Timothy Clayton

Caroline Topping 
Surrey HM Coroner’s Court  
Station Approach 
Woking  
GU22 7AP 

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

25 June 2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Timothy Charles Clayton 
who died on 12 December 2022.   

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 
2024  concerning  the  death  of  Timothy  Charles  Clayton  on  12  December  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Timothy’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Timothy’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Timothy’s family or friends. I realise that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them.     

Your Report raised the concern that the pressure to vacate bed spaces impacted on 
clinicians’ ability to prepare a properly considered discharge plan and could lead to 
rushed and underinformed decision-making.  

The  delivery  plan  for  recovering  urgent  and  emergency  care  services  committed  to 
providing  the  NHS  with  additional  bed  capacity  to  improve  hospital  flow  and 
performance.  The  target  of  5,000  additional  core  general  and  acute  beds,  against 
previously  planned  levels,  was  met  and  consistently  exceeded  in  January  2024, 
supported  by  £250  million  for  30  capital  schemes  across  the  country.  2024/25 
operational planning guidance sets out an ask for systems to maintain their levels of 
acute core general and acute beds in 2024/25, and to expand their bedded and non-
bedded intermediate care capacity, through the additional £400 million distributed via 
the  Better  Care  Fund  (BCF),  to  support  improvements  in  hospital  discharge  and 
enable step-up care in the community. 

The plan additionally set out to improve discharge by improving discharge processes, 
scaling up intermediate care and scaling up social care services, based on learning 
from the 6 national Discharge Frontrunner sites that have led the way in exploring how 
new  long-term  initiatives  can  be  used  to  free  up  hospital  beds  for  those  who  need 
them, and the 100-day discharge challenge run across the NHS in 2023. Central to 

                                                                                                                       
 
 
 
 
 
 
  
 
  
 
 
 
 
 
  
 plan  was  the  requirement  that  all  Trusts  work  together  with  local  authorities  and 
system partners to establish a Care Transfer Hub to manage discharges for patients 
with more complex needs.  

During 2023/24, the NHS met the ambition to ensure all hospitals have a care transfer 
hub  in  place  and,  due  to  improvements  in  discharge  processes  and  increased 
intermediate and social care capacity, on average 500 fewer patients per day had to 
spend  the  night  in  hospital  because  of  a  discharge  delay,  and  13%  more  patients 
received  a  short-term  package  of  health  or  social  care  to  help  them  continue  their 
recovery  at  home  or  in  a  community  bed  after  being  discharged  from  hospital.  The 
government’s  refreshed  statutory  discharge  guidance,  published  in  March  2022, 
reiterates that system partners across health and social care should work together, 
and  with  patients,  their  families  and  carers,  to  ensure  that  needs  are  appropriately 
assessed to support recovery and reablement after hospital. 

The  Urgent  and  emergency  care  recovery  plan  year  2:  Building  on  learning  from 
2023/24,  published  in  May  2024,  sets  out  commitment  to  continue  to  improve  in-
hospital  discharge  processes  by  ensuring  early  discharge  planning,  including  the 
effective involvement of patients, carers and families, in line with statutory guidance. 
Acute  providers  are  asked  to  continue  to  improve  in-hospital  processes  to  improve 
timeliness of discharge, including early discharge planning from the point of admission 
and  early  involvement  of  care  transfer  hubs  where  patients  are  likely  to  have  more 
complex discharge needs. 

NHS England has also been sighted on Epsom and St Helier University Hospitals NHS 
Trust’s response to your Report. We note that the Trust has taken a number of actions 
related to the care experienced by Timothy. This has included updating the Hospital 
Discharge and Criteria to Reside Policy and process for identifying vulnerable patients 
under the Trust’s care, emphasising the importance of family involvement in decision-
making  and  undertaking  communications  with  staff  to emphasise  the  importance  of 
safe discharge.  

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

Epsom and St Helier University Hospitals NHS Trust 
Wrythe Lane 
Carshalton, Surrey 
SM5 1AA 

Ms Caroline Topping 
Assistant Coroner, HM Coroner’s Court 
Station Approach, 
Woking,Surrey, GU22 7AP 

11 June 2024 

Dear Ms Topping, 

Mr Timothy Clayton (Deceased) 
Response to Regulation 28 Report to Prevent Future Deaths 

This  letter  comprises  the  formal  response  of  Epsom  and  St  Helier  University  Hospitals  NHS 
Trust ‘the Trust’ to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 
17 April 2024 ‘the Report’, made after the inquest into the death of Timothy Clayton which was 
opened on 29 December 2022 and resumed on 16 January 2024 and concluded on 12 March 
2024. The Trust would like to again express our deepest sympathy and condolences towards 
the family. 

Background 

The findings from the Inquest were that “Mr Timothy Clayton was suffering from alcohol related 
brain damage and malnutrition result of chronic alcohol use. His mobility was impacted and he 
had fluctuating confusion. He was found hypothermic at his home on 27 October 2022, taken to 
hospital and discharged. On 20 November 2022, he was again hypothermic and was admitted 
to hospital. He was discharged on 24 November 2022, to be cared for by a family member. On 
29  November  2022,  he  was  admitted  to  hospital  and  transferred  to  Epsom  General  Hospital 
suffering  with  reduced  mobility,  slurred  speech  and  confusion.  The  underlying  cause  of  his 
condition  was  not  diagnosed.  He  was  found  to  be  medically  fit  for  discharge.  The  discharge 
planning was not undertaken in accordance with the hospital policy. No heed was paid to his 
family’s concerns that he was not well enough to care for himself. He was discharged on the 5 
December  2022 to  live  at  his own  flat.  The heating  was  inadequate  and  he  self-neglected  in 
relation to eating. He was found profoundly hypothermic on the 11 December 2022 and admitted 
to Epsom General Hospital. 

He died from the effects of hypothermia on the 12 December 2022. Pressure on staff to vacate 
hospital bed spaces led to inadequate discharge planning and more than minimally contributed 
to the death.” 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 A narrative conclusion was delivered at the inquest as follows: 

“There was a lack of information sharing and investigation in relation to the discharge planning 
for Mr Clayton. Contrary to the Trust’s policy he was not identified as a vulnerable patient. His 
family was not involved in the discharge planning. On a number of occasions, they raised their 
concerns as  to  his  ability  to  live  independently  and  were  ignored.  Staff  were  unaware  of  the 
discharge  planning  policy.  The  underlying  cause  for  his  presentation  was  not  diagnosed. 
Discharge  decisions  were  taken  in  a  vacuum  without  understanding  the  recent  history  of 
frequent admission, his diagnosis and without sufficient investigation of his home circumstances. 

An assumption that Mr Clayton had capacity was made and used to justify his discharge without 
considering  whether  he  could  make  informed  decisions  about  his  ability  to  live  alone  without 
knowing what underlay his deterioration and how his ability to self-care was impacted. 

It was accepted that pressure to vacate hospital bed spaces played a part in the inadequacy of 
discharge  planning.  The  imperative  to  free  up  a  bed  space  led  to  a  rushed  discharge  on  5 
December 2022 without an adequate care plan being in place.” 

The medical cause of death was found to be: 

1a) Hypothermia 
1b) Self neglect and Chronic Alcohol Excess 

The Report raises the following concerns: 

1. The  policy  in  relation  to  discharge  planning  remains  under  review,  including  how 
families are to be involved, so it has not been possible to assess the adequacy of the 
new policy. 

2. There was a misunderstanding by a clinician in relation to whether capacity to make a 
decision can be relied on to justify actions taken when the requisite information which 
needed  to  be  considered  by  Mr  Clayton  in  relation  to  that  decision,  and  its 
consequences,  had  not  been  provided  to  him.  Mr  Clayton’s  expressed  wish  to  go 
home alone, without any care plan in place, was relied on, erroneously, to justify an 
unsafe discharge on the bases that he had capacity. 

In relation to both Epsom General Hospital and NHS England 

3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly 

considered discharge plan and led to rushed under-informed decision making. 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 First Concern 

The first concern set out in the Report is as follows: 

‘The  policy  in  relation  to  discharge  planning  remains  under  review,  including  how 
families are to be involved, so it has not been possible to assess the adequacy of the 
new policy’. 

Trust response: 

The Root Cause Analysis undertaken following this incident identified the fact that Mr Clayton 
was  a  vulnerable  adult  and  so  a  complex discharge  pathway  should  have  been  triggered  as 
required  within  the  Trust’s  discharge  policy.  As  a  result of  this  investigation,  the principles  of 
effective  discharge  processes  were  reviewed,  safe  check  lists  embedded  into  practice  and 
clinical  practice  reviewed.  Subsequent  to  the  Inquest  the  Hospital  Discharge  and  Criteria  to 
Reside Policy (ESTH/POL/64521) has been reviewed, updated and approved and shared with 
staff in the organisation.  This policy provides clarity on the identification of vulnerable patients 
for discharge and outlines the responsibilities of patients, family and carers to be in included in 
the discharge planning. The policy encourages families to raise concerns and, where concerns 
are  raised,  supports  how  these  are  managed.  The  effectiveness  of  the  new  policy  will  be 
reviewed through a planned Trust-wide audit in November 2024 which will be presented and 
any actions resulting from this monitored by the Patient Safety and Quality Group. 

The process for identifying vulnerable patients has been strengthened and is defined in section 
7.2: 

Across  both  simple  and  complex  discharges,  particular  attention  will  be  paid  to  patients 
considered  as  vulnerable,  who  may  not  be  coping  with  living  in  the  community  (i.e.  lack  of 
utilities) and/or have multiple needs or a high level of dependency. This could include, but is not 
limited to, patients with the following features: 

•  Are elderly and live alone. 
•  Are terminally ill or have a rapidly deteriorating condition. 
•  Have functional disabilities in self-care or have a history of self-neglect or hoarding. 
•  Are confused or have a cognitive impairment or memory loss. 
•  Are nutritionally compromised. 
•  Have any form of communication difficulties. 
•  Have mental health problems or a history of self-harm. 
•  Have a learning disability. 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 •  Are homeless and have ‘no fixed abode’ or those patients in temporary accommodation. The 
Trust has a duty to refer any adult who is declaring themselves to be homeless, or at risk of 
becoming homeless under the Homelessness Reduction Act (2017). 

•  Have  specialised  medical/nursing  needs,  e.g.  patients  on  home  non-invasive  ventilation, 
tracheostomies,  enteral  feeding,  Hickman  lines,  continuous  ambulatory  peritoneal  dialysis 
(CAPD) or home dialysis. 

•  Are prisoners. 
•  Asylum seekers. 
•  Overseas visitors, or those not entitled to NHS care. 

The process for ensuring families are involved when patients are discharged from hospital are 
embedded within the policy. See below: 

Section 6 

•  Risks  associated  with  discharge  will  be  promptly  identified  through  discussion  with  the 
patient, relatives, and carers. Other personnel will be involved according to the needs of the 
individual. 

•  Patients,  relatives,  and  carers  will  be  central  to  the  planning  of  care  and  the  successful 

discharge. 

•  Prior to discharge, patients, relatives, or carers are given details of arrangements; contact 
details;  support;  and  any  relevant  information  regarding  their  future  treatment  and  care. 
Discharge  medication  information  and  counselling  will  be  given  by  the  Registered  Nurse 
discharging the patient and the ward pharmacist. 

Section 17 Patient/carer (or relative/family member) Involvement 

It is essential that the patient and, with permission, their carer, relative or family member are included 
in the ongoing assessment and care planning in relation to discharge planning, and that information 
is provided in a way that helps them to make decisions about their treatment and care, along with 
plans for discharge. 

During their stay in hospital a patient, and, if appropriate, their carer or family member should be 
provided with verbal/written information which will include: 

Investigations carried out, what the results were and what does that mean; 

•  Treatment plan and expected discharge date; 
•  Reason for admission and what the diagnosis is; 
• 
•  Treatment received and relevant information i.e. what treatment to continue and for how long; 
•  What side effects the patient might expect and what they should do if they experience them; 
•  What are the follow-up arrangements, including the needs for any further investigations; 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
  
 
 
 
  
 
  
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
  
 
  
 
 
  
 
 
  
 
 
  
 
  
 •  What is likely to happen in the future and does the patient have to change anything; 
•  Arrangements,  contact  details  and  any  relevant  information  regarding  the  patient’s  future 

treatment and care; 

•  Full information on the assessment of their health and/or social needs; 
• 
Information regarding their medication; 
•  Discharge arrangements and expectations; 
•  Where  patients  have  undergone  a  surgical  procedure,  they  will  be  given  written  /  verbal 

information which must include post-discharge advice. 

If  and  when  a  patient’s  care  needs  are  complex,  there  is  a  difference  of  opinion  between  the 
patient/carer/relative and the MDT, or there have been concerns raised either by the patient 
and/or their carer or relative in relation to the discharge plan, an MDT meeting should be held to 
collectively discuss the concerns and work through any mitigations or further action required. 
The Patient Advice and Liaison (PALS) team can support the patient, relative or carer with further 
negotiation with the MDT if required. 

If a patient lacks capacity and has no one appointed to act in their best interests relating to health 
and wellbeing (or finances), an Independent Mental Capacity Advocate (IMCA) will be required. This 
will be a joint decision between the Consultant (or GP in community settings), the discharge team 
(acute hospital), nursing teams and the relevant social care team i.e. allocated social worker. 

18.Carer’s Assessment 

A carer is a person who provides or intends to provide care for another adult. It is either a relative or 
a friend who assists another person in their day-to-day life. This is different from someone who offers 
care  professionally  or  through  a  voluntary  organisation.  This  could  include  helping  with  personal 
care, washing, and  dressing, nutritional needs, escorting them to appointments, or keeping them 
company when the cared person is lonely or anxious. 

A carers needs must be considered during the discharge planning process, and a carers assessment 
may need to be undertaken by the appropriate social work team, as per the Care Act (2014) and the 
Health and Care Act (2022). Factors that need consideration include: the carers role, breaks and 
social  life,  physical  and  mental  wellbeing,  finance,  work  responsibilities,  education  and  training, 
future caring role, practical and emotional support, emergencies and alternative care arrangements, 
access to information and advocacy, personal safety, and risk management. 

All staff have been informed of the updated policy through the staff bulletin which is sent out to 
all staff and the importance of safe discharge including the new policy through learning bulletin 
for  patient  safety  “Topic  of  the  Week”  which  provides  information  on  Trust  patient  safety 
priorities.  Departmental leads are required to provide evidence to the senior leadership team 
that the clinical staff in their areas have read and understood the policy by 1st July 2024. 

To monitor the effectiveness of these changes, discharge process has been registered for the 
2024-2025 clinical audit plan for trust wide audit. There has been additional focus in the area 
where Mr Clayton was cared for with a baseline audit in May 2024 prior to the policy and weekly 
audits led by the senior nursing staff. 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
  
 
  
 
  
 
 
  
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
   
 Second Concern 

The second concern is as follows: 

‘There was a misunderstanding by a clinician in relation to whether capacity to make a 
decision can be relied on to justify actions taken when the requisite information which 
needed  to  be  considered  by  Mr  Clayton  in  relation  to  that  decision,  and  its 
consequences had not been provided to him. Mr Clayton’s expressed wish to go home 
alone, without any care plan in place, was relied on, erroneously, to justify an unsafe 
discharge on the bases that he had capacity’. 

Trust response 

Following the investigation, the safeguarding training at the Trust has been reviewed and training 
has  been  updated  include  Mr  Claytons  case  anonymised  to  support  training.  Following  the 
inquest,  further  actions  have  been  taken  to  strengthen  the  training.  Whilst  currently  Mental 
Capacity Act training is included as part of Safeguarding Training, the Trust has reviewed the 
safeguarding training, and will deliver the training in 2 separate sessions with eLearning modules 
which are being imported from St George’s Hospital to support the face-to-face offering. This 
will  further  allow  staff  to  have  further  developed  their  understanding  and  responsibilities  and 
duties under the Mental Capacity Act than currently in one single session. The specific Mental 
Capacity Act training objectives are; 

•  Understand the 5 principles of the Mental Capacity Act (MCA); 
•  Understand the stages of decision-making outlined by the MCA; 
•  Knowledge of the key steps to assist people to make moderately complex decisions; 
•  Understand the two-stage test of capacity; 
•  Understand what a comprehensive capacity assessment looks like; 
•  Knowledge of when and how to make a "best interests" decision; 
•  Understand  how  to  document  both  the  capacity  assessment  and  the  "best  interests" 

decision making process. 

This will go live on 1 August 2024. 

As well as the existing scheduled safeguarding training sessions during 2024/2025, an additional 
member of the Safeguarding team has been employed to facilitate increased training sessions 
to provide additional training within areas where there are high numbers of medical discharges 
including Buckley Ward and provide additional sessions above previously scheduled sessions. 
The discharge coordinators across the Trust will additionally receive individualised training on 
safeguarding  and  mental  capacity  assessments.  Compliance  with  safeguarding  and  mental 
capacity  assessment  training  will  be  monitored  through  the  statutory  and  mandatory  training 
dash boards for each division in the Senior Leadership Team Meetings. 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 Third Concern 

The concern in relation to both Epsom General Hospital and NHS England set out in 
the Report is as follows: 

‘The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly 
considered discharge plan and led to rushed under-informed decision making’ 

Trust Response: 

As a result of the Inquest and the concerns raised, the Trust has revised the discharge 
policy to ensures that the processes to gather the information required, the responsibilities of 
clinicians and the escalation processes for safe, timely and appropriate discharge of patients 
are clear. Staff have been encouraged to escalate to their senior managers when they have 
concerns regarding discharge through the Topic of the Week. The Site Chief Medical Officer 
and Site Chief Nursing Officer has presented this at key senior leadership meetings including 
the Clinical Leads meeting, Divisional Senior Leadership Team meeting and Divisional 
Medical Directors meetings. Escalation processes have been strengthened to ensure that 
there is a clear pathway for escalating concerns for clinical and clinical operational teams 
within working hours and out of hours. 

Conclusion 

As a result of the inquest and the concerns raised 

1.  The Trust has reviewed, updated and approved the Hospital Discharge and Criteria to 

Reside Policy. This has highlighted: 

a)  The  process  for  identifying  vulnerable  patients  under  the  care  of  the  Trust  is 
emphasised including the importance of considering these patients in the context of 
complex discharge processes. 

b)  The importance of family involvement in decision making in patients when planning to 

discharge including the safety of the discharge. 

c)  The policy is now being shared across the trust and the effectiveness of the policy will 
be monitored to provide assurance of compliance with the standards within the policy. 
The effectiveness of the new policy will be reviewed through planned audits which will 
be presented and monitored by the Patient Safety and Quality Group. 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience. 

 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 2.  The Trust has reviewed and refreshed the safeguarding and mental capacity staff training 

with: 

a)  An  immediate  focus  for  improving  the  skills  for  staff  working  in  high  discharge 
departments  by  completing  any  outstanding  aspects  of  safeguarding  training, 
including mental capacity assessment and providing additional bespoke sessions for 
staff in these areas. 

b)  As well as existing scheduled safeguarding training sessions during 2024/25 which 
includes anonymised information in relation to Mr Clayton’s case, a member of the 
Safeguarding team has been employed to facilitate further training in departments and 
other  sessional  opportunities,  to  ensure  training  completion  across  professional 
groups. This includes discharge coordinators who support the discharge processes in 
the Trust. Compliance with safeguarding training by divisions is monitored through the 
divisional score card at the monthly Finance and Performance meeting chaired by the 
Managing Director of the Trust. 

c)  Communication  has  been  sent  across  the  Epsom  &  St  Helier  University  Hospitals 
Trust site and Group which provides anonymised learning and actions taken in relation 
to Mr Clayton’s case. 

3.  Concern in relation to both Epsom General Hospital and NHS England: 

a)  The  Trust  has  emphasised 

through 
that  safe  discharge 
communications with staff particularly highlighting the expectations of safe discharge 
encompassed within the policy including escalation processes where required. 

is  a  key  priority 

I hope that this letter has provided you with assurance that your concerns have been taken very 
seriously  by  the  Trust and  that our procedures  and  processes have  been revised  to address 
those concerns. 

We will share this letter with the family of Mr Clayton and hope that it provides them with some 
reassurance that the Trust now has safeguards in place to ensure patients, their families and 
carers are actively involved in discharge processes to ensure safety. 

Yours sincerely, 

Group Chief Executive 

GESH is a collaboration between St George’s, Epsom and St Helier University Hospitals 
Health Group. We’re working to create an outstanding healthcare experience.