Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0339, written 25 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jun 2024 |
|---|---|
| Reference | 2024-0339 |
| Deceased | John Howe |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION(cid:3)28(cid:3)REPORT(cid:3)TO(cid:3)PREVENT(cid:3)FUTURE(cid:3)
DEATHS(cid:3)THIS(cid:3)REPORT(cid:3)IS(cid:3)BEING(cid:3)SENT(cid:3)TO:(cid:3)
1. Chief(cid:3)Executive,(cid:3)Manchester(cid:3)City(cid:3)Council(cid:3)
2. Chief(cid:3)Executive,(cid:3)East(cid:3)Midlands(cid:3)Ambulance(cid:3)Service(cid:3)
3. Group(cid:3)Chief(cid:3)Executive(cid:3)Manchester(cid:3)University(cid:3)NHS(cid:3)Foundation(cid:3)Trust(cid:3)
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CORONER(cid:3)
I(cid:3)am(cid:3)Lauren(cid:3)Costello,(cid:3)Assistant(cid:3)Coroner,(cid:3)for(cid:3)the(cid:3)Coroner(cid:3)Area(cid:3)of(cid:3)
Manchester(cid:3)South(cid:3)
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CORONER’S(cid:3)LEGAL(cid:3)POWERS(cid:3)
I(cid:3)make(cid:3)this(cid:3)report(cid:3)under(cid:3)paragraph(cid:3)7,(cid:3)Schedule(cid:3)5,(cid:3)of(cid:3)the(cid:3)Coroners(cid:3)and(cid:3)
Justice(cid:3)Act(cid:3)2009(cid:3)and(cid:3)Regulations(cid:3)28(cid:3)and(cid:3)29(cid:3)of(cid:3)the(cid:3)Coroners(cid:3)(Investigations)(cid:3)
Regulations(cid:3)2013.(cid:3)
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INVESTIGATION(cid:3)and(cid:3)INQUEST(cid:3)
On(cid:3)2nd(cid:3)June(cid:3)2023(cid:3)an(cid:3)investigation(cid:3)was(cid:3)commenced(cid:3)into(cid:3)the(cid:3)death(cid:3)of(cid:3)John(cid:3)Howe,(cid:3)
then(cid:3)aged(cid:3)81(cid:3)years.(cid:3)The(cid:3)investigation(cid:3)concluded(cid:3)at(cid:3)the(cid:3)end(cid:3)of(cid:3)the(cid:3)inquest(cid:3)on(cid:3)24th(cid:3)
May(cid:3)2024.(cid:3)At(cid:3)the(cid:3)end(cid:3)of(cid:3)the(cid:3)Inquest,(cid:3)I(cid:3)recorded(cid:3)a(cid:3)narrative(cid:3)conclusion(cid:3)that(cid:3)Mr(cid:3)
Howe(cid:3)died(cid:3)as(cid:3)a(cid:3)result(cid:3)of(cid:3)hospital(cid:3)acquired(cid:3)pneumonia(cid:3)against(cid:3)a(cid:3)background(cid:3)of(cid:3)
necessary(cid:3)surgery(cid:3)to(cid:3)treat(cid:3)diabetic(cid:3)foot(cid:3)sepsis.(cid:3)
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CIRCUMSTANCES(cid:3)OF(cid:3)THE(cid:3)DEATH(cid:3)
John(cid:3)Howe(cid:3)was(cid:3)an(cid:3)81-year-old(cid:3)man(cid:3)with(cid:3)type(cid:3)2(cid:3)diabetes(cid:3)and(cid:3)peripheral(cid:3)vascular(cid:3)
disease.(cid:3)His(cid:3)diabetes(cid:3)was(cid:3)not(cid:3)always(cid:3)controlled,(cid:3)and(cid:3)he(cid:3)had(cid:3)frequent(cid:3)episodes(cid:3)of(cid:3)
high(cid:3)blood(cid:3)sugar.(cid:3)In(cid:3)December(cid:3)2021(cid:3)he(cid:3)started(cid:3)to(cid:3)experience(cid:3)issues(cid:3)with(cid:3)his(cid:3)foot(cid:3)
including(cid:3)sepsis(cid:3)as(cid:3)a(cid:3)result(cid:3)of(cid:3)the(cid:3)diabetes(cid:3)and(cid:3)peripheral(cid:3)vascular(cid:3)disease.(cid:3)His(cid:3)
foot(cid:3)deteriorated(cid:3)and(cid:3)by(cid:3)October(cid:3)2022(cid:3)he(cid:3)was(cid:3)advised(cid:3)that(cid:3)amputation(cid:3)was(cid:3)
necessary,(cid:3)but(cid:3)he(cid:3)did(cid:3)not(cid:3)consent(cid:3)to(cid:3)this.(cid:3)
During(cid:3)an(cid:3)admission(cid:3)on(cid:3)28th(cid:3)April(cid:3)2023,(cid:3)it(cid:3)was(cid:3)discovered(cid:3)that(cid:3)his(cid:3)condition(cid:3)had(cid:3)
deteriorated,(cid:3)and(cid:3)he(cid:3)agreed(cid:3)to(cid:3)an(cid:3)amputation(cid:3)which(cid:3)took(cid:3)place(cid:3)on(cid:3)10th(cid:3)May(cid:3)2023(cid:3)at(cid:3)
Manchester(cid:3)Royal(cid:3)Infirmary.(cid:3)He(cid:3)was(cid:3)discharged(cid:3)home(cid:3)on(cid:3)19th(cid:3)May(cid:3)2023(cid:3)but(cid:3)
thereafter(cid:3)he(cid:3)deteriorated(cid:3)and(cid:3)was(cid:3)admitted(cid:3)to(cid:3)Stepping(cid:3)Hill(cid:3)Hospital,(cid:3)Poplar(cid:3)
Grove(cid:3)Stockport(cid:3)on(cid:3)23rd(cid:3)May(cid:3)2023.(cid:3)Despite(cid:3)treatment(cid:3)he(cid:3)continued(cid:3)to(cid:3)deteriorate(cid:3)
and(cid:3)died(cid:3)there(cid:3)on(cid:3)28th(cid:3)May(cid:3)2023(cid:3)as(cid:3)a(cid:3)result(cid:3)of(cid:3)hospital(cid:3)acquired(cid:3)pneumonia(cid:3)against(cid:3)
a(cid:3)background(cid:3)of(cid:3)necessary(cid:3)surgery(cid:3)to(cid:3)treat(cid:3)the(cid:3)diabetic(cid:3)foot(cid:3)sepsis(cid:3)and(cid:3)
haemorrhage(cid:3)from(cid:3)the(cid:3)wound.(cid:3)
The(cid:3)Inquest(cid:3)heard(cid:3)that(cid:3)when(cid:3)Mr(cid:3)Howe(cid:3)was(cid:3)discharged(cid:3)from(cid:3)hospital(cid:3)on(cid:3)19th(cid:3)
May(cid:3)2023,(cid:3)and(cid:3)he(cid:3)was(cid:3)woken(cid:3)from(cid:3)sleep(cid:3)at(cid:3)23:00(cid:3)to(cid:3)be(cid:3)transported(cid:3)home(cid:3)
meaning(cid:3)that(cid:3)he(cid:3)arrived(cid:3)at(cid:3)his(cid:3)home(cid:3)address(cid:3)in(cid:3)the(cid:3)early(cid:3)hours(cid:3)of(cid:3)the(cid:3)
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morning(cid:3)on(cid:3)20th(cid:3)May(cid:3)2023.(cid:3)His(cid:3)family(cid:3)were(cid:3)not(cid:3)aware(cid:3)that(cid:3)this(cid:3)was(cid:3)
happening,(cid:3)access(cid:3)to(cid:3)his(cid:3)home(cid:3)was(cid:3)difficult,(cid:3)and(cid:3)it(cid:3)resulted(cid:3)in(cid:3)him(cid:3)being(cid:3)left(cid:3)
outside(cid:3)whilst(cid:3)this(cid:3)was(cid:3)addressed.(cid:3)
A(cid:3)serious(cid:3)Incident(cid:3)Review(cid:3)took(cid:3)place,(cid:3)and(cid:3)a(cid:3)report(cid:3)was(cid:3)prepared(cid:3)after(cid:3)a(cid:3)
lengthy(cid:3)delay.(cid:3)
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CORONER’S(cid:3)CONCERNS(cid:3)
During(cid:3)the(cid:3)course(cid:3)of(cid:3)the(cid:3)inquest,(cid:3)the(cid:3)evidence(cid:3)revealed(cid:3)matters(cid:3)giving(cid:3)rise(cid:3)to(cid:3)
concern.(cid:3)In(cid:3)my(cid:3)opinion(cid:3)there(cid:3)is(cid:3)a(cid:3)risk(cid:3)that(cid:3)future(cid:3)deaths(cid:3)could(cid:3)occur(cid:3)unless(cid:3)
action(cid:3)is(cid:3)taken.(cid:3)In(cid:3)the(cid:3)circumstances(cid:3)it(cid:3)is(cid:3)my(cid:3)statutory(cid:3)duty(cid:3)to(cid:3)report(cid:3)to(cid:3)you.(cid:3)
The(cid:3)MATTERS(cid:3)OF(cid:3)CONCERN(cid:3)is(cid:3)as(cid:3)follows.(cid:3)–(cid:3)
(1)(cid:3)The(cid:3)inquest(cid:3)heard(cid:3)that(cid:3)there(cid:3)has(cid:3)been(cid:3)a(cid:3)change(cid:3)in(cid:3)policy(cid:3)with(cid:3)regards(cid:3)
to(cid:3)the(cid:3)timing(cid:3)of(cid:3)discharge(cid:3)of(cid:3)patients(cid:3)from(cid:3)Manchester(cid:3)Royal(cid:3)
Infirmary(cid:3)in(cid:3)circumstances(cid:3)where(cid:3)a(cid:3)patient(cid:3)is(cid:3)unable(cid:3)to(cid:3)manage(cid:3)
independently(cid:3)when(cid:3)they(cid:3)arrive(cid:3)home.(cid:3)However,(cid:3)the(cid:3)Inquest(cid:3)heard(cid:3)
that(cid:3)late(cid:3)discharges(cid:3)were(cid:3)still(cid:3)happening.(cid:3)In(cid:3)addition,(cid:3)the(cid:3)Inquest(cid:3)
heard(cid:3)that(cid:3)the(cid:3)East(cid:3)Midlands(cid:3)Ambulance(cid:3)Service(cid:3)were(cid:3)unaware(cid:3)of(cid:3)
the(cid:3)change(cid:3)in(cid:3)discharge(cid:3)timings.(cid:3)
(2)(cid:3)Completion(cid:3)of(cid:3)the(cid:3)Serious(cid:3)Incident(cid:3)Review(cid:3)was(cid:3)delayed,(cid:3)and(cid:3)the(cid:3)
report(cid:3)contained(cid:3)factual(cid:3)inaccuracies,(cid:3)giving(cid:3)rise(cid:3)to(cid:3)a(cid:3)concern(cid:3)
relating(cid:3)to(cid:3)the(cid:3)approach(cid:3)taken(cid:3)by(cid:3)Manchester(cid:3)City(cid:3)Council(cid:3)to(cid:3)Serious(cid:3)
Incident(cid:3)Reviews.(cid:3)
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ACTION(cid:3)SHOULD(cid:3)BE(cid:3)TAKEN(cid:3)
In(cid:3)my(cid:3)opinion(cid:3)action(cid:3)should(cid:3)be(cid:3)taken(cid:3)to(cid:3)prevent(cid:3)future(cid:3)deaths(cid:3)and(cid:3)I(cid:3)believe(cid:3)
you(cid:3)and(cid:3)have(cid:3)the(cid:3)power(cid:3)to(cid:3)take(cid:3)such(cid:3)action.(cid:3)
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YOUR(cid:3)RESPONSE(cid:3)
You(cid:3)are(cid:3)under(cid:3)a(cid:3)duty(cid:3)to(cid:3)respond(cid:3)to(cid:3)this(cid:3)report(cid:3)within(cid:3)56(cid:3)days(cid:3)of(cid:3)the(cid:3)date(cid:3)of(cid:3)this(cid:3)
report,(cid:3)namely(cid:3)by(cid:3)20th(cid:3)August(cid:3)2024.(cid:3)I,(cid:3)the(cid:3)coroner,(cid:3)may(cid:3)extend(cid:3)the(cid:3)period.(cid:3)
Your(cid:3)response(cid:3)must(cid:3)contain(cid:3)details(cid:3)of(cid:3)action(cid:3)taken(cid:3)or(cid:3)proposed(cid:3)to(cid:3)be(cid:3)taken,(cid:3)
setting(cid:3)out(cid:3)the(cid:3)timetable(cid:3)for(cid:3)action.(cid:3)Otherwise,(cid:3)you(cid:3)must(cid:3)explain(cid:3)why(cid:3)no(cid:3)action(cid:3)is(cid:3)
proposed.(cid:3)
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COPIES and PUBLICATION
I(cid:3)have(cid:3)sent(cid:3)a(cid:3)copy(cid:3)of(cid:3)my(cid:3)report(cid:3)to(cid:3)the(cid:3)Chief(cid:3)Coroner(cid:3)and(cid:3)to(cid:3)the(cid:3)following(cid:3)
Interested(cid:3)Persons:(cid:3)
(cid:3)on(cid:3)behalf(cid:3)of(cid:3)the(cid:3)family(cid:3)and(cid:3)Stepping(cid:3)Hill(cid:3)Hospital(cid:3).(cid:3)
I(cid:3)am(cid:3)also(cid:3)under(cid:3)a(cid:3)duty(cid:3)to(cid:3)send(cid:3)a(cid:3)copy(cid:3)of(cid:3)your(cid:3)response(cid:3)to(cid:3)the(cid:3)Chief(cid:3)Coroner(cid:3)
and(cid:3)all(cid:3)interested(cid:3)persons(cid:3)who(cid:3)in(cid:3)my(cid:3)opinion(cid:3)should(cid:3)receive(cid:3)it.(cid:3)
The(cid:3)Chief(cid:3)Coroner(cid:3)may(cid:3)publish(cid:3)either(cid:3)or(cid:3)both(cid:3)in(cid:3)a(cid:3)complete(cid:3)or(cid:3)redacted(cid:3)or(cid:3)
summary(cid:3)form.(cid:3)He(cid:3)may(cid:3)send(cid:3)a(cid:3)copy(cid:3)of(cid:3)this(cid:3)report(cid:3)to(cid:3)any(cid:3)person(cid:3)who(cid:3)he(cid:3)believes(cid:3)
may(cid:3)find(cid:3)it(cid:3)useful(cid:3)or(cid:3)of(cid:3)interest.(cid:3)
You(cid:3)may(cid:3)make(cid:3)representations(cid:3)to(cid:3)me,(cid:3)the(cid:3)coroner,(cid:3)at(cid:3)the(cid:3)time(cid:3)of(cid:3)your(cid:3)
response,(cid:3)about(cid:3)the(cid:3)release(cid:3)or(cid:3)the(cid:3)publication(cid:3)of(cid:3)your(cid:3)response.(cid:3)
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DATE(cid:3)
SIGNED(cid:3)BY(cid:3)CORONER(cid:3)
25th(cid:3)June(cid:3)2024(cid:3)
3
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Confidential
Ms L Costello
Assistant Coroner
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Ms Costello
Trust Headquarters
1 Horizon Place
Mellors Way
Nottingham Business Park
Nottingham
NG8 6PY
Telephone:
Fax:
Website: www.emas.nhs.uk
9 August 2024
Regulation 28 – Prevention of Future Deaths report regarding the case of Mr John
Howe deceased
Thank you for your Regulation 28 report dated 25 June 2024, bringing to my
attention HM Coroner’s concerns arising from the inquest into the death of Mr
John Howe.
I would like to assure you that the Trust takes all matters relating to patient safety
extremely seriously. Matters arising from Coroner’s Inquests, from which lessons
can be learned, including Prevention of Future Deaths reports ,are discussed by
the Trust’s Incident Review Group.
Matters of Concern for East Midlands Ambulance Service Non-Emergency Patient
Transport
The Inquest heard that there had been a change in policy with regards to the
timing of discharge of patients from Manchester Royal Infirmary in circumstances
where a patient is unable to manage independently when they arrive home.
However, the Inquest heard that late discharges were still happening. In addition,
1
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the Inquest heard that the East Midlands Ambulance Service (EMAS) were unaware
of the change in discharge timings.
Sequence of events
Mr Howe was discharged from hospital on 19 May 2023, and he was woken from
his sleep at 23:00 to be transported home from Manchester Royal Infirmary,
meaning that he arrived at his home address in the early hours of the morning on
20 May 2023. Prior to the crew travelling, a call was made to the hospital to
confirm that Mr Howe was still able to travel. The attending discharge crew did
raise concerns on arrival at the ward around the appropriateness of Mr Howe
going home at a late hour. I understand his family were not aware that he was
being discharged and the access to his home was difficult. This resulted in Mr
Howe being left outside whilst this was addressed.
Firstly, I would like to apologise that Mr Howe had an extended wait outside his
address whilst arrangements were made to access his property.
During the Inquest, it was ascertained that discharges for patients on the wards at
Manchester Royal Infirmary now have a cut off time at 21.00 hours for discharge
from a hospital ward. At the time of the Inquest EMAS was not aware of this. EMAS
has subsequently contacted Manchester Royal Infirmary for a copy of the new
policy, but this is not available to share at present. From previous learning EMAS
do already contact the ward when a patient is going to be discharged into the
evening to ensure that this is appropriate, as happened with this case. This will
continue as a safeguard to patients until the policy is received from Manchester
Royal Infirmary.
I hope that this response provides you with the appropriate level of assurance in
relation to our commitment to continuous improvement of our services.
Please do not hesitate to contact me should you require any additional
information or any clarification, in connection with the above.
Yours sincerely
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Deputy Chief Executive
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Directorate for Families, Health & Wellbeing Hospital Discharge and Manchester Community Response Adult Social Care PO Box 532 Town Hall M60 2LA Email: Lauren Costello, Assistant Coroner, for the Coroner Area of Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 5th September 2024 Dear HM Assistant Coroner Costello, RE: John Howe: Prevention of future deaths report Firstly, I would like to apologise for the delay in my response to your issuing of the report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I am extremely saddened by the events of the Mr John Howe’s death and, following your report, we have amended the inaccuracies in the report and reshared the Serious Incident Review (SIR) with Derbyshire Safeguarding Adults Board. I have also reshared the amended SIR with Manchester Foundation Trust Safeguarding Team. I recognise the delay in completing the initial SIR due to myself not being in work, and as such we have set up a system, as a service, to ensure all investigations are completed in a timely manner going forward. In reviewing the systems it is essential we are not dependent on a single person within the service and, as such, we have put in place processes to ensure that this does not happen again. We are also reviewing our processes where a person is discharged from a Manchester hospital into an ‘out of area’ locality and if a safeguarding concern takes place on discharge. This will include ensuring engaging with partners in carrying out the SIR and sharing with them the outcomes and recommendations to those organisations. We will also ensure that, in future, we will share with agencies who have been consulted so the information provided can be reviewed and checked for accuracy, before finalising the report. Where there is still a need for further engagement with other partners to review where the areas of learning which the serious harm experienced by an adult at risk of abuse or neglect could have been prevented, it will be sent to the appropriate Safeguarding Board for screening with a recommendation for a Safeguarding Adults Review. 1 A6 I hope that this satisfies the matters of concerns that you have raised in your report and that the actions taken demonstrates how serious we take the investigation and completion of SIRs in a timely manner as well as involving partners in those investigations. Yours sincerely Strategic Lead for Hospitals, Reablement and Digital 2 A7
Joint Group Medical Directors’ Office Trust Headquarters Room 218, Cobbett House Oxford Road M13 9WL Tel: 5th August 2024 HM Assistant Coroner Ms L Costello HM Coroner’s Office - Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Costello Re. Mr John Francis Howe. Regulation 28: Prevention of Future Deaths Thank you for highlighting your concerns in respect of this case, which I have now had the opportunity to look into. The response required from Manchester University NHS Foundation Trust (MFT) is in relation to the following: • Timing of discharges for patients from the Manchester Royal Infirmary (MRI) MFT was notified of the second concern outlined within the Regulation 28 report issued following the inquest, we understand that this relates to Manchester City Council and therefore no response is required from MFT on this matter. With regard to the timing of discharges from the MRI, as advised during the inquest there had been a locally implemented discharge process which should prevent vulnerable patients being discharged home after 21:00 hours. Since the inquest, I can confirm that actions have been taken to strengthen this process, which I have explained below. Across all adult services within MFT the group wide Discharge Policy (reviewed January 2024) is utlised which outlines that “where possible discharges from a ward area should be avoided after 20:00 hours”. Within the MRI, the Transfer and Discharge Unit (TDU) is utlised which operates until 21:00 hours, Monday – Friday and supports the safe discharge of patients from within the hospital. During weekends, patients are discharged directly from ward areas. In Mr Howe’s case, he had been transferred to the TDU within the MRI, however the booked transport (via East Midlands Ambulance Service) had not arrived by 21:00 hours and therefore Mr Howe was transferred to the Ambulatory Care Unit to await transport. It is acknowledged that the continuation of Mr Howe’s discharge out of hours took place in the absence of any formal guidance relating to delayed transport. I am aware that during the inquest, a narrative update was provided to you which described the informal arrangements the MRI team had taken to support the management of late discharges, in line with the Discharge Policy. This included the requirement for TDU staff to undertake an assessment at 20:00 hours to consider any remaining patients awaiting discharge. Any such patient would then be escalated to the MRI Hospital Site Management team to enable appropriate bed allocation back within the hospital bed base, if was felt that transport would not arrive in a timely manner. A1 I acknowledge that whilst the inquest heard about this process, there was a lack of evidence provided to the hearing demonstrating how this had been formally implemented across the hospital site which could provide you with sufficient assurance regarding the robustness of these arrangements. The MRI team have confirmed that a formal process for managing delayed discharges has now been developed via an “Out of Hours Discharge Avoidance” Standard Operating Procedure (SOP), which will be utlised as part of the operational application of the MFT Discharge Policy. Whilst this SOP is still in draft, it is due to be presented for ratification at the MRI Quality and Safety Committee on Tuesday 13th August 2024. For completeness a copy of the draft SOP has been enclosed within this correspondence. MFT comprises of several adult hospital sites, and ambulance transport services are utilized across the organisation. The draft SOP has therefore also been shared with the teams at Wythenshawe Hospital and North Manchester General Hospital who have confirmed their intention to take it through their relevant governance structures to ratify and implement. I anticipate that this will prevent inconsistencies in discharge practices across the organisation, which could have led to challenges for external providers. I also note within the Regulation 28 report that the Inquest heard that the East Midlands Ambulance Service were unaware of the change in discharge timings. I hope that this correspondence assures you of the steps taken to implement a formal and robust process that supports decision making when discharges have been delayed. I can confirm that once the draft SOP is formally ratified across the relevant sites, MFT intends to formally communicate this to the external transport providers that support in the discharges of our patients. Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues raised. If you require anything further then please do not hesitate to contact me. Yours sincerely Joint Group Chief Medical Officer / Responsible Officer Enclosed. Draft Out of Hours Discharge Avoidance SOP A2
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