Andrew Naylor

Executive Corridor
Darlington Memorial Hospital
Hollyhurst Road
Darlington,
DL3 6HX

E-mail:

Our Ref: 

29th July 2024

Ms. Janine Richards,
Assistant HM Coroner,
County Durham

Dear Ms Richards,

Re: Andrew Naylor

We are writing in response to your request for the Trust to take action in relation to concerns
as detailed below:

(1) There is no specific protocol or policy in place to ensure that patients are warned of the
acute  risk  of  respiratory  depression  and  death  following  administration  of  the  drug

, should they drink alcohol or misuse drugs.

(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and
drug treatment teams, and mental health teams, to consider the safety of a discharge, and to
ensure that crucial information relevant to risk is shared appropriately (which may also be, to
an  extent,  hampered  by  a  continuing  inability  to  see  each  other’s  records),  and  whether
discharge should be delayed or care stepped down, until a place of safety is identified, and to
ensure that a robust safety plan is in place upon discharge.

(3) There was no consideration given by either the acute or mental health teams to contacting
the  deceased’s  family  or  friends,  which  may  have  provided  an  essential  safety  net  in  the
absence of accessible professional support. The TEWV Trust are candid that work in relation
to this issue is a work in progress and remains incomplete.

You  felt  that  although both  Trusts  indicated  that they are  in the  process of  addressing  the
concerns raised in this Inquest, but considered that at the time of the conclusion of this Inquest
that there remained a risk that future deaths could arise.

The Trust would like  to  offer its sincere  condolences to  Andrews’s family for their loss. We
take very seriously the concerns which you have raised and have provided a response below.

There is no specific protocol or policy in place to ensure that patients are warned of the
acute  risk  of  respiratory  depression  and  death  following  administration  of  the  drug

, should they drink alcohol or misuse drugs.

The Trust has a Management of Acute Alcohol Withdrawal Policy which has been extended
until September 2024 to enable the Organisation to explore the most appropriate, and safest,
way  to  include  the  suggestion  raised  by  yourself.  This  will  require  careful  stakeholder

 engagement to establish the safest advice to give the patient.  Initial advice from a community
drug  and  alcohol  service provider  is  that  a  blanket  statement  to  the  patient  advising  not  to
drink or take drugs for 24 hours in the event someone leaves early in a detoxification treatment
could  actually  cause  more  harm.    This  could  be  viewed  negatively  by  patients  undergoing
detoxification, reduce confidence in their care team and ultimately be counter-productive to a
good  outcome.  The  importance  of  establishing  a  constructive  therapeutic,  reciprocal
relationship and conveying key messages in this context cannot be overstated.

This policy is being reviewed and the Trust intend to have the updated policy, incorporating
patient advice after seeking further advice, approved by September 2024.

There appears to be a lack of a joined up process between acute clinicians, alcohol and
drug treatment teams, and mental health teams, to consider the safety of a discharge,
and to ensure that crucial information relevant to risk is shared appropriately (which
may  also  be,  to  an  extent,  hampered  by  a  continuing  inability  to  see  each  other’s
records), and whether discharge should be delayed or care stepped down, until a place
of safety is identified, and to ensure that a robust safety plan is in place upon discharge.

Mr  Naylor  was  reviewed  by  liaison  psychiatry  on  the  ward  prior  to  discharge  and  it  was
documented by the team as being under the care of the community mental health team, who
liaison psychiatry would request follow up by, and that he was safe for discharge.  In relation
to post discharge care, the Management of Acute Alcohol Withdrawal Policy details the follow
up that should occur for the patients such as Mr Naylor, including referral on to specialist drug
and alcohol teams and services and there was a plan for him to be followed up by the alcohol
liaison  service  post  discharge.    In  relation  to  his  residential  status,  this  was  consistently
documented as being in a named hostel during his admission.

There  was  no  consideration  given  by  either  the  acute  or  mental  health  teams  to
contacting  the  deceased’s  family  or  friends,  which  may  have  provided  an  essential
safety  net  in  the  absence  of  accessible  professional  support.  The  TEWV  Trust  are
candid that work in relation to this issue is a work in progress and remains incomplete.

Whilst the Trust had next of kin contact details it is acknowledged that there is no evidence
within Mr Naylors records that any attempt was made to contact them.  As he had capacity
our staff would not automatically have contacted them, however the importance of informing
next of kin in scenarios such as Andrews has been reinforced to the clinical teams at huddles.

Conclusion
We trust that the responses detailed in this letter are sufficient to address the concerns you
have highlighted. However, please feel free to contact us if you need any additional information
or have further queries.

Yours sincerely

Executive Director of Nursing

  Executive Medical Director

cc.  

, CEO

, Associate Director of Nursing, Patient Safety and CNIO

31 July 2024 

Ms J Richards 
HM Assistant Coroner 
For County Durham and Darlington 

By Email: 

Dear Ms Richards 

Office of the Chief Executive 
West Park Hospital 
Edward Pease Way 
Darlington 
Co Durham 
DL2 2TS 

Re: Response to Report to Prevent Future Deaths issued on 04.06.2024 in relation to 
the Andrew Naylor Inquest 

I am writing to you in response to the Prevention of Future Death (PFD) Report issued to 
Tees, Esk and Wear Valleys NHS Foundation Trust ("TEWV", or "the Trust") on 04.06.2024 
following the inquest touching the death of Andrew Naylor. I note that the PFD Report issued 
has been directed to both TEWV and County Durham and Darlington NHS Foundation Trust 
(CDDFT), on the basis you have concerns in respect of both organisations. I have not 
responded to point 5(1) as this issue relating to Chlordiazepoxide, appears to be for CDDFT 
to respond to and I am assured that they have responded. 

I have provided a response below in respect of concerns 5(2) and 5(3) of your PFD Report 
as it appears those are the matters where your concerns are directed to TEWV (with the 
second of those also being a matter for CDDFT to respond to). Point 5(4) is noted. I set out 
below your concerns, as well as the response from TEWV in respect of each matter: 

5.2. There appears to be a lack of a joined up process between acute clinicians, 
alcohol and drug treatment teams, and mental health teams, to consider the 
safety of a discharge, and to ensure that crucial information relevant to risk is 
shared appropriately (which may also be, to an extent, hampered by a 
continuing inability to see each other’s records), and whether discharge 
should be delayed or care stepped down, until a place of safety is identified, 
and to ensure that a robust safety plan is in place upon discharge. 

I will reiterate the Trust's position which we explained at the inquest, that it is recognised that 
communication between the liaison staff and acute staff could have been improved in 
Andrew's case. As I understand HM Assistant Coroner heard during the evidence at the 
inquest, the following measures have been put in place to address this concern:   

1.  TEWV access to CDDFT Electronic Patient Record:  

When liaison staff attend and assess a patient within the acute Trust, the expectation is that 
a verbal handover is given of the contact, along with a written entry on the acute Trust's 
Electronic Patient Record (EPR) system (as well as TEWV's EPR system, Cito). This system 
allows all involved in a patient's care to see discussions and plans from all involved. As 

 
 
 
 
 
 
 
 advised, the EPR team within CDDFT attended the liaison team office on Wednesday 27 
March 2024 to take steps to begin the process of putting the acute Trust's EPR on to the 
TEWV clinician's laptops. The EPR team have assisted, a data protection impact 
assessment was completed however we then experienced issues with organisational 
firewalls. The two IT teams have been working together to resolve this and we are now 
testing the platform. The testing concludes 06/08/24 and if it has been successful, it will be 
rolled out further from 12/08/24. 

The significant benefit of this is that TEWV liaison clinicians will be able to copy full details of 
their assessment from TEWV's EPR (Cito) on to the acute Trust EPR. Prior to this, liaison 
staff were reliant on being able to locate an available CDDFT computer on the ward/ 
department, which are understandably in high demand. It can be difficult to capture the full 
detail of an assessment with such constraints, but the new process of having CDDFT's EPR 
on TEWV laptops, will enable the full assessment to be detailed much more efficiently. 

For reassurance, TEWV were very recently inspected by the CQC. We had 24 hours notice 
of the inspection which focussed on the Crisis Care pathway which included Liaison 
services. The CQC read the EPR entries of a sample of patients in ED reviewing both the 
acute hospital entry and the TEWV entry to ensure there was joined up information. We are 
awaiting the final report however we have received good feedback and there were no 
actions for immediate follow up or statutory warning notices.  

2.  Team meeting discussions:  

As you are aware, it was not possible to conclude Andrew's inquest in the one day initially 
allocated on 14 March 2024, and therefore it was adjourned and later concluded on 3 June 
2024. Following the first day of Andrew's inquest, the initial learning identified during day one 
was picked up, and discussions took place within the team meeting, on 15 March 2024. 
Those discussions have continued within daily MDT meetings, to remind liaison staff of the 
importance of documenting, and verbally handing over if a patient reports themselves to be 
homeless. Conversations continue with regard to ensuring the important information relevant 
to a patient's risk, is handed over. 

3.  Audits:  

I can reiterate that in order to provide a check that improvements are being made in respect 
of communicating with acute Trust staff, a further check has been added when completing 
the team's monthly audit to ensure it is documented that a verbal handover has been 
completed.  This check is completed alongside the Trust Quality Assurance Schedule audit 
(a Trust standard) and the Advanced Nurse Practitioners (ANPs) completing the Quality 
Assurance Schedule have been asked to carry out a deep dive to check documentation 
around communication with other Trusts/ services.  As part of this, we now check that it is 
documented that a verbal handover has been given. If any issues are identified, this is 
picked up with the team as part of team meetings/ supervision to ensure it is addressed as 
soon as possible. Verbal assurance has been given by the Advanced Nurse Practitioners 
carrying out the audit/ deep dive into assessments, that they are assured it is now more 
consistently documented that verbal handovers have been completed.  

 
 
 4.  Discharge arrangements. 

As  we described to HMAC, the experience of the Liaison team working within CDDFT is that 
discharge would not usually be delayed for a homeless patient, in circumstances where the 
patient (1) has capacity, (2) is medically optimised and deemed fit for discharge, (3) is 
considered fit for discharge following review by the mental health liaison team, (4) has been 
appropriately signposted to the Local Authority regarding homelessness, and (5) has support 
in place in the community from the Community Mental Health Team as well as Drug and 
Alcohol services. Clearly, it is imperative that capacitous, homeless patients who are fit for 
discharge, are given the correct advice, signposting and support around homelessness, but 
in our experience, this does not mean remaining as an inpatient until accommodation 
arrangements have been secured. Health providers are not commissioned to carry out the 
role of the Local Authority in supporting and accommodating homeless people whilst their 
housing needs are addressed.   

5.3 There was no consideration given by either the acute or mental health 
teams to contacting the deceased’s family or friends, which may have provided 
an essential safety net in the absence of accessible professional support. The 
TEWV Trust are candid that work in relation to this issue is a work in progress 
and remains incomplete. 

5.4 Although both Trusts indicated that they are in the process of addressing 
the concerns raised in this Inquest, I consider that at the time of the conclusion 
of this Inquest that there remains a risk that future deaths could arise. 

By way of context, it is relevant to note that there was reference in the medical records to 
Andrew indicating that he was going to contact his brother. Although Andrew himself did not 
have access to his own mobile telephone, liaison staff were aware he had been making calls 
on the morning of his discharge, presumably utilising the hospital telephone. At that time, 
Andrew was considered to have capacity and was not presenting with any acute mental 
health difficulties and therefore it would not have been unreasonable for staff to accept that 
Andrew would be making contact with family himself in these circumstances.  

More broadly, and as previously advised, staff are expected to ask all patients if we can 
speak with family/careers/friends about their care – if they accept then we do this and 
document it within our records. If a patient refuses, then we have to consider whether the 
patient has capacity to make that decision, consider the level of risk, and take a sensible 
approach to this, balancing confidentiality. Staff have to be mindful our patients are adults 
and sometimes don’t want their family to know or be involved.  

A number of initiatives are ongoing across the Trust in promoting the importance of contact 
with family and carers. It is a significant piece of work to develop a culture across the 
organisation and although we consider we have made huge strides towards achieving this, it 

 
 
 
 
 will never be 'complete', as the Trust will always be striving to improve communication with 
carers, and we will continually reflect, learn and improve, as well as continuing training and 
processes of induction for those joining the organisation. This will not have an end date but 
as previously advised, the current initiatives to improve Trust processes are: 

1.  Open letter to all staff: 

On 13 May 2024, I personally reissued a letter (initially sent in June 2021) to all Trust staff 
members about the support the Trust will offer when making decisions about the difficult 
balance between patient confidentiality and appropriate sharing of information. In particular, 
the letter provides "We want to emphasise however to you all, that we would rather support 
you for saving a person's life by breaching their confidentiality than have to explain why we 
held onto information that could have made a difference."  I understand that you have 
already received a copy of this open letter.  

2.  Common sense confidentiality guidance: 

The Associate Directors and Associate Nursing Directors have met to discuss and review 
the Trust's current common sense confidentiality guidance leaflet, it will be consistent with 
the open letter to staff. This has included a review of the guidance issued by other Trusts on 
this matter. As a result, an updated guidance leaflet is being created to assist staff in better 
communicating with families and carers.  

3.  Sharing lived experience: 

A bereaved family were recently invited to speak to Trust staff at the Trust Fundamental 
Standards Group about their lived experience particularly around the importance of 
communicating effectively with families and carers of those experiencing mental illness, to 
offer staff an incredibly useful insight from their perspective. Attendees at the meeting 
worked with the family to identify impactful ways to share their experience further, and to 
identify practice changes that could be made organisationally and at service level. The group 
sought to identify short, medium and long term goals relating to training, process, 
environment and culture, working with the family to consider impactful changes to service 
delivery. We committed to identifying the priority actions and identify leads to take those 
actions forwards. The Trust also committed to sharing the message from the campaign and 
has shared the message on the Trust Intranet; created a slide to be shared with the CQC as 
part of our monthly updates and discussed the campaign with the Chair of the Board. The 
family also attended our Board of Directors meeting 13th June 2024 to ensure the Board 
would understand from a bereaved family the importance of giving families the opportunity to 
share their understanding of a situation and their loved ones needs. 

In addition to our commitment to carers has been restated in our Carers Charter which is 
signed by our Chairman and myself. We have recently had the success of our Triangle of 
Care (an initiative from the carers trust which aims to improve the quality of care and support 
for patients and their carers) recognised with national accreditation. 

I trust that this provides assurance that these concerns have been taken very seriously by 
the Trust and we will continue to strive to improve the service that we offer. 

Our Chief Nurse, Medical Director and I have made repeated offers to meet with the 
Coroners in the Durham and Darlington jurisdiction and all offers have been declined. We do 

 
 meet with other Coroners, and we are aware of some of our partners who meet with 
Coroners in this jurisdiction. I would like to repeat our sincere offer to meet at your 
convenience and discuss the developments at TEWV and how we are working with our 
partners and the people who use our services to improve care. 

Yours Sincerely  

Brent 

Chief Executive