 
as best they could, but they reported that the ward was chaotic, and that staff would 
tell them they had only just found out they were working on the ward before their shift 
started and there was no consistency of nursing staff on the ward.  

Mrs Reed was dehydrated, and family reported that there was a paucity of personal 
care afforded on that ward. There was a risk of cross infection as patients’ personal 
effects  such  as  toiletries  were  not  with  the  right  patients  and  had  to  be  located  by 
family. There was no established cohort of permanent staff on the ward at that time 
and no signposting to the ward sister or matron and therefore no way of patents, their 
friends,  or  their  families  being  able  to  have  a  clear  escalation  pathway  to  ventilate 
concerns.  Although  HUTH  now  have  an  established  team  and  leadership  chain  on 
Ward H130 there is a real concern that wards opened in response to winter pressures 
in the future in any busy hospital may give rise to the same peripatetic staffing regime, 
that is to say, agency staff and no fixed team in place and a lack of visible leadership. 
This  could  lead  to  the  deterioration  of  patients  not  being  recognised  if  there  is  no 
continuity of care by the same team of nursing staff. 

An issue with the Lorenzo electronic patient record keeping system has been 
(2) 
identified in respect of the system not auto populating the identification of the author 
of any changes made in the immediate discharge letter (IDL) after it has been finalised. 

 
 
 
 
 
 
 
 This could lead to miscommunication of critical issues and difficulties in establishing 
who  made  what  decisions  which  could  lead  to  delays  in  treatment  in  the  next  post 
discharge setting which in turn could lead to future deaths. 

The trust’s last comprehensive inspection was in November 2022 and the report was 
published in March 2023. CQC rated the trust as “Requires Improvement.” A copy of 
the report can be found on our website - Trust - RWA Hull University Teaching 
Hospitals NHS Trust (23/03/2023) INS2-13905362001 (cqc.org.uk) 

The trust subsequently provided CQC with a copy of their post inspection action plan 
detailing the immediate action taken in response to the concerns raised at 
inspection. The trust provided details of the longer-term actions required to ensure 
the improvements made would become sustained and embedded.  

CQC has had regular monthly engagement with the trust, reviews evidence and 
closely monitors their progress against all action plans to ensure sustained 
improvement.  

CQC first became aware of the death of Mrs Reed’s death on 8 March 2023. Holy 
Name Community Rehabilitation Centre submitted a statutory notification to report 
Mrs Reed’s death as an expected death on 1 March 2023. The notification stated 
Mrs Reed had been referred for a level 4 rehabilitation bed on the 26 February 2023 
following a therapy assessment. Staff identified Mrs Reed’s health was deteriorating 
naturally and she was put on an end of life pathway. Mrs Reed and her family were 
aware that palliative care had commenced, and staff offered support and comfort. 
CQC had no concerns regarding this expected death based on the information 
received on this notification.  

Following  receipt  of  the  preventing  future  deaths  report  CQC  held  a  management 
review meeting on 20 February 2024. CQC agreed to request and review the inquest 
medical evidence bundle in line with CQC specific incident guidance. In addition, CQC 
asked Hull University Teaching Hospitals NHS Trust to provide evidence of any action 
they had taken to date following the tragic death of Mrs Reed by Thursday 7 March 
2024.  

CQC noted the information supplied at the inquest that H130 ward had only been 
open for 2 weeks when Mrs Reed was admitted in January 2023. The ward had 
been opened due to the significant pressures and demands on the trust.  

The trust began its “Discharge to Assess” (D2A) transformation programme in 
January 2023, bringing together care partners across Hull and the East Riding of 
Yorkshire to reshape and improve discharge processes and care planning.  

In June 2023, the trust permanently opened two “no criteria to reside wards” H130 
East and H130 West on the 13th floor at Hull Royal Infirmary as part of its 
“Discharge to assessment” model. This model is staffed by a multidisciplinary team 
which includes therapists, nurses, medics, social workers, and pharmacists. Once 
patients are assessed as medically fit, they are transferred to these wards to have an 
assessment with a plan for a same day discharge. The discharge team has been 
relocated to be close to these wards.  

 Since the last inspection, the trust made improvements to their staffing on medicine 
wards. All associated post inspection action plans for staffing have been completed. 
CQC regularly monitors staffing in terms of fill rates (planned vs actual), reduction in 
the number of vacancies, improved turnover rates and improved sickness rates. 
CQC continues to monitor staffing levels to ensure these actions are fully 
implemented, embedded, and sustained.  

The trust submitted further assurance around the current staffing levels for the 13th 
floor which includes wards H130 East and E130 West. There is now an established 
team including leadership, nursing, and medical teams. A funding request has been 
submitted to the board for a permanent third registered nurse as this additional post 
has demonstrated improved performance in relation to medicines management and 
quality of patient care. A non-clinical coordinator role has also been introduced to 
support these wards. The trust is now over-recruited against its nursing staff which 
reduces the need for bank and agency staff.  

CQC have not been informed of any further staffing concerns from medical care 
wards but will continue to monitor the trust if they are any further wards opened at 
short notice.  

The trust conducted their own internal multidisciplinary inspection to ensure the new 
“discharge to assess” model for H130 East and E130 West was embedded. The trust 
provided assurance that lessons have been learnt and improvements have been 
made from when the wards was first opened in January 2023.  

CQC regularly monitors the access and flow of patients in and out of medical care 
wards. There has been measured improvements with a reduction in patient moves, 
improved length of stay, reduction in delayed discharges and improved patient 
pathways. All associated post inspection action plans have been completed.  

The trust now has  clear escalation pathways to review patients who deteriorate and 
transfer them to an acute medical ward if considered appropriate. Staff on these 
wards are fully aware of this model and also have clear escalation and 
communication channels with medical teams.  

The trust submitted additional assurance that personal care is provided on these 
wards. There is now a cohort of volunteer staff and activity champions to support 
patients and relatives. Patients also have visits from therapy dogs. The trust were 
exploring how to make patients feel more comfortable and had requested funding for 
televisions and radios. The trust have also established a “relative” clinic to ensure 
good communication with families. In addition, staff are being supported to complete 
appropriate care training.  

The trust has made improvements with communication with patients and their 
families. The ward sisters are present on wards; H130 East and E130 West on a 
daily basis. They have set up a “relatives clinic” which provides dedicated time for 
patients or relatives to meet with ward sisters and ask questions, seek advice, or 
raise concerns. The wards promote positive feedback using the Friends and Family 
Test (FFT) and display feedback, results and any action taken. There are clear 
contact details available for PAL’s, complaints, and the ward matron.  

 Following the Lorenzo System related incident the trust sent out communications to 
reinforce the process that needs to be followed when completing Immediate 
Discharge Summaries (IDS) for patients using the Trust’s Electronic Patient Record 
(EPR) on Lorenzo. The trust’s digital team are also in the process of exploring further 
system functionality that may improve the current process and help to mitigate 
further issues. In the meantime, the trust’s digital team will continue to work with the 
clinical teams to reinforce and embed current processes and provide support or 
additional training as needed. 

In addition to our inspection activity, inspectors regularly monitor the National 
Reporting and Learning System (NRLS) and Strategic Executive Information System 
(StEIS), reviewing a Trust’s National Patient Safety Incident Reports and Serious 
Incident investigations data. Currently these data sources are going through a 
significant transformation, as NHS England implements the new Learn from Patient 
Safety Events system, which limits CQC’s ability to carry out further national analysis 
until this has been completed.  

CQC will continue to monitor information we receive about the service. Where CQC 
identifies that regulations are not being met, we will use our enforcement powers to 
require improvements to be made.  

CQC  will  also  check  the  provider’s  compliance  with  the  regulations  on  our  next 
inspection of the service using our new single assessment framework methodology in 
accordance  with the  CQC regulatory  remit. CQC  will  highlight any  repeated or new 
breaches of regulation and ask the trust to make necessary improvements.  

CQC’s next inspection of the service is not yet confirmed, however we have adopted 
a more risk based approach to inspections should CQC receive negative intelligence 
or have further concerns about the service we would carry out responsive inspections.  

CQC hope that this response addresses your concerns.  

Yours sincerely 

Deputy Director of Operations 

Network North

22 April 2024 

Sally Robinson 
Assistant Coroner for Hull & the East Riding of 
Yorkshire 
The Coroner’s Court & Offices 
The Guildhall 
Alfred Gelder Street 
Hull 
HU1 2AA 

Dear Ms Robinson, 

Hull Royal Infirmary 
Anlaby Road 
Hull 
HU3 2JZ 

Re: Death of Ethel Doreen Reed – Response to Regulation 28 Report to Prevent Future Deaths 

I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the 8th 

February 2024, issued as a result of the concluded inquest into the death of Ms Ethel Doreen Reed. 

I would like to take this opportunity to express my sincerest condolences to the family of Ms Reed for their 

loss. 

During  the  course  of  the  inquest,  the  evidence  revealed  matters  giving  rise  to  concern.  These  are  as 

follows: 

1.  H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full 

floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary 

was placed under significant pressure in terms of admissions and staffing. The ward been open only 

a  matter  of  some  two  weeks  by  the  time  Mrs  Reed  was  transferred  to  that  ward.  Despite  being 

medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised 

concerns as best they could but they reported that the ward was chaotic and that staff would tell them 

they had only just found out they were working on the ward before their shift started and there was no 

consistency of nursing staff on the ward.  

Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that 

ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with 

the right patients and had to be located by family. There was no established cohort of permanent staff 

on the ward at that time and no signposting to the ward sister or matron and  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 therefore  no  way  of  patents,  their  friends,  or  their  families  being  able  to  have  a  clear  escalation 

pathway to ventilate concerns. Although HUTH now have an established team and leadership chain 

on Ward H130 there is a real concern that wards opened in response to winter pressures in the future 

in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff 

and  no  fixed  team  in  place  and  a  lack  of  visible  leadership.  This  could  lead  to  the  deterioration  of 

patients not being recognised if there is no continuity of care by the same team of nursing staff. 

2.  An issue with the Lorenzo electronic patient record keeping system has been identified in respect of 

the system not auto populating the identification of the author of any changes made in the immediate 

discharge letter (IDL) after it has been finalised. This could lead to miscommunication of critical issues 

and difficulties in establishing who made what decisions which could lead to delays in treatment in the 

next post discharge setting which in turn could lead to future deaths. 

Please find below the response from the Trust and the detail of the actions being taken in relation to each 

concern. 

Concern 1 - Ward H130 and future winter pressure wards 

At the time of the deceased’s admission to ward H130 in January 2023, the ward had been opened as a 

temporary winter ward to manage the capacity issues across the organisation and had been open for two 

weeks. 

The Trust recognises that there are a number of patients who cannot be discharged due to lack of care 

home or home care capacity, which has placed different capacity pressures on the organisation since the 

winter of 2023. It is recognised that this is both a local and national situation.  

In June 2023, in response to these capacity issues, the Trust took the action to use the 13th floor and open 

‘No Criteria to Reside Wards’ on the 13th floor (H130 East and H130 West) at Hull Royal Infirmary on a 

longer term footing. 

When patients are assessed as medically ready, they will transfer to the 13th floor for ‘Discharge to Assess 

assessment’;  this  includes  all  partners  (therapists,  nurses,  medics,  social  workers,  pharmacist, 

intermediate care workers, trusted assessors, progress to discharge assistants, housekeepers and  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 hygienists) working in an MDT approach to assess and discharge patients on the same day (wherever 

possible). 

The Trust acknowledges that this new model was embedding into practice in the summer of 2023 and did 

require improvement. Since the ward opened, the Trust has taken the opportunity to make the required 

improvements, learn from patient experience and address recommendations following an internal multi-

disciplinary inspection to the 13th floor. This visit was led by the Director of Quality Governance and had 

attendance from the Chairman and a Non-Executive Director for Hull University Teaching Hospitals NHS 

Trust,  Practice  Development  Matron,  Compliance  Team  as  well  as  Health  and  Safety  and  external 

representation from Kingston upon Hull Healthwatch. An improvement plan for the 13th floor has been in 

place since October 2023, with progress against delivery of the plan. The improvement plan is attached at 

Appendix A for information.   

The Trust can confirm that there is now a very well established team on the 13th floor, including leadership, 

nursing  and  medical  teams.  The  Ward  Sisters  are  present  on  the  wards  on  a  daily  basis  with  clear 

signposting for patients, relatives and carers if they need it. The Ward Sisters have set up ‘relative clinics’, 

which provides dedicated time for patients or relatives to meet the Ward Sisters to ask questions, seek 

advice or  raise concerns. The  wards  promote patient feedback  via Friends  and Family  Test  (FFT)  and 

displays  feedback,  results  and  actions  taken  by  the  areas.  The  wards  also  have  volunteer  presence, 

activity champions and visits from the therapy dogs.  

The Trust has made great strides in improving the care, treatment and experience for patients transferred 

to the 13th floor as a No Criteria to Reside base and recognises that, at times, additional capacity during 

winter pressures or increased times of demand on the service it will need to opened. The Trust can provide 

assurance  that  learning  from  opening  of  the  13th  floor  has  been  undertaken  and  informed  a  planned 

methodology for opening additional capacity on an urgent basis, safely. The Trust is now over-recruited 

against its nursing staff and is able to lean on that resource as required, reducing the need for bank and 

agency staff. 

Concern 2 - Immediate Discharge Summary letter 

The Trust have met with Daedalus, the supplier of the Lorenzo system, to discuss potential solutions to 

the concerns raised by the Coroner in the system, which is utilised by a number of providers nationally.  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 We have not yet been able to identify a single remedy to the issue raised around the identification of all 

authors  making  changes  to  the  Immediate  Discharge  Summary  (IDS).  The  primary  barrier  to  a  simple 

solution to this issue is that there are often non-clinical staff involved in the management of the IDS before 

it is finalised. 

However, we have completed an internal review of the current process and consulted with other Lorenzo 

users. The outcome of these discussions is that the Trust is now looking to change the current process of 

completing the IDS as detailed below: 

The Trust currently have in excess of 60 different IDS templates created as clinical notes in the Lorenzo 

system.  A review of the data items within these documents shows approximately 40 data items consistent 

across most of the templates and 46 variable data items.  Templates have been created at the request of 

departments  or  users  to  accommodate  variable  data  required  between  departments,  clinicians  or 

procedures  and  treatments.  We  now  believe  that  this  level  of  variability  would  be  more  appropriately 

managed using the clinical data capture (CDC) forms in Lorenzo and not in the IDS. This change would 

allow mandatory data to be captured for all, and the variables to be added as and when required. This in 

turn can create a final clinical note at discharge that is reflective of the individualised care received by the 

patient. 

This  piece  of  work  will  require  resources  of  Project  Management,  Change  Management,  CDC  Form 

Developer,  System  Support  and  Information  and  reporting.    There  will  also  be  significant  stakeholder 

engagement required including the pharmacy team.  Due to this and other similar concerns raised recently, 

it has been recommended that this piece of work be given a priority 1 and resources allocated as soon as 

they become available.  The timescales for deployment will depend on the approach, but would likely begin 

with those areas with a significant number of IDS templates set up currently. 

We are in the process of our internal Digital Information and Systems approving this change and then will 

begin the work to make this change. 

I hope that this letter provides both you and Ms Reed’s family  with assurance that the Trust has taken 

seriously the matter of concerns you raised in your report. 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
  
 
 
 
 
 
 
 
 Yours sincerely 

Interim Group Director of Quality Governance 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence.

Sally Robinson 
East Riding and Hull Coroner’s Service 
The Guildhall 
Alfred Gelder Street 
Hull  
HU1 2AA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

2 April 2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ethel Doreen Reed who 
died on 2nd March 2023 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  8th 
February  2024  concerning  the  death  of  Ethel  Doreen  Reed  on  2nd  March  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Ethel’s  family  and  loved  ones.  NHS  England  are 
keen to assure the family and the coroner that the concerns raised about Ethel’s care 
have been listened to and reflected upon.  

In  your  Report  you  raised  the  concern  that  H130  at  Hull  Royal  Infirmary  had  no 
established permanent staff and was placed under significant pressures. You raised 
that other wards opened during winter pressures may have the same issues, using 
agency staff without a fixed team in place and with a lack of visible leadership, posing 
risk to patients.  

While  staffing  is  the  responsibility  of  individual  Trusts,  growing  the  healthcare 
workforce is one of NHS England’s chief priorities and we were pleased to achieve the 
government target of having 50,000 more nurses working in the NHS by November 
last year than in 2019. Nurse, Allied Healthcare Professionals, and wider health and 
care  vacancies  remain  a  pressing  concern  which  we  are  addressing  through  the 
delivery  of  the  NHS  Long  Term  Workforce  Plan,  offering  flexible  routes  into  the 
professions including apprenticeships and working with employers to support retention 
of the current workforce.  

Winter remains a challenging period for NHS organisations, amidst significant existing 
pressures. Recovery plans, such as those for urgent and emergency care (UEC) and 
primary care, together with broader strategic and operational plans have also provided 
a firm basis to support NHS organisations to prepare for challenging winter periods. In 
July 2023, NHS England wrote to Integrated Care Boards (ICBs) and Trusts setting 
out  the  national  approach  to  2023/24  winter  planning  and  delivering  operational 
resilience. This set out four areas of focus for health systems:  

1.  Continuing delivery of the UEC Recovery Plan and ensuring that high-impact 

interventions are in place.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
  
 2.  Completing  operational  and  surge  planning  to  prepare  for  different  winter 

scenarios.  

3.  ICBs  to  ensure  effective  system  working  across  all  parts  of  the  system, 
including acute trusts and community care, elective care, children and young 
people, mental health, primary, community, intermediate and social care and 
the Voluntary, Community and Social Enterprise sector. 

4.  Supporting the workforce and their wellbeing to deliver over winter. 

taken 

learning 

NHS England has engaged with Humber and North Yorkshire (ICB) on the concerns 
raised  around  the  care  delivered  to  Ethel.  Following  an  internal  multi-disciplinary 
inspection  of  the  ward,  we  are  advised  that  Hull  Royal  Infirmary  has  made 
improvements, 
from  patient  experience,  and  addressed 
recommendations.  They  have  confirmed  that  there  is  now  an  established  team  on 
Ward H130 including leadership, nursing and medical teams. Hull University Teaching 
Hospitals NHS Trust has provided assurance that learning from the opening of H130 
has  been  undertaken  and  informed  a  planned  methodology  for  opening  additional 
capacity on an urgent basis safely. The Trust is now over-recruited against its nursing 
staff and can use this resource as required, reducing the need for bank and agency 
staff. We would refer you to the Trust for further information.  

Your  Report  also  raised  a  concern  around  the  Lorenzo  electronic  patient  record 
keeping  system  not  auto-populating  the  identification  of  the  author  of  any  changes 
made in the immediate discharge letter after it has been finalised. NHS England no 
longer have a contract with Dedalus (Lorenzo system) and therefore the relationship 
sits directly with the Trust(s) and supplier.  

We are advised that the Trust have informed the supplier of this issue, and they are 
working on a solution which displays the identification of the author of the Immediate 
Discharge Summary (IDS) relating to the amendment. The system currently provides 
a full audit trail of access and amendments to the system, the solution would either 
display all amendments or force the author of the amendment to be displayed when 
the form is finalised and distributed. In the meantime, communications have been sent 
to staff to reinforce the process that needs to be followed when completing IDS’s for 
patients using the Trust’s Electronic Patient Record (EPR) on Lorenzo. We understand 
that  the  Trust’s  Digital  Team  are  also  in  the  process  of  exploring  further  system 
functionality that may improve the current process and help to mitigate further issues.  

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

 
 
 
 
 
 Yours sincerely, 

National Medical Director