Thomas Loxton

12th April 2024 

Headquarters 
Trafalgar House 
47-49 King Street 
Dudley 
B70 9PL 

Mr Adam Hodson 
Assistant Coroner for Birmingham and Solihull 

Dear Mr Hodson 

Re. Regulation 28 report, prevention of future death pertaining to Mr 
Thomas Loxton, deceased. 

Firstly  on  behalf  of  Black  Country  Healthcare  NHS  Foundation  Trust  may  I 
extend our most sincere condolences to the family of Mr Loxton. 

During the course of the inquest the evidence revealed matters giving rise to 
concerns in such a way that there is a risk that future deaths will occur unless 
action is taken. In response to your regulation 28 report to prevent future deaths 
we  have  outlined  below  the  actions,  Black  Country  Healthcare  has  taken  to 
address the matters of concern that affected our organisation. 

1.  The evidence on behalf of Black Country Healthcare NHS Foundation Trust 
(BCH)  was  that  there  are  numerous  recommendations  as  detailed  in  its 
Root Cause Analysis (RCA) report that remain outstanding that have target 
completion dates that arise after the conclusion of this inquest. These dates 
have been pushed back once already. I am concerned that if these targets 
are pushed back further and/or are not met, for whatever reason, there is a 
risk  that  future  deaths  will  occur.  Upon  conclusion  of  the  inquest,  I  am 
Functus Officio, with no power to request updates from the Trust to check 
and ensure that the targets have been met and changes have been made. 
the  efforts  of  reassurance  provided  by 
Whilst 
representatives  of  the  Trust  at  the  inquest,  I  am  reluctant  to  dismiss  my 
concerns,  particularly  where  actions  remain  outstanding,  and  I  have 
opportunity  to  take  action  now  to  ensure  that  the  risk  of  future  deaths  is 
reduced.  

I  am  grateful 

for 

We have enclosed alongside this letter a copy of the action plan presented to 
you  during  inquest  on  the15th  February  2024.  This  update  provides  further 
insight into the completion of all areas of learning identified as a result of our 
investigation. Where applicable we have referenced the assurance processes 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 adopted  that  test  the  successful  delivery  of  each  learning  objective  as  we 
continue  to  work  with  our  community  services  to  embed  these  changes  and 
monitor the impact. 

2.  Secondly, in this inquest, there was evidence that Thomas' family received 
letters from clinicians from Dudley Integrated Health and Care NHS Trust 
(DIH)  requesting  that  Thomas  made  contact,  which  were  sent  after  his 
death, causing obvious distress to his family. It is not difficult to see that this 
type of administrative error could lead to significant distress to families who 
are already vulnerable by virtue of their bereavement, and which could give 
rise to a risk of death. An RCA carried out by DIH identified that action was 
to  be  taken  -  namely  that  DIH  should  work  with  colleagues  at  BCH  to 
establish and embed the process for notifying of patient deaths. However, 
this does not appear to be an action that has been identified in BCH's RCA 
report, and I am concerned by the apparent lack of collaborative working to 
ensure this process is carried out.  

Building on the collaborative working arrangements we already have in place 
between Dudley Integrated Healthcare and Black Country Healthcare, we have 
implemented  a  more  enhanced  process  across  both  organisations  to  try  to 
minimise any opportunities for delay and the impact this might have on families, 
as  well  as 
further 
improvements: 

identified  some  broader  actions 

to  help  develop 

On being informed about the death of a patient known to any BCH service, we 
are now routinely contacting DIHC to enquire as to whether they were aware of 
the death and what involvement (if any) they had with the patient. We recognise 
that there will be instances where there has been no involvement from BCH but 
as typically individuals will likely to have been in contact with secondary care 
MH services ,and the overall numbers will be relatively small, the benefit has 
been  acknowledged  as  outweighing  those  few  instances  where  it  is 
unnecessary 

To further support this we are now reviewing patient notes in more detail to help 
identify any interaction with other organisations; where there is any doubt as to 
whether DIHC had been involved in the care then we are routinely contacting 
DIHC to confirm. 

In addition, we recognise that a patient’s GP will often be best placed to receive 
death  notifications,  reflective  of  their  role  as  being  at  the  heart  of  individual 
patient care. However, it is not always possible for each GP to be able to easily 
recognise all of the relevant organisations which would require being informed. 
Both DIHC & BCH have therefore raised this issue with our local Black Country 
ICB to explore how we might be able to better manage this with our primary 
care colleagues. 

 
 
 
 
 
 
 
 
 
 We have also identified that the full implementation of local medical examiner 
services also provides an excellent opportunity to improve the death notification 
process  for  all  organisations  and  so  are  also  exploring  this  with  the  relevant 
colleagues. 

We fully recognise how challenging it is for families when a loved one is lost 
and  would  never  want  to  create  any  additional  distress  caused  by  making 
contact  after  a  patient  has  died.  We  believe  that,  alongside  the  actions 
described above, the systems we already have in place to support families at 
such  a  difficult  time  should  provide  a  robust  safety  net  to  these  individuals, 
especially  given  their  vulnerability  at  such  a  difficult  time.  As  a  provider  of 
mental  health  services,  we  have  the  skills  and  expertise  to  provide  the 
necessary professional support as required, as well as work with our colleagues 
at DIHC where we identify that more intensive support might be necessary. 

I hope this provides you with assurance that the Trust has taken the concerns 
raised in your regulation 28 response very seriously and will continue to take 
action to reduce the likelihood of a similar incident from reoccurring. We hope 
that  the actions highlighted above will make a difference and we will review 
changes made at regular intervals to ensure that they are embedded whilst 
sharing the outcome and lessons learnt with all affected staff. 

Yours sincerely, 

      Chief Executive

Brierley Hill Health & Social Care Centre 
Venture Way 
Brierley Hill 
  DY5 1RU 

Date:  11th April 2024 

Mr Adam Hodson 
Assistant Coroner for Birmingham and Solihull 

Dear Mr Hodson 

Re: Regulation 28 report, prevention of future death pertaining to Thomas Loxton, deceased 

Firstly,  on  behalf  of  Dudley  Integrated  Health  and  Care  NHS  Trust,  may  I  extend  our  most  sincere 
condolences to the family of Thomas Loxton. 

During the course of the inquest the evidence revealed matters giving rise to concerns in such a way that 
there is a risk that future deaths will occur unless action is taken. In response to your regulation 28 report to 
prevent future deaths we have outlined below the actions Dudley Integrated Health and Care NHS Trust has 
taken to address the matters of concern that affected our organisation. 

1.  In  the  inquest,  there  was  evidence  that  Thomas'  family  received  letters  from  clinicians  from  Dudley 
Integrated  Health  and  Care  NHS  Trust  (DIH)  requesting  that  Thomas  made  contact  with  them,  which 
were sent after his death, causing obvious distress to his family. It is not difficult to see that this type of 
administrative error could lead to significant distress to families who are already vulnerable by virtue of 
their bereavement, and which could give rise to a risk of death. An RCA carried out by DIH identified that 
action was to be taken - namely that DIH should work with colleagues at Black Country Healthcare NHS 
Foundation Trust (BCH) to establish and embed the process for notifying of patient deaths. However, this 
does not appear to be an action that has been identified in BCH's RCA report, and I am concerned by the 
apparent lack of collaborative working to ensure this process is carried out. 

Building  on  the  collaborative  working  arrangements  we  already  have  in  place  between  DIH  &  BCH,  with 
immediate effect, we have implemented a more enhanced process in both organisations to try to minimise 
any opportunities for delay and the impact this might have on families, as well as identified some broader 
actions to help develop further improvements: 

•  On being informed about the unexpected death of an adult patient known to any DIHC service, we 
are now routinely contacting BCH to enquire as to whether they were aware of the death and what 
involvement (if any) they had with the patient. We recognise that there will be instances where there 
has been no involvement from BCH but as typically individuals will likely to have been in contact with 
secondary care MH services, and the overall numbers will be relatively small, the benefit has been 
acknowledged as outweighing those few instances where it is unnecessary 

 
 
         
                                         
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 •  To  further  support  this,  BCH  are  now  reviewing  their  notes  in  more  detail  to  help  identify  any 
interaction with other organisations; where there is any doubt as to whether DIHC had been involved 
in the care then they are routinely contacting DIH to confirm. 

• 

In addition, we recognise that a patient’s GP will often be best placed to receive death notifications, 
reflective of their role as being at the heart of individual patient care. However, it is not always possible 
for each GP to be able to easily recognise all of the relevant organisations which would require being 
informed. 
Both DIH & BCH have therefore raised this issue with our local Black Country ICB to explore how we 
might be able to better manage this with our primary care colleagues. 
Within DIH, we have also engaged with our own GPs – we manage two GP practices in Dudley – to 
help identify any further opportunities for improvement. 

•  We have also identified that the full implementation of local medical examiner services also provides 
an excellent opportunity to improve the death notification process for all organisations and so are also 
exploring this with the relevant colleagues. 

•  We fully recognise how challenging it is for families when a loved one is lost and would never want to 
create any additional distress caused by making contact after a patient has died. We believe that, 
alongside the actions described above, the systems we already have in place to support families at 
such  a  difficult  time  should  provide  a  robust  safety  net  to  these  individuals,  especially  given  their 
vulnerability at such a difficult time. As a provider of mental health services, we have the skills and 
expertise  to  provide  the  necessary  professional  support  as  required,  as  well  as  work  with  our 
colleagues at BCH where we identify that more intensive support might be necessary. 

2.  Secondly, the evidence on behalf of DIH was that the above action to be taken remains outstanding and 
has a target completion date that arises after the conclusion of this inquest. I am concerned that if this 
target is pushed back and/or is not met, for whatever reason, there is a risk that future deaths will occur. 
Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to 
check and ensure that the targets have been met and changes have been made. Whilst I am grateful for 
the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss 
my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to 
ensure that the risk of future deaths is reduced. 

The actions described above have already been implemented, and so hopefully help demonstrate the joint 
commitment from both ourselves and BCH to addressing the relevant actions. 

In addition, we are both ensuring that these immediate changes are now being appropriately reflected in the 
relevant procedural documents within each organisation. 

Finally, following a decision by our commissioners regarding the future delivery of the clinical model of care 
for Dudley, DIH is currently in the process of transferring all of its services to other provider organisations. 

For our mental health services, this will result in a transfer over to BCH from 1st July 2024 which we see as a 
further  opportunity  to  establish  and  improve  robust  systems  and  death  notification  processes  as  part  of 
bringing our services together. 

 
         
                                          
 
 
 
 
 
 
 
 I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 
response very seriously and will continue to take action to reduce the likelihood of a similar incident from 
reoccurring. We hope that the actions highlighted above will make a difference and we will review changes 
made at regular intervals to ensure that they are embedded whilst sharing the outcome and lessons learnt 
with all affected staff. 

Yours sincerely  

Chief Executive