Rosie Young

Chief Executives Office 
2 Kings Court 
Charles Hastings Way 
Worcester 
WR5 1JR 

Tel: 

Email:  

www.hacw.nhs.uk 

11 April 2024 

Mr D D W Reid  
HM Senior Coroner  
Worcestershire Coroner’s Court  

Sent via email to: 

Dear Mr Reid,  

Re:   The Late Rosie Young  

Regulation 28 report to prevent future deaths - response 

Thank you for sending your Regulation 28 report. I appreciate that issues arose in this 
Inquest, which led to your concerns that appropriate learning had not taken place.  In your 
report, you highlighted the following points of concern, and I will respond to these 
individually:- 

1.  Over  the  course  of  the  inquest,  it  was  quite  apparent  that  few,  if  any,  of  the 
witnesses who gave evidence, including several employees of your Trust, were 
familiar with the version of the Mental Health Act Transportation Policy which 
was in force at the time of these events. This policy governed the assessment of 
risk involved in transporting a patient detained under the Mental Health Act 1983 
to a psychiatric unit and stipulated the measures to be deployed to mitigate that 
risk. 

2.  The witness who presented your Trust’s internal investigation report into events 
surrounding  Rosie’s  death  told  the  inquest  that  your  Trust  had  not  actually 
obtained, or even requested the applicable version of the policy (v.5) until April 
2022 – 14 months after the previous version had expired – and that Trust staff at 
the  s.136  suite  in  Worcester  were  still  not  aware  of  it  by  October  2023  –  30 
months  after  the  previous  version  had  expired.  That  same  witness  told  the 
inquest “I cannot tell you that a system is now in place to ensure that the Trust’s 
staff  have  read,  understood  and  signed  a  document  to  confirm  that  they  are 
aware of every policy that applies to their role – despite the fact that the Trust’s 
own internal review which highlighted this deficiency was months ago” 

Chief Executive: 
Chair: 

 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 The  Trust  fully  recognises  that  the  process  for  clinical  policy  management  requires 
improvement. This observation has also been made during our recent CQC inspection and 
forms part of our improvement plan to address these concerns. As  an immediate action we 
are undertaking current state analysis over the next three months to establish a tracker for 
clinical policies that outlines: 

•  Policies that are in date and have expired, or are approaching expiry, 
•  Policy owners and authors and the appropriateness of the allocation, 
•  Analysis of the completion of equality impact assessment, 
•  Which services and teams each policy is applicable to so that services and teams are 

fully sighted on which policies are applicable to their service. 

Once current state analysis is established, we will formulate more detailed remedial actions 
for any gaps identified. We are already aware of a need to review the governance process for 
policy management, including provision of education and support for those involved in writing 
and reviewing policies. We are also aware of a need to clarify process and expectations in 
relation to equality impact analysis for each policy.  

Part of the enhanced process will include management of policies written by system partners 
that are applicable to services within our organisation.  

I  can  confirm  that  following  the  adoption  of  the  West  Midlands  Ambulance  (WMAS) 
Transportation  policy on 1  February 2024  that  this has  been  disseminated  through  clinical 
teams who may need to use the policy. The policy has also been updated on our intranet.  
However, due to issues unrelated to this matter, the Trust now contract with an independent 
provider (E-Med) to  convey  patients  who  are  liable  to  be  detained  under the  MHA  and so 
whilst we have the WMAS transportation policy in place, it may be used less frequently on a 
practical basis. 

For  further  assurance  in  relation  to  this  specific  case,  following  discussion  at  the  monthly 
Urgent Care Interface Meeting (attended by all Clinical Leads and Service Managers), it has 
been agreed to broadly standardise the local induction process while accepting that there are 
a number of policies/procedures that will be specific to certain teams. As a consequence of 
these discussions, all services in Urgent Care will now employ the following guiding principles 
in addition to the standard corporate induction process; 

- Local Induction (new starter): paperwork must include a list of policies and procedures that 
are service specific and/or necessary for staff to perform their role effectively. On completion 
of  the  induction,  new  staff  should  sign/date  a  form  confirming  that  they  have  read  and 
understood these documents (a copy of this form should be retained in their personal file). 
Given the remit of services, it is inevitable that any list may not be exhaustive – it will therefore 
remain the responsibility of individual staff to find relevant information (where necessary) or 
seek further advice/support from their immediate line manager.   

- New and updated policies/ procedures: each service will create an electronic spreadsheet 
(on  Excel)  containing  the  names  of  all  clinical  staff  –  the  team  Administrator  will  then  be 
responsible for local upkeep of the spreadsheet, listing the name/date of any new or updated 
policies or procedures and how this information has been communicated to individual staff 
members i.e. read-receipt email, business meeting, supervision. 

 
 
 
 
 
 
 I hope that you will feel assured that this will ensure staff are sighted on policies relevant to 
their roles. 

3.  Your  Trust’s  own  internal  investigation  into  the  events  surrounding  Rosie’s 
death was itself flawed, in that it had failed even to identify, let alone investigate, 
important  issues  with  the  care  which Trust  employees  had  provided  to  Rosie 
around  the  time  of  her  death.  Natalie  Willetts,  the  Trust’s  Head of  Quality and 
Nursing, said in her evidence to the inquest that although the report disclosed 
to the Coroner purported to be a root cause analysis (RCA) investigation report, 
it was nothing of the sort, not least because RCA techniques were not used in 
the investigation. Ms Willetts told the inquest: 

a.  Neither of the two co-authors of the Trust’s report (Della Jay – then Head 
of  Safety,  and  Alison  Schanz  –  another  member  of  the  Patient  Safety 
Team) were actually named on the report, or identified to the Coroner’s 
Office as co-authors of the report; 

b.  One  of  the  co-authors  of  the  Trust’s  report  (Della  Jay)  had  signed  the 
Incident  forum,  something  which  was 

report  off  at  the  Serious 
inappropriate and should not have happened; 

c.  When the witnesses who ended up presenting the Trust’s report at inquest 
escalated concerns in March 2023 about the report’s inadequacies, and 
suggested  that  the  Trust  needed  to  conduct  a  more  comprehensive 
investigation  before  the  inquest,  the  decision  was  taken  that  this  was 
unnecessary, and that learning could be identified from gaps in the report 
which the witness was now identifying. That decision was taken by Alison 
Scands,  something  that  was  inappropriate  for  her  to  do,  given  that  she 
was one of the report’s co-authors. 

My concern is that, unless proper structures and procedures are put in place at 
the Trust, future investigations like this may continue to be flawed, and may fail 
(as this one did) to identify the sorts of issues which should be identifying. If the 
issues  are  not  identified,  the  Trust  is  unlikely  to  identify  learning  from  these 
issues, or to take action to prevent them in future. That, it seems to me, will mean 
that circumstances creating a risk of other deaths will occur of continue to exist 
in the future.  

In relation to management of Serious Incident investigations the Organisation fully accepts 
that in this case our approach was flawed and insufficient. This appears to be due to internal 
miscommunication which led to confusion in approach. As an immediate action to rectify this, 
we have commissioned a Patient Safety Incident Investigation (PSII, the methodology under 
the new Patient Safety Incident Response Framework replacing Root Cause Analysis). The 
investigator has met with Rosie’s parents as an integral part of the investigation, as have our 
Director of Nursing and Quality and Medical Director. Our investigation is almost complete 
and we are currently working on appropriate improvement actions prior to taking the report 
through our governance sign off process. The investigator will keep Rosie’s parents updated 
as the investigation progresses. We would also be willing to share a copy of the report with 
your office should this be of assurance to you.  

As you may already be aware we are transitioning across from the Serious Incident framework 
to the Patient Safety Incident Response Framework (PSIRF) and we will cease reporting of 
Serious  Incidents  on  the  old  framework  from  8th  April  2024.  We  anticipate  embedding  the 
transition over the next twelve months which includes finalising a policy and an organisational 

 
 
 
 
 
 
 
 incident response plan. One key difference of PSIRF being that incidents that involve multiple 
system partners will be coordinated by the Patient Safety Team at the Integrated Care Board 
(ICB) in order to ensure a joined up and cohesive approach to system learning.   

To ensure incidents are appropriately investigated we have instigated a new set of processes. 
A daily incident triage involving patient safety experts has commenced which ensures that all 
incidents are reviewed and allocated to the appropriate level of investigation. Where further 
clarity or a multi-disciplinary decision is required, this is escalated to the twice weekly safety 
huddle which is attended by the Medical and Nursing Directors. A tracker has been developed 
to enable the patient safety team to maintain oversight of all open investigations and ensure 
they are completed in the relevant timescales. Incidents of the highest severity or with learning 
are  presented  at  the  Serious  Incident  Forum,  chaired  by  the  Director  of  Nursing  and  all 
learning is then monitored through our quality governance processes. 

We  have  some  work  to  do  to  ensure  that  cases  subject  to  inquest  that  are  not  being 
investigated under PSIRF, and therefore will not have an investigation report, have a sound 
methodology to outline service delivery to support the progress of the inquest. We hope to 
engage with you alongside our system partners, to find a solution that meets the needs of the 
Coronial process. We have also recognised that we can do more to join up working between 
our  legal  and  patient  safety  teams  and  with  this  in  mind  have  established  a  series  of 
collaboration touch points to enhance the working relationship. 

Further to this, we plan to hold a debrief session with all staff involved in this inquest to offer 
wellbeing support and identify further learning on our approach to the coronial process.  

I hope that this reassures you that the Trust recognises short comings in relation to this tragic 
case  and  is  taking  steps  to  learn  and  improve  as  a  result  and  hope  that  this  adequality 
addresses your concerns.   

I would be grateful if you would kindly send a copy of my response to those whom you copied 
your regulation 28 report. I have no submissions to make about publication of the response. 

Yours sincerely 

Chief Executive

Your Ref: N/A 
Our Ref: 

Mr D Reid 
HM Senior Coroner for Worcestershire 
The Civic 
Martins Way  
Stourport on Seven  
DY13 8UN 

9 April 2024 

Dear Mr Reid 

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  Rosie  Catherine  Young 
(Deceased) 

Thank you for your email dated 22 February 2024 attaching your Regulation 28 Report.  

On behalf of West Midlands Ambulance Service (WMAS), I am sorry that you have had to 
raise concerns following the inquest of Ms Young.  May I please take this opportunity to 
pass on my sincere condolences to the family of Ms Young. 

Please see our response to your concerns. 

Concern 1 
Over the course of the inquest, it was quite apparent that few, if any, of the witnesses who 
gave evidence, including several employees of your Trust, were familiar with the version 
of  the  Mental  Health  Act  Transportation  Policy  which  was  in  force  at  the  time  of  these 
events. This Policy governed the assessment of the risk involved in transporting a patient 
detained under the Mental Health Act 1983 ( the MHA) to a psychiatric unit, and stipulated 
the measures to be deployed to mitigate that risk; 

Response 

1.  A piece of work has already been undertaken to review the Trust’s Mental Health 
Act Transportation Policy, in consulation with multi-agency partners, in order to 
update  this  document  to  ensure  that  lessons  learnt  in  this  case  have  been 
captured.  This  revised  document  is  now  live  and  has  been  shared  with  multi-
agency partners across the West Midlands. 

2.  A  clinical  notice  has  be  produced  and  disseminated 

internal 
communications  channels  to  highlight  the  requirements  of  the  Trust’s  Mental 
Health Act Transportation Policy to its staff 

through 

3.  Further  education  will  be  disseminated  to  staff  through  the  weekly  briefing  and 
clinical times publications to expand upon the requirements of the Mental Health 
Act  Transportation  Policy  and  the  role  of  WMAS  staff  in  supporting  this  patient 
group. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 2 
The  witness  who  presented  your  Trust's  internal  investigation  report  into  the  events 
surrounding Rosie's death told the inquest: 
"None of our employees would have received specific training about the Transportation 
Policy- I accept that means this crew would not have known to ask for the Risk Assessment 
Tool [ an important document provided in the Policy to assess the risk posed by the patient 
to be transported ]. I would have thought they would have known to ask for the Written 
Authority to Transport [ another important document provided in the Policy, by which the 
Approved Mental Health Professional ( AMHP) delegates responsibility for the detained 
patient to those transporting her ], as they do receive training about that. If they didn't know 
about either of those forms, I accept that they may not have been an appropriate crew for 
this job." 

Response 

1.  Additional specific training has been incorporated into the Trust’s Statutory and 
Mandatory  eLearning  workbook  for  24/25  in  respect  of  Mental  Health  Act 
Transportaiton, including in respect of the risk assessment. 

2.  With  recent  funding  from  NHS  England  the  Trust  has  employed  Mental  Health 
Clinical  Development  Officers  to  improve  the  training  and  education  to  all  staff 
across the Trust in relation to the care provided to patients suffering from a mental 
health crisis. 

3.  The Trust will review its initial training packages for all new staff in patient facing 
roles  to  ensure  that  appropriate  content  is  provided  to  support  their  knowledge 
and practice in respect of patients transported under the Mental Health Act. 

Concern 3 
It seems that your Trust appeared at the time of these events to have had no system in 
place to ensure that those of your employees who dealt with the transportation of patients 
detained  under  the  MHA  were  familiar  with  and  trained  to  apply  the  provisions  of  the 
version of this Policy which was in force at the time. It is of concern therefore that if that 
remains the case, not only in relation to the MHA Transportation Policy, but in relation to 
other  policies  and  procedures  under  the  MHA,  circumstances  creating  a  risk  of  other 
deaths will occur, or will continue to exist, in the future. 

Response 

1.  Work is ongoing to implement changes to the Trust’s electronic patient record to 
ensure  that  risk  assessment  documentation  and  Mental  Health  Act  paperwork, 
including  section  papers  and  delegation  of  authority  authorisation,  can  be 
appropriately recorded within a dedicated section of the WMAS patient record. 
2.  Additional specific training has been incorporated into the Trust’s Statutory and 
Mandatory  eLearning  workbook  for  24/25  in  respect  of  Mental  Health  Act 
Transportaiton, including in respect of the risk assessment. 

3.  With  recent  funding  from  NHS  England  the  Trust  has  employed  Mental  Health 
Clinical  Development  Officers  to  improve  the  training  and  education  to  all  staff 
across the Trust in relation to the care provided to patients suffering from a mental 
health crisis. 

4.  The Trust will review its initial training packages for all new staff in patient facing 
roles  to  ensure  that  appropriate  content  is  provided  to  support  their  knowledge 
and practice in respect of patients transported under the Mental Health Act. 
5.  Following all the above actions an audit will be produced to ensure compliance 

with the Mental Health Act Transportation Policy. 

 
 
 
 
 
 
 
 
 
 All of the Trusts Policies and Procedures are available to all staff through a web based 
platform called Policystat. All staff throughout the organisation can access this platform 
through a variety of devices both internally and externally. The requirments relating to the 
transport  of  persons  detained  under  the  Mental  Health  act  form  part  of  the  basic 
ambulance training. 

May I once again pass on my sincere condolences to the family of Ms Young. I am sorry 
we let Rosie and her family down. 

I hope this response provides you and the family with the appropriate level of assurance 
that as a Trust we are actively dealing with the concerns highlighted within your report, 
with the actions being undertaken managed through our Trust governance structures. 

If you require any further assistance, please do not hesitate contact me. 

Yours sincerely 

Executive Director of Nursing 

     Paramedic Practice & Patient Safety Director