Owen Gardner

Senior Coroner Nigel Parsley 
Suffolk Coroner’s Court 
Beacon House 
Whitehouse Road 
Ipswich 
IP1 5PB 
E mail: Coroners.service@suffolk.gov.uk  
By email only 

Dear Mr Parsley, 

NSFT Trust Management 
Norfolk & Suffolk Foundation Trust 
County Hall 
Martineau Lane 
Norwich 
NR1 2DBH 
Tel: 01603-421421

Date: 09 September 2024  

Regulations  28  (Coroners  Investigations  Regulations  2013)  notification  made  in  response  to  the 
death of Owen Donal Gardner 

I am writing in respect of the prevention of future deaths report you sent to the Trust following the inquest 
into the death of Mr Gardner, concluded on 3 July 2024. 

You wrote to the Trust to raise matters of concern which you assessed the Trust could take action to reduce 
the risk of future deaths. I am grateful for you writing which supports our drive to provide safe services. 

You identified concern that an individual with a short term memory difficulties and a cognitive deficit will miss 
an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also 
told of short notice changes to the timings of that appointment.  

Your concern was based on the evidence that the Trust had agreed to inform Mr Gardner’s next of kin of his 
appointment with his clinical team. On occasions, short notice changes to dates resulted in Mr Gardner being 
informed but sometimes not his agreed next of kin. The impact of this was that Mr Gardner missed a number 
of appointments as he was unable to retain information of appointment changes. You heard evidence there 
was no robust system in place to facilitate this. 

The Trust agrees it is critical that people are provided with the right support to enable them to access care at 
the right time. The practical role that families and carers play cannot be underestimated and the Trust’s goal 
is to work in collaboration with families to enable the best outcomes for people that access our services. 

To this end, it is our policy, at the commencement of care, to identify who the family and/or carer is and how 
we may communicate with them, based on the consent and agreement from the service user. The policy and 
expectation is for staff to record service user consent to information sharing on the Trust ‘Your Data: Your 
Choices’  form.  In  addition,  communication  preferences  should  be  noted  in  their  care  plan/combined 
assessment and those preferences used in accordance with the patient wishes, whether the communication 
takes place by telephone, email or text message. 

It is most often the case that routine appointments are communicated by letter however urgent or cancellation 
appointment offers may be made via text, email or through telephone calls based on the agreed method and 
timeframe to the appointment. This means there is no one single technical solution that will fully mitigate the 
risk but a range of actions. 

1. 

The Trust is in the process of procuring a new Electronic Patient Record (EPR) which includes 
‘patient  portal’  functionality  that  will  enhance  our  capabilities  for  appointment  scheduling, 
particularly in terms of visibility for patients. This new EPR is approximately two years from being 

Chair: Zoë Billingham CBE  Chief Executive Officer: Caroline Donovan 
Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH 
Tel: 01603 421421   Web: www.nsft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2. 

3. 

4. 

5. 

available  however,  as  we  are  following  the  nationally  mandated  procurement  route  for  such 
purchases. 

In the interim the trust has commenced work on enhancing the current EPR, Lorenzo. We have 
identified  a  potential  enhancement 
indicate,  when  generating 
correspondance (including appointments) that the correspondence should also be sent to the Next 
of Kin or Carer, according to stated patient preference 

that  will  allow  staff 

to 

We have some concern that this feature could result in correspondance being sent to Next of Kin 
or Carers without appropriate permissions so the change would only be implemented once we 
have  been  reassured  that  it  is  clinically  safe  and  compliant  with  our  Information  Governance 
policy. 

Following this assessment, if the change goes ahead it will be completed as a priority as soon as 
possible, our current expectation is that it will be in place by the end of November 2024.  

The Trust has also issued a patient safety alert to ensure the process remains a primary focus for 
our staff while this work is completed. This is attached for information. 

In addition, our community services standard operating procedure will be updated to include the 
guidance on the enhanced changes to Lorenzo, along with confirmation of the expectation that 
communication preferences will be noted in the service user care plan/combined assessment for 
ease of reference when communicating with service users and those supporting them. 

The Trust had also initiated a Listening into Action™ pioneer programme called Think Carer and 
Family. The Listening into Action™ programme approach is a comprehensive, systemic, outcome-
oriented approach to empower staff at all levels to work through any challenges to ensure quality 
outcomes. In order to bring greater consistency to recording next of kin details to ensure that the 
technical  improvement  and  system  expectation  mentioned  in  the  above  paragraphs  can  be 
meaningfully applied, the aim of the Think Carer and Family LiA programme which was launched 
on 10 June 2024 is to have 90% of carers and 100% of Next of Kin documented on service users’ 
records. Initially within Child and Adolescent Mental Health Team, West Suffolk, and Adult Crisis 
and  Resolution  Home  Treatment  Team,  West  Suffolk,  rolling  out  to  the  rest  of  the  trust  from 
October 2025.    

Finally, you are aware that the Trust undertook a safety incident review in order to identify any learning to 
improve practice and shared that report with the clinical team that provided care to Mr Gardner.  

6.

The clinical team involved in Mr Gardner’s care have undertaken further reflection and consideration 
of  the  Safety  Incident  Review  investigation  undertaken  by  the  patient  safety  team  alongside  the 
findings made at inquest, and the Regulation 28 report. This has enabled the clinical team and its 
managers  to  reflect  upon  any  human  factors  that  contributed  to  the  situation  which  arose  in  Mr 
Gardner’s case regarding family not being directly invited to the discharge appointment that had been 
brought forward by 90 minutes, by agreement directly with Mr Gardner. This further reflection took 
place on Thursday 5 September 2024 for this purpose. 

The outcome from this meeting was that the EPR system enhancement noted at paragraph 2 will be 
helpful  and  the  team,  will  robustly  ensure  that  all  future  assessments  will  include  consideration  of 
possible short term memory difficulties and confirmation of communication preferences which will be 
recorded in the combined assessment/recovery plan and safety plans.  

I  hope  the  above-mentioned  actions  provide  assurance  to  you  and  Mr  Gardner’s  family  that  NSFT  is 
committed to improving practice for all our service users. 

 
 
                                       
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely  

Caroline Donovan