Samantha Angel

INHS

Portsmouth Hospitals

University
NHS Trust

Trust Headquarters
F Level, Queen Alexandra Hospital
Southwick Hill Road
Cosham
PORTSMOUTH, POG 3LY
Tel;

27" June 2024
Dear Mrs Whitby

Response to Regulation 28 report to prevent future deaths following the inquest into
the death of Samantha Jane Angel

| write to provide the Trust’s response to your regulation 28 report issued following the
inquest into the death of Samantha Jane Angel. For ease of reference the matters of
concern identified by you during the inquest are stated in italics below followed by the Trust’s
response.

1. The delay in resolving the investigation commissioned into the deceased's behaviour at
work.

2. The ease with which the circumstances leading to the allegation were made public
amongst the deceased's work colleagues and the consequences of that.

3. The recognition that the distress caused to the deceased by the publication of the
circumstances, should be a factor in accelerating a conclusion to an investigation, not just
the consequences of any findings of an investigation if negative to the deceased.

Trust Response

1. The delay in resolving the investigation commissioned into the deceased’s
behaviour at work.

3. The recognition that the distress caused to the deceased by the publication of the
circumstances, should be a factor in accelerating a conclusion to an investigation,
not just the consequences of any findings of an investigation if negative to the
deceased.

With regard to concerns 1 & 3 the Trust responds as follows:

Since Samantha’s sad death the Trust has made a number of improvements to the way it
handles and investigates Human Resources (HR) issues. A summary of those changes was
submitted to HM Coroner in the form of a statement from Nicole Cornelius, former Chief

Chair: EE Chief Executive:

|
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham,
PO6 3LY
Registered charity number: 1047986
Working To drive excellence in care for
our patients and communities

INHS

Portsmouth Hospitals

University
NHS Trust

People Officer at the Trust. Below is a summary of those points together with details of
further improvements which have been made since submission of that statement:

1. We have refreshed the leadership within the HR Operational Team, appointing a new
Head of Employee Relations and Inclusion to focus on providing methods to support our
managers and their supporting HR staff to enable them to keep checking on cases and to
ensure that staff welfare remains paramount. Concurrently, the new Head of Service, a
senior role, collaborates with the team to establish reporting metrics and Key Performance
Indicators (KPIs) for all HR case work.

2. We are utilising our partnership with the IOW Trust to explore the integration of their Case
Management System or a separate joint Case Management System to enhance our
investigative processes.

3. In the meantime, we are using our existing resources, namely the Electronic Staff Record
and Excel, to manage our caseload effectively. At any given time, we handle 35-40 cases
with the support of a proficient HR Advisory Team comprising 7 qualified professionals. In
line with our commitment to enhancing our investigative processes, significant improvements
are in development in the recording and monitoring of cases. These enhancements provide
a comprehensive overview of our total casework, facilitating more efficient prioritisation and
systematic review based on the length and complexity of each case. By refining our
recording and monitoring systems, this enables us to strategically prioritise cases based on
various factors, including their length, complexity, and urgency.

4. The HR Advisory Team utilise the just culture approach and understand the critical
importance of assessing the necessity for an investigation before a manager proceeds with
that course of action, often highlighting the viability of informal actions or learning
interventions as an appropriate alternative to a formal investigation. Ongoing efforts include
providing refreshed training sessions for managers, utilising anonymised cases that
underscore the significance of sound decision-making and adept case management.

5. In looking ahead to the future, our long-term vision includes a strategic and thorough
assessment of our policies and processes to solidify and promote a culture centred on
fairness and continuous learning. This involves a proactive and comprehensive review of all
existing policies and procedures to ensure they align with the principles of a just and learning
culture. Our plan encompasses a structured approach to embedding this culture throughout
the organisation, focusing on fostering transparency, accountability, and a commitment to
ongoing improvement. By revisiting and revising our policies, we aim to create a supportive
and empowering work environment where employees feel encouraged to learn from
‘experiences, share feedback openly, and contribute to a culture of continuous development.
This long-term strategy involves the implementation of tailored training programmes,
workshops, and awareness campaigns to reinforce the values and behaviours associated
with a just and learning culture.

6. Regular reviews of cases are routinely conducted by our HR operational team and a
monthly review of cases completed by our professional standards committee ensures
ongoing oversight of case progress. Our letters which go out to employees during informal

Chair: Chief Executive:
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham,
PO6 3LY

5 Registered charity number: 1047986
Working To drive excellence in care for
together our patients and communities

INHS

Portsmouth Hospitals

University
NHS Trust

and formal processes routinely contain information about support and wellbeing services
available, including access to “Care First” for confidential counselling and mediation
services. In addition, employees under investigation are assigned a wellbeing contact who
will check in with the employee throughout the duration of the investigation.

7. Further enhancing our initiatives, we are developing a comprehensive training programme
for our HR advisory team, specifically focusing on areas such as safeguarding and fostering
equality in the workplace. To bolster our investigative capabilities, we are expanding our pool
of trained investigators across the Trust, a move intended to enhance the efficiency and
effectiveness of our hearing procedures. While external investigators are occasionally
engaged for cases involving urgent or serious issues, the associated costs inhibit routine
utilisation.

8. The introduction of a Protected Time Agreement and Protocol for Investigating Officers
underscores our commitment to prioritising the health and wellbeing of all parties involved in
investigations. Notably, the Protocol outlines steps for immediate action to address signs of
distress or wellbeing concerns during the investigation process. It is designed to establish a
framework that ensures Investigating Officers have dedicated time to effectively conduct
investigations, review documents, interview involved parties, and prepare reports in
accordance with disciplinary and grievance processes. It also emphasises the importance of
ensuring the wellbeing of all individuals involved in the investigation process. Included in the
protocol are the following points:

1. Observation and Action: Investigating Officers are tasked with observing signs of
distress, anxiety, or other issues that may impact the mental or physical health of any
party during the investigation PIOGESS: Immediate action is required to address these
situations promptly.

2. Supportive Measures: If signs of distress or concerns regarding health and
wellbeing are identified, appropriate steps should be taken to offer support and
assistance. This can include referring individuals to internal support services, HR
representatives, occupational health services, or external counselling services as
necessary.

3. Escalation Process: In cases where distress or wellbeing concerns are significant
and require urgent attention, the Investigating Officer is instructed to escalate the
matter promptly to the designated authority in the Human Resources department.

4. Documentation and Sensitivity: Instances where concerns are raised for the health
and wellbeing of individuals involved in the investigation should be documented
properly and handled with sensitivity, confidentiality, and professionalism to ensure
effective support and resolution.

2. The ease with which the circumstances leading to the allegation were made public
amongst the deceased's work colleagues and the consequences of that.

With regard to concern 2 the Trust responds as follows: .

Chi Chief Executive
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham,
PO6 3LY
Registered charity number: 1047986
Working To drive excellence in care for
our patients and communities

INHS

Portsmouth Hospitals

University
NHS Trust

1.The Trust has an established risk management system (Datix Cloud IQ, known as Datix or
DCIQ) and this includes a category for staff to report staff on staff incidents. In some cases,
there may be direct conversations which are not reported onto the system, and instead
discussed with Managers and/or the Human Resources team who will log this.

When an incident is submitted there is a pop up on the narrative section to remind staff not
to include any personal identifiable data (PID) information in the free text box, however staff
on occasion continue to do this. All training that is provided, and in the guidance documents,
it is clearly stated not to use PID in free text boxes. The reviewers of incidents are advised to
ensure that PID is removed when an incident review commences and to remind the reporter
not to do this if it has been included.

As a result of learning from this case, a new message has been added to the front page of
the system that all reporters of incidents see when they log in:

“Please be aware that Personal Identifiable data (PID) MUST NOT be included in the
description and action taken fields of any incident that you are reporting”. ;

2.The distribution list for incident forms includes those members of staff who require visibility
of the incident in their area of work or speciality to enable them-as part of their role and
responsibilities-to review, investigate, have awareness of, and manage incidents. For
example, the Accredited Security Management Specialist is notified in order that they can
give specialist input and offer advice regarding any review/investigations related to violence
and aggression.

In response to concerns raised regarding the notification list, we have requested
Governance Leads to review their notifications lists to check for accuracy, this is planned for
completion by the end of July.

3.In partnership with the Trust Communications Team, we have also initiated a
communications and engagement plan for all staff to remind them of the importance of not
including PID, in the “description” and “actions taken” fields of any incident reported on
DCIQ.

This plan includes direction and guidance regarding not circulating details, including PID of
incidents they have visibility of, in line with Caldicott Principle 4: Access to confidential
information should be on a strict need-to-know basis.

The Trust wide messaging will be via ‘Trust Talk’, a weekly electronic newsletter delivered to
all staff with a Trust email account, various Trust authorised social media accounts and
across associated:-social media platforms and finally the Trust screensaver which has reach
across all Trust computers.

ni iii Chief Executive:
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham,
PO6 3LY
e Registered charity number: 1047986
Working To drive excellence in care for
together our patients and communities

INHS'

Portsmouth Hospitals

University
NHS Trust

Sam’s death was a tragedy for her, her family and friends, and colleagues as well as the
Trust which lost a valued employee. | hope that the contents of this response provides HM
Coroner with appropriate assurance that the Trust has learnt from Sam’s sad death and is
working hard to provide the wellbeing support needed to those employees involved in HR
investigations.

Yours sincerely

Chief Executive

Chair: Melloney Poole OBE Chief Executive: Penny Emerit
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham,
PO6 3LY
u Registered charity number: 1047986
Working To drive excellence in care for
t our patients and communities

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