Linda Heath

The Office of H.M Coroner
FAO HMAC Miss Sally Robinson

chcp

Excellence + Compassion + Expertise

City Health Care Partnership CIC
Business Support Centre
5 Beacon Way

Hull
The Guildhall HU3 4AE
Alfred Gelder Street
Hull Tel: as
HU1 2AA

Date 23" May 2024

Dear Miss Robinson
Inquest into the death of Ms Linda Heath

Following the above Inquest, assurance was requested from CHCP in regard to the following
matters.

(1) The Immediate Discharge Summary did not include relevant or sufficient information
about treatment in the community needs or a nursing summary.

(2) Despite the presence of a difficult sacral sore which would have benefitted from district
nursing care, no referral was made post discharge by the GP surgery.

(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients
who have recently been discharged from hospital and who are complaining of a
condition which may worsen and failing to attend routine appointments due to a
worsening of their condition.

(4) An over reliance upon private hygiene care packages with insufficient inquiry into the
parameters of care provided by the private domiciliary carers.

Part of my role as the Executive Nurse is to ensure that CHCP adopt a robust and
comprehensive approach to taking action following recommendations formulated by our
independent investigators.

| am extremely saddened by Ms Heath’s death and the circumstances surrounding this. |
appreciate the concern and upset which this has no doubt caused her family and | sincerely
hope that the actions we have taken will ensure, as far as is possible, patient safety.

City Health Care Partnership (CHCP) is unable to provide any feedback in relation to the above
concerns, as there was no referral made to CHCP Community Nursing by Hull University
Teaching Hospital (HUTH) or St Andrew's Surgery Hull. CHCP has a 24-hour Care Co-
Ordination Hub, which manages all referrals into CHCP.

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Referrals can be made by any Health Care Professional (HCP). Patients / relatives and carers
can also make referrals for certain interventions. Pressure ulcer/wound care is an intervention
that enables self-referral and non-HCP referrals.

The patient had previously received wound care from CHCP Community Nursing in 2018; it is
unclear from the patient's electronic care record or information provided if safety netting was
provided to the patient or their family by HUTH staff, that community nursing was required
following discharge from hospital, or if the patient/family was provided with information by HUTH
staff regarding contacting the CHCP Care Co-Ordination Hub if the community nurse did not
attend.

Referrals to CHCP can be made via various routes —

e Telephone via this telephone line is staffed through-out the 24-hour
period, every day, so callers will always speak to a call advisor.

e Email via

e NHS e-Referral Service (e-RS) which includes copies of the referral criteria and available
services.

e Internally CHCP services can send SystmOne to SystmOne referrals, (SystmOne is
CHCP main Electronic Care Record (ECR) system). CHCP is currently exploring options
to enable external SystmOne users to also send SystmOne to SystmOne referrals.

e CHCP regularly shares updates in relation to the referral criteria, services offered and
how to refer with GPs and other HCP organisations including Secondary Care, and GPs
and HCP organisations also have access to the Directory of Services (DoS) via
www.directoryofservices.nhs.uk & NHS Service Finder via www.servicefinder.nhs.uk

e Referral criteria and how to refer can also be found on CHCP web page
www.chepcic.org.uk Advice and support for the public can also be found on the following
sites -

o www.eastridingofyorkshireccg.nhs.uk

o www.hullccg.org
o www.nhs.uk
(e)

www.111.nhs.uk

Bi-monthly Triangulation meetings between CHCP and HUTH Tissue Viability Nurses (TVN) are
in place to discuss/hand over care for pressure ulcer and complex wound care patients. CHCP
and HUTH Electronic Care Record (ECR) systems cannot communicate with each other,
therefore with the help of CHCP SystmOne team CHCP TVN has been able to create a proforma
that sits within SystmOne which is completed by CHCP TVN and sent electronically via email to
HUTH TVN prior to the Triangulation meetings for discussion.

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HUTH TVN complete the same proforma and email it tol who place it in
the SystmOne notes and task the TVN to inform that the proforma is there for discussion at the
next Triangulation meeting.

The proforma provides details of the patient and the wound type and progress to date along with
any concerns. This enables the relevant Healthcare provider to investigate and feedback to the
relevant team regarding wound concerns/plans, which ensures that any patient with complex
wound needs, who is transferring wound care between CHCP and HUTH will be discussed at
the bi-monthly Triangulation meetings to ensure a co-ordinated approach to tissue viability
management.

For patients where a discharge or admission is planned or imminent in between the bi-monthly
Triangulation meetings, the CHCP TVN will contact the HUTH TVN (and vice versa) either by
email or phone to discuss, both parties document any communication within their own ECR.

This patient's proforma would have been sent to CHCP TVN to communicate the discharge date
and CHCP community nursing would have continued to provide wound care following discharge
from hospital.

The preferable solution to transferring care between CHCP and HUTH would be a digital solution
between the two ECRs. CHCP TVNs are currently attending a time limited Task and Finish
Group established by HUTH in relation to exploring discharge planning for patients with complex
wounds/pressure ulcers and seek a digital solution. This Task and Finish Group is in addition to
the Triangulation meetings.

| do hope this letter responds to your concerns.

Yours sincerely

Executive Nurse

HM Coroner 
The Coroners Courts & Office 
The Guildhall 
Alfred Gelder Street 
Kingston upon Hull 
HU1 2AA 

01 August 2024 

Dear HM Coroner (Mrs Sally Robinson, Assistant Coroner) 

Regulation 28 Report following the inquest into the death of Mrs Heath  

We provide the formal response of the Care Quality Commission (CQC) to the 
Regulation 28 Preventing Future Deaths report made by HM Coroner (Mrs Sally 
Robinson, Assistant Coroner) following the inquest into the death of Mrs Heath. (‘the 
Regulation 28 Report’).  

In the Regulation 28 Preventing Future Deaths report HM Coroner raised the 
following concerns: 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to 
concern. In my opinion there is a risk that future deaths will occur unless action is 
taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. –  

(1)  The Immediate Discharge Summary did not include relevant or sufficient 

information about treatment in the community needs or a nursing summary. 

(2)  Despite the presence of a difficult sacral sore which would have benefitted 
from district nursing care, no referral was made post discharge by the GP 
surgery. 

(3)  No trigger appears to exist whereby GPs conduct follow up enquiries or visits 
to patients who have recently been discharged from hospital and who are 
complaining of a condition which may worsen and failing to attend routine 
appointments due to a worsening of their condition.  

(4)  An over reliance upon private hygiene care packages with insufficient inquiry 

into the parameters of care provided by the private domiciliary carers. 

 
 
 
 
 
 
 Hull University Teaching Hospitals NHS Trust 

NHS trust’s do not report deaths to CQC, and we first became aware of the death of 
Mrs Heath on 10 May 2024 from your prevention of Future Death Report where  we 
were a named responder.  

Following receipt of this report CQC held a management review meeting and agreed 
to request the inquest medical evidence bundle. In addition, we asked Hull University 
Teaching  Hospitals NHS  Trust  to provide evidence of any  action they  had taken  to 
date following the tragic death of Mrs Heath. We reviewed all the information obtained 
by the CQC and concluded there were no grounds to suspect a criminal offence.  

The trust’s last comprehensive inspection was in November 2022 and the report was 
published in March 2023. CQC rated the trust as “Requires Improvement.”  

A copy of the report can be found on our website - Trust - RWA Hull University 
Teaching Hospitals NHS Trust (23/03/2023) INS2-13905362001 (cqc.org.uk) 

CQC hold monthly engagement meetings with the trust to ensure that the 
fundamental standards of quality and safety are being met. At this meeting we 
review the trust’s progress on their post inspection action plan and ensure 
improvements made are sustainable and embedded.  

Since Mrs Heath’s death in March 2022 the trust have completed a number of actions 
relating to the management of pressure ulcers to eliminate the risk of this happening 
again.  

•  Mandatory training compliance levels for tissue viability for registered and 

non-registered nursing and midwifery teams are reported monthly to the safer 
skin committee. Tissue viability training now includes national e-learning 
modules, trust e-learning training videos in recognising and treating of 
moisture associated skin damage and chronic wound assessments.  

•  Audits for tissue viability and ward assurance are reported monthly to the 

safer skin committee who monitor any recommendations actions required and 
check compliance against an evidence based framework.  

• 

Introduction of a senior nurse to regularly review patients who have moderate 
to high risk pressure sores. They ensure all members of the multidisciplinary 
team are involved in the patient care as needed. Referrals can be made to the 
tissue viability teams as well as plastic surgery. They are responsible for 
arranging onward referrals to district nursing teams and arranging appropriate 
equipment prior to discharge.  

•  Updated standard operating procedures for digital wound photography to 

include photographs of wounds on admission, when transferred to a clinical 
areas to identify improvements / deterioration of wound appearance.  

 
 
 
 
 
 •  Monthly meetings with community health care partnership (CHCP) to work in 
partnership to improve communication for discharges and transfers of care 
across both healthcare providers.  

•  Clinical areas now display monthly posters for the number of days they have 

been “pressure ulcer free”.  

•  Updated standing operating procedures for ordering equipment such as 

dynamic mattresses.  

•  Updated patient information leaflet “preventing pressure ulcers – working 

together with patients and carers to prevent pressure ulcers”. 

St Andrew’s surgery at Elliott Chappell Health Centre  

CQC inspected St Andrew’s surgery at Elliott Chappell Health Centre in November 
2017. The report was published in January 2018 and it was rated as good.  

A copy of the report can be found on our website - Elliott Chappell Health Centre 
NewApproachComprehensive Report (GPPractices Location Oct 2017)_INS2-
3890813910 (cqc.org.uk) 

City Health Care Partnership  

CQC inspected Community health services for adults in November 2016 and rated it 
as good.  

In June 2022 we carried out a focussed inspection based upon the quality of 
management of wound care within the Hull and East Riding community nursing 
service. The inspection did not look at other services provided by City Health Care 
Partnership or other areas of the community nursing service. This inspection was not 
rated, which meant the existing rating of good remains in place. CQC did not identify 
any required enforcement action during this inspection.  

A copy of the report can be found on our website - Core Service - Community health 
services for adults - (28/11/2022) INS2-12629169601 (cqc.org.uk) 

A national professional advisor and senior specialist for Primary and Community 
Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical 
records and practice response to the integrated care board who would cover the 
oversight of this GP practice. The findings will be shared with the operations team for 
Primary and Community Care to consider alongside other information held by CQC. 
This will inform our regulatory response. 

During the inspection process we routinely review correspondence, tasks and 
referrals. We will use the regulation 28 report to remind colleagues of the importance 
of this process.  

There will be ongoing monitoring of this provider via our monitoring and inspection 
process.  

 
 
 
 In addition to our inspection activity, CQC continually monitors all the information we 
hold about services for any themes and trends. We review intelligence data from a 
range of sources. For example, for trust’s we look at incidents reported to National 
Reporting and Learning System (NRLS) and Strategic Executive Information 
Systems (StEIS). This will now include incidents reported to the “Learn from Patient 
Safety Events” system (LPSIR). We also receive information from local authority 
safeguarding teams and attend meetings safeguarding meetings. We also engage 
with other regulators (such as the Environmental Health Agency or local Clinical 
Commissioning Groups) and Fire and Rescue Services or the Police.  

CQC receive information directly from patients or relatives of people who use 
services. This is extremely valuable to us as they are best placed to know whether 
they / their relative received safe, compassionate, and high-quality care.  

CQC also receive information from whistle-blowers (serving or former members of 
staff).  

If the CQC receives any information of concern about a service our aim is to respond 
as quickly as possible, assessing the risk using our new single assessment 
framework methodology and identifying the appropriate action to take. We will use 
our enforcement powers if regulations are not being met.  

CQC will discuss the concerns you have raised about Mrs Heath’s death at our next 
engagement meeting with the Hull University Teaching Hospitals NHS Trust. If we 
are not assured that improvements have been made, we will make an appropriate 
regulatory response.  

CQC’s  next  inspection  of  these  services  are  not  yet  confirmed,  however  we  have 
adopted  a  more  risk  based  approach  to  inspections  should  CQC  receive  negative 
intelligence or have further concerns about the service we would carry out responsive 
inspections.  

CQC hope that this response addresses your concerns.  

Yours sincerely 

Deputy Director of Operations 

Network North

Our Ref: C22.7292 
Your Ref: 18780099  

04 July 2024 

Sally Robinson 
Assistant Coroner for Hull & the East Riding of 
Yorkshire 
The Coroner’s Court & Offices 
The Guildhall 
Alfred Gelder Street 
Hull 
HU1 2AA 

Dear Ms Robinson, 

Hull Royal Infirmary 
Anlaby Road 
Hull 
HU3 2JZ 

Tel: 

Email:

Inquest – Linda Heath Deceased – Response to Regulation 28 Report to prevent future deaths  

The Trust is in receipt of the Regulation 28 Report issued by yourself at the conclusion of the inquest you 

held regarding the death of Linda Heath who died in March 2022. This is the response of Hull University 

Teaching Hospitals NHS Trust. 

It was understood by the Trust following the Inquest that there was an agreement that an update would be 

provided by the Trust on the measures already being taken which relate to the concerns raised by the 

Coroner.  Therefore  please  can  we  request  clarification  as to  whether  the  Coroner  requires  any  further 

update  beyond  those  provided  in  this  response?  If  a  response  is  also  being  sought  from  the  national 

organisations listed at point 1, please could any responses provided be shared with the Trust? 

Matters of concern at paragraph 5 of the Report are noted, and the Trust responds as it did at the Inquest 

in relation to points 1 and 4. Points 2 and 3 relate to primary care. 

The first matter of concern relates to the immediate discharge summary not including relevant or sufficient 

information about the required treatment in the community or a nursing summary of care needs.  This issue 

was canvassed extensively during the course of the inquest process.  The Trust indicated that it would 

keep the Court advised as to progress to address issues which arise from the fact that a referral to district 
nursing upon Linda Heath’s discharge in February 2022 was not made.  The problem here is the failure to 

make the referral, not the failure to refer to this issue in the immediate discharge summary as it  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 would not be for primary care to make the referral.  The Trust has concentrated its efforts in seeking to 

address  the  core  problem  and  reduce  the  risk  of  referrals  to  community  services  being  missed,  as 

happened here, at the point of discharge from hospital. 

The Trust confirms that it has developed a pro forma to be utilised by nursing staff in relation to each and 
every discharge of an in-patient.  This pro forma will be used when nurses are planning for a patient’s 

discharge, and it will identify and highlight a number of matters that need to be considered and addressed 

at the point of discharge.  The pro forma is still being finalised, this work is expected to conclude within the 
next two weeks – because it is an electronic system, the Trust’s digital team has been involved in updating 

it. That said a number of wards are already using the document in paper form but  this will be rolled out 

across the Trust very shortly. The pro forma will have a specific prompt to nursing staff to remind them to 

consider whether a referral to community nursing is required, and the form will also require them to insert 
details of to whom the referral has been made.  Therefore in an equivalent case to that of Linda’s now this 

form would be completed by a nurse as plans for discharge are being made: the prompt on the form would 

remind staff of the need to consider whether a referral needs to be made to community nursing, and the 

form requires staff to complete information as to whom the referral has been made.  This should serve to 
reduce the risk that necessary referrals that need to be made upon a patient’s discharge are overlooked. 

In relation to the  immediate  discharge summary  this  is  a document  completed  by  medical  staff, and is 

intended  to  be  a  summary  of  the  medical  care.    There  are  ongoing  discussions  about  the  level  of 

information that should be included within the form, as it is important it does not become too lengthy, but 
the Trust is of the view that in order to prevent the problem that occurred in Linda’s case, the issue to be 

addressed is ensuring that appropriate referrals are made in the first place, by the Trust at the point of 
discharge.  In Linda’s case if the discharge summary had noted the need for community nursing referral it 

is  true  that  it  is  possible  the  GP  could  have  followed  this  up,  but  in  fairness  it  would  not  be  the  GP’s 
responsibility to do that. In Linda’s case she proactively sought input from her GP and their involvement 

was discussed at the Inquest.   

The other issue of concern relevant to the Trust’s involvement (point 4) related to an over-reliance upon 

private hygiene care packages with insufficient enquiry into the parameters of care provided by the private 

domiciliary carers.  At the point of discharge, patients who are in receipt of care packages at home need  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 to  have  them  reinstated.  Staff  are  being  reminded  of  the  need  to  consider  whether  the  packages  may 

require revision and re-assessment, as a result of whatever has brought the patient into hospital, and if 

such is required an appropriate referral usually to Social Services will be made. 

It is also worth noting that the Trust has seen the response prepared by CHCP in relation to the Regulation 

28  report  and,  in  particular,  note  their  comments  regarding  the  triangulation  meetings  taking  place  in 

relation to complex Tissue Viability Nursing (TVN) cases.  The Trust confirms that the system is working 

well in terms of improving liaison and communication between Acute Hospital TVN teams and the CHCP 

Community District Nursing Team in Hull that provide community nursing services.  Plans and discussions 
are  under  way  to  establish  similar  processes  for  community  providers  in  other  parts  of  the  Trust’s 

geographical area including North & Northeast Lincolnshire. 

We trust this responds to the matters raised within the prevention of future deaths report. 

Yours faithfully 

Group Chief Nurse 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence.

Ms Sally Robinson 
HM Assistant Coroner  
East Riding and Hull Coroner’s Service 
The Guildhall 
Alfred Gelder Street 
Hull  
HU1 2AA 

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

29/07/2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Linda Heath who died on 
31 March 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  09 
March 2024 concerning the death of Linda Heath on 31 March 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Linda’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that  the  concerns  raised  about  Linda’s  care  have  been 
listened to and reflected upon.   

I am grateful for the further time granted to respond to respond to your Report, and I 
apologise  for  any  anguish  this  delay  may  have  caused Linda’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 raises some concerns that would be more appropriately answered by the 
providers involved in Linda’s care, who I note you have also addressed your Report 
to.  My  response  to  you  focuses  on  those  areas  that  fall  within  the  remit  of  NHS 
England’s  national  policy  and  programmes,  although  my  regional  colleagues  have 
engaged with the Humber and North Yorkshire Health and Care Partnership on the 
concerns  raised,  as  this  is  system  in  which  the  providers  involved  in  Linda’s  care 
operate.  

We are advised by the GP Surgery involved (St Andrew’s Surgery in Hull) that they 
have implemented improvements to their processes, including mandating use of the 
Task Functionality element of the SystemOne clinical software,  to ensure that tasks 
are more closely monitored and actioned throughout the day, and arranging additional 
training on what to record in the patient record.  

City Health Care Partnership (CHCP) have also advised that referrals can be made to 
them via various routes, and that while their Electronic Care Records cannot currently 
communicate  with  those  of  Hull  University  Teaching  Hospitals  NHS  Trust  (HUTH), 
there is a proforma in place to record the details of the patient, wound type, history 
and  concerns.  Bi-monthly  meetings  take  place  between  CHCP  and  HUTH  Tissue 
Viability Nurses to discuss and hand over care for pressure sores, ulcers and complex 
wound care patients.  

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
 NHS  England’s  Primary  Care  Directorate  have  reviewed  your  Report  and  have 
advised  that  Linda’s  care  highlights  the  importance  of  follow-up  or  referrals  being 
arranged by hospitals on discharge of patients, and the clear communication of any 
concerns or actions required to the GP team post-discharge. It is stated within the GP 
Contract that GPs should respond to a patient’s concerns ‘when they are ill or believe 
themselves to be ill.’ We would refer you to the providers for further information and 
any learning taken, including on HUTH’s discharge policies.  

Nationally, there are several programmes of work underway to improve access to and 
the  sharing  of  patient information  between  providers, both  NHS  and  private.  These 
include the National Care Records Service and Shared Care Records.  

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Linda, 
are shared across the NHS at both a national and regional level and helps us to 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

From the Acting Chief Executive and Registrar 

Sally Robinson 
Assistant Coroner 
The Coroners Courts & Office 
The Guildhall 
Alfred Gelder Street 
Kingston upon Hull 
HU1 2AA 

By email only to: 

Ref no: 

23 September 2024 

Dear Ms Robinson 

Linda Heath – NMC response to Regulation 28 Prevention of Future Deaths 
Report 

Thank you for sending your Regulation 28 Prevention of Future Deaths Report (PFD) 
in connection with the death of Linda Heath for us to review in accordance with 
paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 
and 29 of the Coroners (Investigations) Regulations 2013. I write on behalf of the 
Nursing and Midwifery Council (NMC) to confirm the action we are taking in 
response to the concerns raised. 

Firstly, I am very sorry to hear about the circumstances of Linda’s death and I would 
like to offer my sincere condolences to her family for their loss. We take the concerns 
you have raised with us very seriously. 

We have used the information in the PFD to reflect on the action we can take to 
address the concerns you have identified and to make sure they do not occur again 
where we have the power to do so. We set out below the action we have taken to 
ensure that the professionals on our register are fit to practise safely and 
professionally and that the public is protected in line with our role.   

Additionally, I would like to apologise for the delay in acknowledging and responding 
to your report. We are taking steps to identify why the report did not reach the correct 
team in time for us to respond in accordance with the statutory deadline and will 
make appropriate improvements to prevent this from happening in future. 

 
 
 
 
 
 
 
 
 
 
 
 
 Your concerns 

I note that your investigation concluded that Linda died at Hull Royal Infirmary from 
sepsis caused by an infected sacral sore, also known as a pressure sore. Linda had 
been discharged in February 2022 with a grade 2/healing sore. A combination of 
management issues by healthcare professionals, including her not being referred for 
district nursing care, led to a worsening of her condition. Along with Linda’s pre-
existing co-morbidities this led to an admission to Hull Royal Infirmary on 5 March 
2022. Despite surgical treatment the situation worsened. Tissue viability nursing was 
not reinstituted post-operatively. Difficulties in care with nutrition and hospital 
acquired infections unfortunately led to Linda’s death on 31 March 2022.  

You have raised the following concerns in the PFD report: 

1.  The Immediate Discharge Summary did not include relevant or 

sufficient information about treatment in the community needs or a nursing 
summary.  

2.  Despite the presence of a difficult sacral sore which would have benefitted 
from district nursing care, no referral was made post discharge by the GP 
surgery.  

3.  No trigger appears to exist whereby General Practitioners conduct follow up 

enquiries or visits to patients who have recently been discharged from 
hospital and who are complaining of a condition which may worsen and failing 
to attend routine appointments due to a worsening of their condition.   

4.  An over reliance upon private hygiene care packages with insufficient 

inquiry into the parameters of care provided by the private domiciliary carers.  

Our role 

The NMC is the independent regulator of more than 808,000 nurses and midwives in 
the UK and nursing associates in England. We’re here to protect the public by 
upholding high professional nursing and midwifery standards, which the public has a 
right to expect. We maintain the integrity of the register of those eligible to practise 
and we investigate concerns about individual professionals.  

Our Code of Conduct contains the professional standards that registered nurses, 
midwives and nursing associates must uphold. We will investigate alleged breaches 
of the Code when we become aware of them under our fitness to practise process.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We have two clear aims for fitness to practise: 

a.  a professional culture that values equality, diversity and inclusion, and 
prioritises openness and learning in the interests of public safety, and 

b.  nurses, midwives and nursing associates who are fit to practise safely and 

professionally. 

In appropriate circumstances we enforce the standards set out in the Code through 
fitness to practise proceedings. Fitness to practise proceedings can result in a range 
of outcomes, ranging from the provision of advice to the registrant by the NMC to 
removal from the register. 

Our response to the concerns raised 

The concerns that you have raised indicate that a nurse or nursing associate’s skills, 
knowledge, education or behaviour may have fallen below the standards needed to 
deliver safe and effective care. 

Your report has been shared with our fitness to practise department, who will screen 
the case in accordance with our fitness to practise process. We screen cases to 
make sure that we’re the right organisation to address the concerns and it’s serious 
enough that regulatory action needs to be taken. It’s important to note that more 
often than not, employers can deal with most cases without the need for regulatory 
action. 

In line with our screening process, we will now take steps to: 

•  confirm whether the concerns you have raised relate to a professional or 

professionals on our register; 

•  establish if there is evidence of a serious concern that could require us to 

take regulatory action to protect the public; 

•  confirm if there is clear evidence to show that a nurse, midwife or nursing 

associate is currently fit to practise.   

If concerns are identified that relate to someone on our register, our screening team 
will carry out an initial risk assessment in relation to each concern. If they identify 
particular risks, such as a risk of harm to the public, the case may be referred to an 
interim order hearing. Interim order cases may include cases of serious lack of 
competence or poor clinical practice. An interim order has the effect of restricting the 
nurse or nursing associate’s practice with immediate effect.   

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 To help with our screening enquiries, we contacted your office on 23 August 2024,  
5 September 2024 and 16 September 2024 to obtain further information. We have 
sought disclosure of the Serious Incident report to help us with our enquiries and are 
waiting for a response.  

Finally, we recognise the impact that FtP proceedings can have on families, which is 
why we have a Public Support Service (PSS) to help support people through the 
process and understand how the investigation process works. Through it, our public 
support officers can answer individual questions or provide one-to-one meetings and 
help explain the different decisions that could be made. If we do proceed with an 
investigation our PSS team will reach out to Linda’s family to offer support. More 
information about our PSS can be found here NMC public support service - The 
Nursing and Midwifery Council. 

Conclusion 

We are taking steps to investigate the concerns raised to identify whether we need to 
take regulatory action in relation to a professional or professionals on our register. 
We are also making enquiries to ensure PFD reports are shared across the 
organisation more swiftly in the future. 

Once again, I offer my heartfelt condolences to Linda’s family. If you have any further 
questions concerning this case or the steps we are taking, please do not hesitate to 
contact us. 

Yours sincerely 

Acting Chief Executive and Registrar 

4

@&*» St Andrews
@@ Surgery

ne

22 May 2024

The Office of H M Coroner
The Guildhall

Alfred Gelder Street

HULL

HU1 2AA

FAO HMAC Miiss Sally Robinson
Dear Miss Robinson
Regulation 28-Report Linda Heath

To address concerns regarding the lack of referrals to the district nursing team and other issues
raised, the following measures have been discussed with the practice team and implemented to
prevent future occurrences:

1. Utilisation of Task Functionality in TPP SystmOne: Previously, some staff did not utilise this
feature. All staff, including clinicians and administrative personnel, must now adopt and use
the task functionality within the SystmOne clinical software. This feature enables clearer,
more structured communication from clinicians to the administration team. Tasks are
shared in a monitored inbox, ensuring they are actioned throughout the day. This method
provides a reliable and transparent system for handling patient-related tasks, and tasks
remain within the patient record for future reference.

2. Training: Additional training and updates have been provided to all staff regarding the
importance of good record-keeping. This includes understanding the significance of accurate
and detailed documentation in the patient record. We have recently recruited a Data Quality
and IT Officer to oversee and ensure that data is of a high standard through audits and
training where applicable.

These measures will enhance communication within the practice and the wider team within primary
and secondary care. We will also continue to work with other organisations, including the local trust,
to find ways to improve patient care pathways.

Your sincerely

Partner