Karen Thomason

26 June 2024 

PRIVATE AND CONFIDENTIAL  
Mr Robert Cohen 
HM Assistant Coroner for Cumbria 
Fairfield 
Station Road 
Cockermouth 
Cumbria  
CA13 9PT  

Dear Mr Cohen, 

Re: North Cumbria Integrated Care’s Regulation 28 Response and Action Plan 
Concerning the Inquest into the death of Karen Thomason 

I write following the inquest that you resumed on 02 May 2024 into the death of Karen Thomason. 
You concluded that Ms Thomason sadly died on 01 November 2023 at her home address in Carlisle, 
Cumbria.  The medical cause of death was confirmed as: 

1a Acute Ethanol Toxicity  
1b  
1c  

A conclusion was recorded as Alcohol Related death.  

During the inquest the evidence revealed matters, giving rise to concern and you felt future deaths 
may  arise  if  the  Trust  did  not  take  action.  Therefore,  as  is  your  statutory  duty,  you  reported  the 
matters of concern and issued a Regulation 28 to the Trust.  As you are aware, the Trust was not 
requested  to  be  in  attendance  at  the  inquest.    I  was  saddened  to  learn  of  the  circumstances 
surrounding  Ms  Thomason’s  death  and  on  behalf  of  the  Trust,  I  wish  to  extend  my  sincere 
condolences to her family and friends. 

I am grateful to you for raising your concerns to me. It is imperative to the Trust that safety issues 
are identified and rectified to ensure our services are safe and effective. 

The Trust has undertaken a thorough review of Ms Thomason’s care and the concerns raised within 
the Regulation 28 Report. A number of actions have been identified which will be implemented to 
address the concerns. 

Please  accept  this  letter  as  the  Trust’s  formal  response  to  the  Regulation  28  Report,  which 
incorporates  the  identification  and  embedding  of  all  learning  relevant  to  Ms  Thomason’s  case, 
whether identified by the Regulation 28 Report or not. 

Pillars Building, Cumberland Infirmary, Infirmary Street, Carlisle, Cumbria, CA2 7HY 
01228 523444 www.ncic.nhs.uk 

Safe, high quality care every time 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 Concern 1 

There were errors in the completion of the hospital's safeguarding questions. The clinician 
answered 'no' to the question 'Is there a safeguarding concern?'. The clinician's evidence 
was that, in fact, she did have a safeguarding concern and explored it with Ms Thomason, 
but that she completed the electronic form in error. I am concerned that the form is regarded 
as a 'tick box' exercise rather than a vital safeguarding tool. 

Safeguarding  routine  enquiries  within  Symphony  (the  Emergency  Department’s  (ED)  electronic 
patient record system) is an opportunity for staff to explore and record if there are any safeguarding 
or  mental  health  concerns,  whether  the  patient  feels  unsafe,  and  if  there  are  any  caring 
responsibilities (whether they care for someone or if anyone cares for the patient).  The response to 
all  safeguarding  routine  enquiries  within  Symphony  during  Ms  Thomason’s attendance to  ED  on 
31/10/2023 was ‘No’.   

An ED Advanced Clinical Practitioner (ACP) took a history from Ms Thomason, which did include a 
safeguarding discussion.  A safeguarding alert was also applied on Symphony, albeit this is visually 
quite  subtle  within  the  system.    Ms  Thomason  was  deemed  to  have  capacity  and  was  able  to 
respond  to  questions  of  concern  around  her  social  and  vulnerable  state.  During  this  discussion, 
social circumstances were explored, and Ms Thomason demonstrated her awareness of her alcohol 
related problems.  She stated she was intending to get back in touch with alcohol support services 
(Recovery  Steps),  which  she  was  previously  known  to.    When  asked  about  some  bruising,  Ms 
Thomason explained that this was a result of multiple episodes of falling. When asked specifically if 
anyone cared for her at home, which is part of the safeguarding routine enquiry questions within 
Symphony, Ms Thomason responded “no”, but that a Housing Officer was keeping a close eye on 
her.  Considering  all  of  this  information,  the  treating  team  felt  there  were  no  new  safeguarding 
concerns; she was well known to all relevant services and relevant support was already in place for 
Ms Thomason.    

The ACP’s safeguarding discussion with Ms Thomason was recorded within the clinical assessment 
on  Symphony,  within  a  mandatory field  (‘clinical  narrative’).  This demonstrates evidence  of  good 
assessment  and  record  keeping  and  provides  the  rationale  for  the  decision  to  select  ‘no’ 
safeguarding concerns. Clinical narrative option within symphony is there as a tool/place to free text 
and record discussions with patients. 

While there is always the possibility of clicking the wrong box in error, we found on this occasion the 
ACP had explored the social background thoroughly and clicked “no” safeguarding concerns. 

for  exploration  and  completion.  These  additional  questions 

To  further  explain  and  expand,  clicking  “yes”  opens  up  an  additional  list  of  questions  related  to 
safeguarding 
further 
consideration of patient behaviour, their explanations of any injuries and whether the explanation 
and history provided gives cause for concern or is inconsistent with the presentation. Ms Thomason 
was considered to be sufficiently alert and orientated and with capacity and therefore these would 
have been unlikely to yield anything additional. 

include 

The clinician’s statements coupled with the symphony record for this patient provides evidence that 
on this occasion the safeguarding of Ms Thomason was taken incredibly seriously. The ACP clinician 
has demonstrated that they had a full safety and welfare conversation with Ms Thomason. We do 
not believe the safeguarding box was checked in error on this occasion. 

We do recognise however, that it is possible that our clinicians are limited by the question on our 
electronic  ED  system.  The  question  is  rigid  in  its  current  format  and  doesn’t  allow  clinicians  to 
distinguish between historic safeguarding concerns and new concerns for immediate action during 
an ED attendance.  

 
 
 
 
 
 
 
 
 
 
 RECOMMENDATION  1:  change  the  symphony  safeguarding  question.  Consider  “are  there 
any new safeguarding concerns?” “Is there an existing safeguarding concern that is under 
control?”  Is  there  something  new  today  that  needs  action  today  to  deal  with  something 
different or unusual today? 

Concern 2 

There is evidence that Cumbria Housing staff had asked to be notified of the discharge of a 
vulnerable  patient  so  that  they  could  provide  support  to  her  but  that  they  received  no 
communications  on  several  occasions.  I  am  concerned  that  this  may  mean  that  other 
patients are discharged without appropriate support being alerted to their needs. 

Unfortunately,  the  ED  Team  were  not  made  aware  at  any  stage  during  Ms  Thomason’s  ED 
attendance, of any ask or requirement to notify the Housing Officer of Ms Thomason discharge or 
that the Housing Officer had any concerns, either by the Housing Officer themselves, the Ambulance 
Service, or Ms Thomason.  This was not conveyed verbally nor was it documented in the Ambulance 
records that were shared with ED on Ms Thomason’s arrival into the department.  

Ambulance records show that Housing Officers had been keeping an eye on Ms Thomason and that 
the Housing Staff had called the ambulance. The records also show that the Housing Officer had 
completed  an  adult  safeguarding  referral.  Paramedics  recorded  that  Ms  Thomason  had  capacity 
and they did not complete a vulnerable adult notification. There was no copy of any safeguarding 
referral or any document accompanying Ms Thomason alluding to any concerns or adult social care 
or housing officer contacts.  

Ms Thomason in her discussion with the ACP clearly articulated that the housing officer had been 
supporting her and keeping an eye on her and this was therefore recorded within the ED Symphony 
record as a positive safeguarding element of support. 

Ms  Thomason  was  deemed  sufficiently  recovered  to  book  her  own  taxi  and  make  her  own  way 
home. Every patient who leaves the emergency department after the medical decision has been 
made for discharge will have a conversation with staff about how they're going to get home and with 
whom,  however  these  are  not  mandated  fields  within  the  current  Symphony  system.      We  can 
however evidence this to a degree through our routine practise of arranging transport and taxis for 
multiple patients who struggle to arrange this for themselves on a daily basis.  

We do recognise however that this case highlights how vulnerable adults such as Ms Thomason 
could be better supported and safeguarded in particular when leaving the department and even in 
the knowledge of them being known to support services. Notwithstanding that even if people have 
what  we  regard  as  risky  behaviours  or  unsafe  lifestyles  they  do  have  the  capacity  and  choice 
(freedom of liberty) to do as they wish. 

RECOMMENDATION 2: Update Symphony to include discharge discussions for all patients. 
Include an ask “is there anything we can do or anyone we can notify before you go home?” 
Explore the “discharge screen” options on symphony to include a vulnerable adult question 
set. 

RECOMMENDATION  3: Re-launch our public messaging within the ED and promoting and 
encouraging  patients  to  let  us  know  if  they  feel  vulnerable,  feel  unsafe,  don’t  feel  safe  to 
leave.  

Concern 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The evidence I received places an emphasis on the fact that Ms Thomason had capacity and 
indicated  that  she  felt  safe.  It  is  certainly  correct  that  this  meant  that  there  could  be  no 
question of her being held in hospital. It is also correct that her view of her situation was of 
relevance. However, it does not mean that obvious vulnerability or safeguarding concerns 
could  not  be  addressed.  Regardless  of  what  Ms  Thomason  said,  her  vulnerability  was 
obvious. I am concerned that the concepts of 'having capacity' and 'not being vulnerable' are 
being elided. 

We recorded that Ms Thomason told us she had support and that the Housing Officers were already 
checking on her. She was aware of her need to engage with alcohol services.  We are not entirely 
sure that any further vulnerability measures could/should have been taken at that point that would 
have generated any further input.  Staff could have considered notifying Adult Social Care out of 
hours. 

We  do  recognise,  however,  that  EDs  are  often  placed  in  a  vulnerable  position  due  to  lack  of 
background information provided on attendance, and not having full insight into a patient’s social 
and safeguarding status in order to safely manage the situation.  With this in mind, and accepting 
an element of human factors, complexity, and subjectivity, we should continually aim to improve our 
understanding in this area for this patient group. 

Currently our mandatory Safeguarding Adults Level 3 Training for all clinicians is completed every 
3  years  and  stands  at  80%  completion  across  our  Emergency  Care  Collaborative  (88%  for  the 
organisation overall and 80.5% for our individual EDs).  This needs to improve in order that all our 
staff have an understanding of vulnerability and how to recognise it and act accordingly. We also 
recognise  that  while  this  training  is  important,  there  needs  to  be  some  additional  supplementary 
means of ensuring that staff are continually learning and using safeguarding best practise.  

Safeguarding  supervision  for  staff  working  with  children  is  mandated  within  the  Intercollegiate 
Document.    Staff  working  with  children  are  offered  Safeguarding  Children’s  supervision  which  is 
attended  quarterly.    Safeguarding  adults  supervision  is not  mandated but  recommended  as  best 
practice.  Safeguarding supervision sessions can help staff explore their own experiences as well 
as  support  colleagues  to  understand,  change,  and  improve  their  approach  collectively.    The  ED 
Team  recognise  that  engaging  with  this  approach  for  all  ages  of  patients  would  ensure  our  staff 
regularly discuss this and debate patient vulnerability, options for managing  them safely, improve 
professional understanding, provide peer to peer support through professional conversations, and 
potentially offer suggestions around improvements to systems and processes.  

RECOMMENDATION  4:    Improve  knowledge,  understanding  and evaluation of  practise  for 
vulnerable adults within the Emergency Departments. 

  Develop  an  offer  for  an  ED  safeguarding  supervision  for  adult  patients  (professional 
conversation) programme reflecting that which is mandated for staff working with children. 
Themes  could  be  set  for  the  professional  conversations  by  the  incidents  that  are  being 
shared, as well as local network strategic objectives.  This can be supported by the Trust’s 
Safeguarding Team to ensure that national and local best practice is shared, and support is 
offered for complex or challenging situations.  

  Ensure  that  all  relevant  members  of  staff  attend  mandated  Safeguarding  Training  at  the 

appropriate level (reviewed in relevant governance meetings.)  

  Trust  Safeguarding  Team  to  consider  the  development  of  future  routine  enquiry/domestic 
abuse training for the Trust (761 staff trained to date), and ensure attendance and learning 
for relevant staff.  Consider how this can be best shared with ED clinicians.  

 
 
 
 
 
 
 
 
 
 
 
 Once again, thank you for bringing your concerns to my attention.  I hope that the above provides 
assurance to you, Ms Thomason’s family, and the public, that the Trust has taken them seriously 
and appropriate action is being taken. 

I appreciate not all of the actions are yet implemented and I would be happy to provide updates on 
these in the future, should you require this.  Please also let me know if you require clarity on any of 
the responses I have provided above. 

Yours sincerely 

Chief Executive 
For and on behalf of North Cumbria Integrated Care NHS Foundation Trust