Ellen Woolnough

Darren Stewart OBE 
Suffolk Coroner’s Court and Offices 
Beacon House 
Whitehouse Road 
Ipswich  
IP1 5PB 

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

22nd May 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ellen Ocean Woolnough 
who died on 28 July 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  28 
March  2024  concerning  the  death  of  Ellen  Ocean  Woolnough  on  28  July  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Ellen’s  family  and  loved  ones.  NHS  England  are 
keen to assure the family and the coroner that the concerns raised about Ellen’s care 
have been listened to and reflected upon.   

I  note  that  your  Report  has  also  been  addressed  to  Norfolk  and  Suffolk  NHS 
Foundation Trust who are the appropriate organisation to answer the majority of the 
concerns  raised  in  your  Report.  NHS  England  has  engaged  with  the  Trust  on  the 
issues  raised  in  your  Report  about  Ellen’s  care  and  and  have  been  sighted  on  the 
action plan and statement submitted to you at inquest. We note from the Trust that 
their actions include:  

•  A Quality Improvement Programme led by their Chief Nurse which will focus on 
improving clinical standards and implementing a positive culture change.  
•  Re-evaluation  of  the  Trust-wide  training  standard  and  model  for  risk 

assessment/ Skills Training on Risk Management (STORM). 

•  The implementation of a new Trust-wide Crisis Rehabilitation Home Treatment 
Team (CRHTT) Standard Operating Procedure (SOP) and handover document 
in May 2024.  

•  Changes made to the Patient Safety Screening Form which include a prompt 

to consider whether calls are available for retrieval.  

I would refer you to the Trust’s response to your Report for further details and actions 
taken. NHS England have also been asked to be sighted on their response.  

Regarding concern iv) and the changes to the way that the Trust is now investigating 
patient  safety  incidents  and  the  implementation  of  the  Patient  Safety  Incident 
Response Framework (PSIRF), my colleagues from the national Patient Safety Team 
at NHS England reviewed your Report and have provided input.  

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 The  PSIRF  sets  out  the  NHS’s  approach  to  developing  and  maintaining  effective 
systems and processes for responding to patient safety incidents for the purpose of 
learning and improving patient safety. The PSIRF has replaced the Serious Incident 
Framework (2015) and represents a significant shift in the way the NHS responds to 
patient safety incidents and is a major step towards establishing a safety management 
system across the NHS. It is a key part of the NHS patient safety strategy. 

The PSIRF supports the development and maintenance of an effective patient safety 
incident response system that integrates four key aims: 

•  Compassionate  engagement  and  involvement  of  those  affected  by  patient 

safety incidents 

•  Application  of  a  range  of  system-based  approaches  to  learning  from  patient 

safety incidents 

•  Considered and proportionate responses to patient safety incidents 
•  Supportive  oversight  focused  on  strengthening  response  system  functioning 

and improvement. 

NHS  England  would  refer  the  coroner  to  the  Trust  for  further  details  about  their 
implementation of PSIRF.   

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

-

Area Coroner Darren Stewart OBE
Suffolk Coroner’s Court
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
E mail:

NSFT Trust Management
Norfolk & Suffolk Foundation Trust
County Hall
Martineau Lane
Norwich
NR1 2DBH

Tel:

Date: 22 May 2024

Dear Coroner Stewart

Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to
the death of Ellen Woolnough

I write to you in respect of Ellen Woolnough who died on 28 July 2022. Her inquest concluded on 13
February 2024. At the end of the inquest, you raised concerns outlined in this response within a prevention
of future deaths notification.

I would like to reiterate to you and to Ellen’s family our sincere regret and apologies for the death of Ellen
whilst under our care.

Please see below our response to your requests for further information:

1. STORM© training continues to be rolled out, although the evidence from a number of

witnesses questioned the effectiveness of the rollout in reaching all staff.

Following a pilot of STORM© training in 2022, roll out was undertaken in specific service areas
across the Trust. It is not currently an essential or mandatory training requirement for CRHTT
clinicians.

STORM© training is not a universal training programme within the Trust’s training offer to ensure
clinicians, inclusive of CRHTT staff, are competent and have the relevant skills for assessing and
responding to clinical risks. The current clinical risk training offer for CRHTTs, is inclusive of
mandatory suicide awareness training, Ligature training, Oliver McGowan Autism Training,
Safeguarding level 3 trainings, and physical healthcare training. Throughout May 2024, senior
meetings between the Trust’s Education Department, Chief Nursing Officer and Directors have
been undertaken, to review and refresh the NSFT Education Strategy, inclusive of reviewing the
STORM© training offer and any further roll out across the trust. A final decision will be made in June
2024.

The Trust has recently been reviewing and updating their Clinical Risk Assessment and
Management Policy. This Policy is currently progressing through Trust internal governance
processes and is due to be published end of June 2024, with a Policy implementation plan to be
progressed during July/August 2024. This will provide additional support to staff clinical risk
assessment practice.

Chair:
Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH

Chief Executive Officer:

Web: www.nsft.nhs.uk

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This policy details a suite of essential training for clinicians to evidence they have the required skills
and competencies for assessing and responding to clinical risks. The Clinical Risk Assessing and
Management training offer is inclusive of Record Keeping, Assessment, Formulation and Safety
Planning Training, as applicable in differing areas of specialist mental health clinical practice.

2. Whilst the downgrade policy concerning urgent referrals has been tightened up, key parts of

the process, such as the handover document between shifts, is still to be introduced.

At the time of inquest we were in the process of introducing an updated hand over document.

I can confirm that the use of the updated handover document is now embedded practice in our East
CRHTT.

To secure assurance that we are adhering to required practice when a referral is being considered
for regrade, we have commenced an audit of the hand over document. An audit commenced week
commencing 13.05.24. This audit will continue on a monthly cycle for assurance and improvement
purposes .

Audit results will be reported to the Team and Care Group Quality Assurance Group for monitoring
and to support further improvement. For broader assurance purposes the audit findings will be
presented to the Trust Safety group and onward to the Trust Board Quality Committee.

3. The Trust Standard Operating Procedure (SOP) addressing the downgrading of urgent

referrals, which I was told was revised in 2023, has not been provided to the Court and has
not been implemented by the Trust.

Please find attached the updated Trust wide CRHTT SOP which was confirmed and introduced on
17th May 2024. This aligns to the Trust standard described within the Clinical Harm Review
standard operating procedure (version 4) which was implemented February 2024. Both documents
highlight the required process when considering regrading an urgent referral.

The requirement to discuss referral regrade with another clinician is clearly described within the
Clinical Harm Review SOP and is included within the updated Trust wide CRHTT SOP. These
documents ensure staff are clear on the required approach.

We will evaluate compliance against this standard through local management monitoring with
additional second level assurance provided through an audit that will be completed by the Patient
Safety and Quality Team by mid-July 2024. This will enable us to provide assurance that all
decisions to regrade a referral are being made by two clinicians in line with Trust standard.

This will be reported to the Care Group Quality Assurance Group for monitoring purposes and to
support improvement. For further assurance purposes the report will be presented to the Trust
Safety group and onward to the Trust Board Quality Committee.

4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a
screening tool to determine how the PSIRF process is implemented, the requirement to
retain recordings of calls and which statements are to be taken to inform serious patient
incident investigations, are still to be introduced by the Trust, and

5. The failure by NSFT to preserve important evidence, in the form of recordings of calls

between Ellen and the NSFT crisis call handler, at a time when it was on notice that this
evidence would be important and relevant for the conduct of the Inquest, remains a concern.

Following recognition of the concern raised, we immediately changed the patient safety screening
form that we send out to clinical teams on notification of an incident. We added additional points to

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this screening form, to prompt the clinical team that are providing an initial description of the events
that have occurred, to consider whether any patient calls are available for retrieval, so that they can
be secured for investigation and inquest purposes. We have strong processes in place to ensure
that the retrieval of these calls is undertaken in a consistent and IG compliant manner by members
of the Patient Safety team.

Recognising that we have an extensive network of phone lines, we have also taken steps to secure
assurance that the phone lines that we need recording, across the crisis pathways, are
appropriately enabled. Through a detailed scoping exercise, we identified the need to extend our
current recording facility in one of our CRHTT areas. This went live on 15th May 2024. All phone
lines which have been designated as requiring recording facility have now been enabled.

The tragic death of Ellen has identified a number of key learning points for the Trust. As described
above, a number of actions have been undertaken that address your concerns. Further to this,
quality improvement in our CHRTT will remain a key focus.

Yours sincerely,

Chief Executive Officer