David Thompson

E: 

Date: 23rd October 2024

Private & Confidential
Ms Joanne Kearsley
Senior Coroner for the Coroner area of Manchester 
North
2nd and 3rd Floor
Newgate House
Newgate
Rochdale 
OL16 1AT

Sent by email to: 

Dear Ms. Kearsley

Re: Regulation 28 Report to Prevent Future Deaths 

Thank you for your Regulation 28 Report dated 12th August 2024 regarding the sad death of Mr. David 
Thompson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by 
offering our sincere condolences to Davi’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 31st of July 2024. 
On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our 
attention. We recognise it is very important to ensure we make the necessary improvements to the 
quality and safety of future services.  

During the inquest you identified the following cause for concern: -

There was a complete absence of any Consultant – Consultant discussions or
communication, given this patient was receiving care from both the NHS and privately.

To provide a comprehensive response, we have outlined our response to demonstrate:

• How we oversee Out of Area Placements (OAPs)
• What we would expect in relation to communication between the NHS and any Out of Area 

(OOA) provider

• Any additional action we feel we need to take in relation to this PFD

1. How we oversee Out of Area Placements (OAPs)

Greater  Manchester  has  implemented  a  system  wide,  standardised,  patient  centred  MaDE  (Multi 
agency discharge event) process for oversight of OAPs. The primary objectives are to pinpoint and 
document  any  barriers  in  a  systematic  approach  to  discharge  (for  Clinically  Ready  For  Discharge 

4th Floor, Piccadilly Place, Manchester  M1 3BN  

Tel: 

  www.gmintegratedcare.org.uk

A7 
 
 (CRFD))  and/or  repatriation  (for  OAPs).  These  challenges  can  be  escalated  through  a  three-tiered 
structure, facilitating best practice and lessons learned across the system. 
The process is in place across all ten GM localities and includes: 

•

•

Locality  Patient  level  meetings  -  Weekly  meetings  conducted  by  MH  Trusts  with  locality 
stakeholders, addressing barriers to discharge and/or repatriation to GM for patients that are 
CRFD and OAPs
Locality Escalation Meetings - Weekly meetings chaired by ICB Deputy-Place Based Lead to 
review patients that require closer partnership working/senior leadership to address barriers to 
discharge and/or repatriation to GM for patients that are CRFD and OAPs. and 

• The Greater Manchester MADE (Fortnightly meeting with senior MH Trust and ICB leadership 
(clinical, operational and commissioning) to provide assurance around locality oversight and 
identify system solutions to complex discharges/repatriation.) 

This process allows a tracking system of each patient who is placed out of area which gives the system 
grip and control and enables a high level of oversight.  In addition, a dashboard to track OAPS is widely 
available and updated daily, 

In addition, a process to monitor the quality, experience and care oversight of each patient has been 
implemented. A system wide task and finish group oversees the framework in which OAPs “receiving” 
providers are assigned to a category based on their distance from Greater Manchester and their Quality 
profile ( which includes CQC rating, local intelligence, and information from the host commissioner). 
The list is used at the point of admission to support decision making and ensures that when an out of 
area placement is necessary patients are admitted to the available providers closest to home and there 
is an adequate level of assurance relating to the provider .This oversight framework is designed in line 
with  both  the  NHS  England  Host  commissioner  guidance  and  the  National  Quality  Oversight 
Framework. In the unusual and unfortunate event that a patient is admitted to a provider on the “stop” 
this  is  escalated  into  the  ICB  for  additional  monitoring  and  priority  repatriation,  a  co-designed  GM 
repatriation  framework  which  is  applied  by  both  GM  MH  providers  is  also  in  place  which  ensures 
consistency. Since implementing the oversight framework in April we can see a significant decrease in 
the amount of patients who are admitted to providers furthest away from home and where we have the 
best oversight. There were over 30 patients in April admitted to our “stop” providers and as at 1st Oct 
2024 there were 3 patients. 

Both the MADE structure and the Oversight framework has been designed and implemented in 
collaboration with all stakeholders and is monitored through the GM MaDE which reports to the GM 
Mental Health System Group and then onward to the GM ICB Board. 

2. What we would expect in relation to communication between the NHS and any OOA 

provider

GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who 
is admitted as an Out of Area placement in line with National Host commissioner guidance. This 
includes attendance at ward rounds, face to face visits where appropriate and full engagement in 
discharge and care planning. The processes as described above have been implemented since 
December 2023 and have provided a much tighter grip and control and increased level of oversight 
of each individual patient. 

3. Any additional action we feel we need to take in relation to this PFD

Greater Manchester is working on ensuring these processes are consistent across the system and 

4th Floor, Piccadilly Place, Manchester  M1 3BN  

Tel: 

  www.gmintegratedcare.org.uk

A8 
 further defining the practical actions of individual oversight from the care coordination teams relating 
to those patients admitted into Acute out of area placements, Rehab Beds, Individual non contracted 
beds and trust beds. This will be considered in line with current capacity levels, the required 
escalation, and a wider review of MH community services in GM. 

We will also take this report to the Mental Health Clinical Effectiveness Group for discussion and 
shared learning.

Best wishes

4th Floor, Piccadilly Place, Manchester  M1 3BN  

Tel: 

  www.gmintegratedcare.org.uk

A9

Corporate Legal Services
Trust Headquarters
225 Old Street
Ashton Under Lyne
Lancashire
OL6 7SF

Telephone: 

7th October 2024 

Private & Confidential 
Joanne Kearsley 
HM Senior Coroner 
HM Coroner’s Court 
Floors 2 and 3 
Newgate House 
Newgate 
Rochdale  
OL16 1AT 

Dear Ms Kearsley, 

RE: Inquest touching on the death of David Thompson  

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation 
Trust  and  the  issuing  of  a  Prevention  of  Future  Deaths  Notice  (Regulation  28), 
arising from the inquest into the death of David Thompson. 

May I take this opportunity to extend my own condolences to the family of David and 
apologise that you had to raise concerns relating to the services he accessed prior to 
his sad death.  

The Trust sets out its response to the point below: 

For All: 

1.  There  was  a  complete  absence  of  any  Consultant  –  Consultant 
discussions  or  communication,  given  this  patient  was  receiving  care 
from both the NHS and privately.     

Trust Response: 

The organisation was not aware that David attended an outpatient appointment with 
  at  the  Priory  Hospital,  Altrincham  and  therefore  the  opportunity  for 
Consultant  to  Consultant  communication  to  take  place  did  not  happen.  The 
organisation’s expectation is for 
 to copy the organisation into David’s clinic 
letter  as  per  the  section  of  ‘Contributing  to  continuity  of  care’  within  the  General 
Medical Council’s (GMC) ‘Good Medical Practice.’ The guidance states:  

65 
Continuity of care is important for all patients, but especially those who may struggle 
to  navigate  their  healthcare  journey  or  advocate  for  themselves.  Continuity  is 
particularly  important  when  care  is  shared  between  teams,  between  different 

A4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 members  of  the  same  team,  or  when  patients  are  transferred  between  care 
providers.  

a.  You must promptly share all relevant information about patients (including any 
reasonable adjustments and communication support preferences) with others 
involved in their care, within and across teams, as required. 

b.  You must share information with patients5 about: 

i. 

the progress of their care  

ii.  who is responsible for which aspect of their care 

iii. 

the  name  of  the  lead  clinician  or  team  with  overall  responsibility  for 
their care. 

c.  You must be confident that information necessary for ongoing care has been 

shared: 

i. 

ii. 

before you go off duty  

before you delegate care, or  

iii. 

before you refer the patient to another health or social care provider. 

d.  You  must  check,  where  practical,  that  a  named  clinician  or  team  has  taken 

over responsibility when your role in a patient’s care has ended. 

It was 
’s evidence that the clinic letter was shared with David’s GP and  he 
expected the GP to then share this information with all  other care providers. This is 
not the responsibility of the GP but the responsibility of the doctor who has seen the 
patient. This evidence was factually incorrect and it is the view of the organisation’s 
Medical  Director, 
  that  this  is  in  breach  of  the  GMC’s  Good  Medical 
Practice, which all doctors must follow.  

In order to provide assurance that Pennine Care NHS Foundation Trust’s doctors are 
also  adhering  to  this  guidance  formal  communication  has  been  sent  to  all  doctors 
within  the  organisation  from  our  Medical  Director  reminding  them  of  this  guidance 
and the GMC’s stipulation that all doctors must follow this. It also highlights this case 
and  asks  the  doctors  to  take  particular  care  if  a  patient  is  receiving  treatment  from 
both  an  NHS  and  private  provider  and  that  the  private  provider  will  also  be  copied 
into any correspondence.  

The  organisation’s  Medical  Director  will  also  liaise  with  the  Medical  Directors  of  all 
the private providers that Pennine Care patients are known to be placed. Contact will 
be  made  with  the  Priory,  Elysium  and  Cygnet  to  raise  the  profile  of  this  identified 
issue and to work collaboratively to ensure that this issue does not occur again. 

Out of Area Bed Placements – Private Provider  

David received care within Priory Hospital, Altrincham and Priory Hospital, Dorking. 
He was placed in an out of area bed for the Dorking admission where he was under 

A5 
 
 
 the  care  of  both  an  NHS  Consultant  and  a  private  provider  Consultant.  This  would 
occur  when  there  are  no  inpatient  beds  within  the  organisation  or elsewhere  in  the 
Northwest  Bed  Bureau.  A  private  provider  bed  may  need  to  be  used  in  these 
circumstances and this bed would be funded by the Integrated Care Board (ICB).  

The quality of care provided in these private out of area placements was identified as 
inconsistent  across  the  board  and  ensuring  quality  oversight  of  these  placements 
was difficult. To minimise this issue and to ensure the quality of care provision within 
these private placements, Greater Manchester ICB devised a preferred provider list 
and patients will now only be placed in private provider hospitals where the quality of 
care in these establishments is assured. If any issues are raised in relation to any of 
these  hospitals,  they  will  be  put  on  a  stop  list  which  will  mean  no  patients  will  be 
placed  in  these  hospitals  going  forward  until  the  quality  has  been  raised  and 
assurance is provided that they meet the expected standard.  

To ensure the quality and consistency of the care of Pennine Care patients who are 
placed  in  an  out  of  area  private  bed,  an  Out  of  Area  Practitioner  is  responsible  for 
monitoring  the  inpatient  stay,  linking  in  with  the  relevant  providers  and  inpatient 
operational  leads  to  ensure  all  patients  receive  support  and  discharge  planning  as 
required. The Out of Area Practitioner is a senior mental health practitioner (Band 7) 
who sits within the Patient Flow Team. They act as a case manager for that patient 
including  attending  ward 
(including  all 
Consultants) updated and involvement in repatriation and discharge planning. There 
are  five  of  these  practitioners  within  the  organisation  and  each  practitioner  covers 
one of the five boroughs in which services are commissioned. This is to ensure that 
each practitioner has the capacity to be able to fulfil this case manager role and to 
allow  cross  cover  arrangements  to  take  place  during  period  of  absence  such  as 
annual  leave.  This  process  is  outlined  within  the  ‘Out  of Area  Placement’  Standard 
Operating  Procedure  detailing  the  role  and  responsibilities  of  the  organisation  in 
relation to this type of bed placement and the organisation’s expectations of the Out 
of Area Practitioner.  

rounds,  keeping  key  professionals 

I hope that the information within this response has provided you with the assurance 
that you were seeking in relation to learning from these events. Should you require 
any  further information  or clarification  on  the  details  within  this letter, please do  not 
hesitate to get in touch with me again.  

Yours sincerely 

Chief Executive  

A6

7 October 2024  

Ms Joanne Kearsley 
Senior Coroner 
Manchester North Coroners 

Via email: 

Private and Confidential 

Dear Ms Kearsley 

Mr David Thompson - Response to Regulation 28 report  

I write to you in response to the Regulation 28 report Priory received dated 12 August 2024. The 
report was issued following the Inquest touching the death of Mr David Thompson, which was heard 
on 31 July 2024. 

You raised three areas of concern. The first was regarding Priory Hospital Dorking:  

1.  The  incident  review  of  his  admission  to  the Priory Dorking  indicated  that  there was  no  My 

Safety Plan commenced on admission or complete prior to his discharge. 

2.  There was no engagement prior to discharge with the local Home Based Treatment Team. 
3.  There was no consultation with the Consultants who had treated Mr Thompson at the Priory 

in Altrincham only a few weeks earlier. 

4.  There was no 48-hour follow up call to Mr Thompson following his discharge. 
5.  A discharge clinical entry and discharge risk assessment was not completed and there was no 

evidence of crisis information having been provided. 

6.  There  was  no  evidence  that  the  four  standard  care  plans  had  been  opened  during  Mr 

Thompson’s inpatient stay. 

7.  When  conducting  the  internal  review  no  members  of  the  nursing  staff  were  spoken  to,  to 
consider why the matters highlighted above had not been carried out. There was therefore a 
lack of understanding as to whether this was an individual failing or error or a cultural / system 
failure. Nor was  consideration given to whether any individuals  should be reported to their 
regulatory body. 

The second area of concern you raised was regarding Priory Hospital Altrincham: 

1.  On  the  outpatient  appointment  in  January  2024,  the  fact  that  Mr  Thompson  had  been  an 
inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not 
known.  There was a lack of awareness as to how to access certain parts of the medical records, 
which would have shown this information. Mr Thompson did not volunteer this information so 
there was no discussion with him as to why he had relapsed so quickly. 

2.  At the time of his appointment in January 2024, Mr Thompson was not under the care of any 
NHS community services such as the home based treatment team. This was not recognised or 
known when formulating his ongoing plan. 

3.  No internal review was undertaken of Mr Thompson’s admission within the Priory Altrincham 

to consider whether there was any learning. 

Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD 

Tel: 

Fax: 

Registered in England No. 09057543 

www.priorygroup.com 

A10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The third area of concern you raised was addressed to Priory, Greater Manchester Integrated Care 
Board and Pennine Care NHS Foundation Trust:  

1.  There was a complete absence of any Consultant to Consultant discussion or communication, 

given this patient was receiving care from both the NHS and privately.     

Response to your concerns regarding Priory Hospital Dorking  

Matters of concern 1, 2, 3, 5 and 6  

These  were  all  identified  by  Priory  as  part  of  the  internal  Team  Incident  Review  (TIR)  that  was 
undertaken in the days following Mr Thompson’s death. The TIR report was shared with the court 
ahead of the inquest. It is the purpose of such a review to understand what happened and identify 
any  areas  of  learning.  Action  was  already  being  taken  to  address  the  learning  points  identified  in 
accordance with our usual processes. As these were all learnings Priory had already highlighted and 
were addressing, we were surprised and disappointed that these were listed as matters of concern in 
the Regulation 28 report, particularly as “It is acknowledged that in the case of Mr Thompson there 
was no evidence any of these concerns caused or contributed to his death”. A detailed action plan 
(see  appendix  1)  offers  assurance  that  these  learning  points  have  been  taken forward  and  recent 
audits have evidenced improvements at Priory Hospital Dorking.   

Matter of concern 4 - 48 hour follow up call 

In accordance with Priory policy H02 Admission, Transfer and Discharge, a follow up call within 48 
hours of discharge is not required if a patient has a confirmed appointment with an NHS community 
service within 72 hours of their discharge, as was the case for Mr Thompson. This is made clear in the 
TIR report and therefore this is not a matter that requires further attention.  

Matter of concern 7 - limitations of internal review 

It was recognised that Mr Thompson had been a recent patient at both Priory Hospital Altrincham and 
Priory Hospital Dorking and hence why it was considered at the time that inviting representatives from 
both services to attend a joint TIR was good practice. On reflection, we conclude that we should have 
hosted a separate TIR at each service, inviting those involved in the care and treatment of the patient 
(to include nursing colleagues), and thereafter brought together the key findings at a joint meeting 
attended by the senior managers, to identify any areas for cross service learning. This learning point 
has since been reiterated to Priory’s Director of Quality and our regional Associate Directors of Nursing 
and Quality who are responsible for the commissioning and quality review of TIR’s. 

Consideration was given at the time (and subsequently as the investigation progressed) as to whether 
any individuals involved in the care  of Mr Thompson should be  reported to their regulatory body.  
Reference was made to The Just Culture Guide, as promoted by NHS England in the Patient Safety 
Incident  Response  Framework.  This  states  that  it  is  rarely  appropriate  to  blame  or  single  out 
individuals (save for instances of wilful harm or neglect), but instead consider how learning can be 
implemented on a wider platform. The fair treatment of staff supports a culture of fairness, openness 
and learning by ensuring staff feel confident to speak up when things go wrong, rather than fearing 
blame.  With that in mind and in light of the facts, Priory considers there is no requirement to refer 
any individual to their regulatory body in this instance.  

Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD 

Tel: 

Registered in England No. 09057543 

 www.priorygroup.com 

A11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response to your concerns regarding Priory Hospital Altrincham  

Matter of concern 1 - accessing Dorking and Altrincham records 

This concern was addressed in the action plan that was embedded within the TIR report and this was 
shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of 
concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on 
CareNotes  (Priory’s  electronic  patient  records  platform),  the  system  defaults  to  show  only  active 
documents. This is intended to ensure only records relevant to the current episode of care are present. 
To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A 
reminder  of  the  presence  of  this  function  has  since  been  circulated  to  all  Priory  colleagues  and  a 
prompt to select ‘entire record’ will be added to the admission checklist. 

Matter of concern 2 - no reference to NHS community home treatment services 

This also relates to the third matter of concern you raised regarding communications between private 
and NHS services: please see further below for Priory’s response to that concern.  

Matter of concern 3 - internal review following incident 

A review was undertaken of Mr Thompson’s inpatient admission to Priory Hospital Altrincham and 
this is recorded within the  TIR  report that was  shared with the court ahead of the inquest, with a 
detailed timeline embedded and a summary of this period of care. The conclusion of this review was 
that Mr Thompson received adequate inpatient care and treatment during his inpatient admission to 
Priory Hospital Altrincham, and he was discharged appropriately into the care of the Home Treatment 
Team.  

Response to your concerns regarding communication between Private and NHS services 

Matter of concern 1 - communications between NHS and private services  

Priory  expect  that  when  a  consultant  psychiatrist  or  doctor  is  gathering  background  psychiatric 
information from a patient at the point of their first assessment, professional curiosity should guide 
the conversation to ascertain whether the patient is currently receiving care or treatment from any 
other  care  provider  (NHS  or  private  services).  Despite  recognising  this,  patients  may  not  wish  to 
disclose the facts of previous or current episodes of treatment for a number of reasons. This is their 
right. 

However,  in  order  to  aid  consideration  and  exploration  of  this  by  those  undertaking  the  initial 
admission assessment, the inpatient admission template on CareNotes has recently been amended, 
and now includes a field specific to ‘Any current NHS or private service involvement in care’. Inclusion 
of this field will act as a prompt to encourage discussion with the patient to establish the arrangements 
and details of any other current care providers involved in the patient’s care. 

To ensure a similar question is asked at the first point of contact for Priory outpatients, a question has 
now been added to the referral form in use by Priory’s central customer service contact centre, ‘Are 
you under the care of any other service?’. This information gathered at first contact is shared with the 
allocated consultant for their review and to aid discussion during the first outpatient assessment.   

Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD 

Tel: 

Registered in England No. 09057543 

 www.priorygroup.com 

A12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Upon receipt of details about any external services involved in a patient’s care, it may be appropriate 
to make contact with these organisations but this will be dependent on the detail of the information 
made available and whether the patient consents to such contact being made.   

To  ensure  this  learning  point  is  reiterated  to  all  consultants  across  Priory,  the  importance  of 
identification and  liaison  (where  appropriate)  with external organisations  involved  in  the  care  and 
treatment of a patient was raised at: 

  Priory’s Acute service network meeting on 25 September 2024; and  
  The Private and Wellbeing service network meeting on 1 October 2024 

These meetings are chaired by the Network Clinical Directors (senior doctors within the organisation) 
for discussion and noting by all in attendance (including Hospital Directors, Consultant Psychiatrists, 
Directors  of  Clinical  Services,  Ward  Managers,  Senior  Nurses  and  other  healthcare  professionals). 
Minutes  of  the  meeting  are  thereafter  circulated  to  all  relevant  colleagues  for  onward  sharing  as 
required.  

This learning point has also been included in a learning cascade that was issued to all site leaders and 
thereafter disseminated to all hospital colleagues on 12 September 2024.  

It is important to mention that whilst Priory have made advances to the systems and process in place 
to  gather these  details  and  encourage  our  multi-disciplinary  teams  to  facilitate  such  contact  (with 
patient consent), all correspondence relating to a patient’s admission, discharge and outpatient care 
is shared with a patient’s GP (with patient consent). The patient’s GP remains the central coordinator 
of a patient’s care. Other care services involved in a patient’s care and treatment can request access 
to this information via the GP. Should an external service (whether private or NHS) seek additional 
detail  to  the  information held  by  the  GP, Priory  clinicians  will make  themselves  available,  at  short 
notice if required, to engage in discussions about a patient’s care and treatment.  

We will carefully review the responses submitted by Greater Manchester Integrated Care Board and 
Pennine Care NHS Foundation Trust to this Regulation 28 report to ensure our approaches align.  

I trust that the actions outlined above will provide the assurances you seek in respect of this matter. 

Yours sincerely, 

Chief Executive Officer 
Priory  

Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD 
Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com 
Registered in England No. 09057543 

A13 
 
 
 
 
 
 
 
 
 
 
 Operational 

Patient Safety Incident - Action Plan 

Reference: 499948 

Date of patient safety incident: 18.03.2024 

Division and Site: Healthcare, Priory Hospital 
Dorking  

Summary of the patient safety incident   
DT had an NHS funded inpatient admission to Priory Hospital Dorking between 
27.10.2023 and 08.11.2023. He was diagnosed with Bipolar Affective Disorder. DT was 
discharged into the care of the Home Treatment Team and resumed outpatient care at 
Priory Hospital Altrincham.  
DT later came by his death on 03.03.2024. 

Manager(s) responsible for implementation  

, Hospital Director  

, Director of Clinical Services (DoCS) 

, Medical Director 

Manager signing off final action plan  

, Hospital Director  

Implementation categories: 

Score 
0 
1 
2 
3 
4 

Implementation category 
Insufficient evidence to support action progress / action incomplete / not yet commenced 
Action commenced 
Action significantly progressed 
Action completed but not yet tested 
Action complete, tested and embedded 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 1 of 10 

A14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Area for improvement 1: Ensure a My Safety Plan is completed for all patients requiring one  

Operational 

Implementation actions  

Person 
responsible 

Evidence of actions taken 

Issue a reminder to all staff of 
the requirement to complete a 
My Safety Plan, and to outline 
the circumstances when a My 
Safety Plan is required. 

An email was sent by the DoCS on 
11.09.2024 reminding all staff to 
complete a My Safety Plan for all 
patients with a current or historic risk of 
suicide and self-harm. Guidance 
including a video about how to 
complete a My Safety Plan was also 
shared: 

This email has been followed up with 
staff during safety huddles and 
discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff.  

Implementation 
category and 
target date for 
completion 
4 - Complete  

Completion 

01/10/2024 
(audit will 
continue) 

Details of how 
implementation will 
be/has been tested 

Patient’s requiring 
completion of a My 
Safety Plan are 
highlighted on the 
CareNotes clinical 
dashboard which is 
reviewed daily during 
the morning flash 
meeting. Where review 
does not evidence 
100% compliance, this 
is allocated to a specific 
member of staff for 
immediate action, and 
reviewed again the 
following day to ensure 
completion.   

Flash Meeting minutes 
for 13.09.2024 reflect 
that all patients 
requiring a My Safety 
Plan had one in place  
(meeting minutes 
available if required).  

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 2 of 10 

Area of Improvement 7 - My safety plan.msgA15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Operational 

Area for improvement 2: Ensure engagement with a patient’s Community Mental Health Team (CMHT) (where involved) prior to inpatient 
discharge 

Implementation actions  

Person 
responsible 

Evidence of actions taken 

Details of how 
implementation will 
be/has been tested 

Issue a reminder to all staff 
regarding the expectation that 
referrals to a patient’s 
community team are to be 
clearly confirmed and 
documented on CareNotes prior 
to a patient’s discharge.  

An email was sent by the DoCS on 
29.08.2024 reminding all staff to ensure 
that once a discharge date has been 
confirmed and there is a need for a 
community team’s involvement, a 
referral is to be made by the nurse in 
charge to the relevant community 
mental health team. The time and date 
of the confirmed follow up appointment 
and contact details for the CMHT are to 
be recorded on CareNotes: 

A sample of five patient 
records were audited by 
the DoCS on 
10.09.2024, and 
evidenced 100% 
compliance of 
engagement with a 
patient’s CMHT and 
documentation of the 
time and date of follow 
up: 

Implementation 
category and 
target date for 
completion 
4 - Complete 

Completion 

01/10/2024 
(audit will 
continue) 

A follow up email was sent by the 
DoCS on 12.09.2024, re-sharing 
Priory’s Admission, Transfer and 
Discharge policy, which makes clear 
the expected discharge processes and 
the requirement to engage with a 
patient’s community team prior to their 
discharge: 

These emails have been followed up 
with staff during safety huddles and 
discussion during the daily flash 

Monthly audits will 
continue for a minimum 
of three months, until 
assurance is gained 
that this practice is 
embedded. The 
outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 
Clinical Governance 
report from October 
2024. 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 3 of 10 

Area of Improvement 5 -Documented evidence that referrals to community teams or home treatment.msgArea of Improvement 5 - Admission, Transfers and Discharge Policy.msgArea of Improvement 3, 5  &  6  -Priory Dorking Discharge Process Audit Log 2024 reviewed.xlsxA16 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Operational 

meetings to ensure it reaches and is 
understood by all relevant staff. 

The DoCS completed a monthly clinical 
governance report on 17.09.2024, 
which was further discussed in the 
clinical governance meeting on 
20.09.2024 focusing on the areas of 
improvement identified following review 
of this patient’s care: 

Area for improvement 3: Ensure staff gain an understanding of a patient’s background history at the point of admission 

Implementation actions  

Person 
responsible 

Evidence of actions taken 

Issue a reminder to all staff 
regarding the expectation that a 
patient’s background history is 
gained and understood at the 
point of admission. 

, 

Medical 
Director  

An email was sent to all responsible 
clinicians by the Medical Director on 
17.09.2024 reminding colleagues to 
ensure a patient’s background 
information is gained and understood 
on a patients admission, and where 
other services are or have previously 
been involved, consider whether 
contact with them is required (with 
patient consent): 

This email has been followed up with 
staff during safety huddles and 

Implementation 
category and 
target date for 
completion 
4 - Complete 

Completion 

01/10/2024 
(audit will 
continue) 

Details of how 
implementation will 
be/has been tested 

A sample of five patient 
records were audited by 
the DoCS on 
27.09.2024 and 
reflected that where 
required, background 
clinical information, 
current and previous 
treatment community 
team involvement and 
GP details were 
obtained at the point of 
admission.  

One patient had a 
previous admission at 
another Priory service 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 4 of 10 

Director of Clinical Services CG Report September 2024- FINAL.docxArea of Improvement 9 - Collateral History.msgA17 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Operational 

discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff. 

in 2022. The consultant 
had access to all details 
on CareNotes and thus 
no direct contact was 
required.  

Monthly audits will 
continue for a minimum 
of three months, until 
assurance is gained 
that this practice is 
embedded. The 
outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 
Clinical Governance 
report from October 
2024. 

Area for improvement 4: Discharge documentation is to be completed in accordance with Priory policy 

Implementation actions  

Person 
responsible 

Evidence of actions taken 

Details of how 
implementation will 
be/has been tested 

Priory Hospital Dorking are to 
evidence safe discharge 
planning in accordance with 
Priory policy H02 Admission, 
Transfer and Discharge - to 
include completion of a clinical 
entry, updated risk assessment 
on discharge and issue all 
patients with a crisis card with 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

, 

DoCS 

An email was sent by the DoCS on 
11.09.2024, reminding all staff to 
complete a discharge checklist, a 
discharge risk assessment, a discharge 
clinical entry and provide the patient 
with a crisis card with contact details of 
services they can contact in a crisis at 
the point of a patient’s discharge. 
Guidance was also provided on how to 

An audit of five recently 
discharged patient 
records was conducted 
by the DoCS on 
10.09.2024. All 
expected areas of 
discharge were 
completed, save for the 
issuing of crisis cards 

Implementation 
category and 
target date for 
completion 

4 - Complete 

Completion 

01/10/2024 
(audit will 
continue) 

OP Form: 46L 
Page 5 of 10 

Area Of Improvement - Audit Tool Evidencing Background Clinical Information Received on Admission.xlsbA18 
 
 
 
 
 
 
 
 
 
 Operational 

contact details of services they 
can contact in a crisis. 

complete a detailed discharge entry on 
CareNotes: 

This email has been followed up with 
staff during safety huddles and 
discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff. 

(crisis cards have since 
been ordered as none 
were in stock). Whilst 
awaiting delivery, this is 
mitigated by the 
patients being provided 
with crisis numbers 
either written on paper 
or storing them in their 
phones prior to 
discharge: 

Monthly audits will 
continue for a minimum 
of three months, until 
assurance is gained 
that this practice is 
embedded. The 
outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 
Clinical Governance 
report from October 
2024.  

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 6 of 10 

Area of Improvement  3 -Discharge clinical entry, discharge risk assessment and crisis card.msgArea of Improvement 3, 5  &  6  -Priory Dorking Discharge Process Audit Log 2024 reviewed.xlsxA19 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Area for improvement 5: Ensure all patients have four core care plans in place during their admission 

Operational 

Implementation actions  

Person 
responsible 

Evidence of actions taken 

Issue a reminder to all staff 
regarding the expectation that 
all patients have the four core 
care plans in place throughout 
the hospital admission. 

, 

DoCS  

An email sent by the DoCS on 
11.09.2024 shares with all staff 
guidance on creating the four standard 
care plans as well reminding staff of the 
expectation for weekly care plan 
reviews:   

This email has been followed up with 
staff during safety huddles and 
discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff. 

Implementation 
category and 
target date for 
completion 

4 - Complete 

Completion 

01/10/2024 
(audit will 
continue) 

Details of how 
implementation will 
be/has been tested 

A sample of five patient 
records were audited by 
the DoCS on 
30.09.2024, and 
evidenced 100% 
compliance, with all 
having the four core 
care plans in place: 

Completion of the four 
core care plans is now 
also reviewed daily 
during the morning 
flash meeting (via 
review of the 
CareNotes dashboard). 
Where reporting does 
not evidence 100% 
compliance, this is 
allocated to a specific 
member of staff for 
immediate action, and 
reviewed the following 
day to ensure 
completion.   

Monthly audits will 
continue for a minimum 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 7 of 10 

Area of Improvement 8 - There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.msgArea Of Improvement 8 - Monthly Care Plan Audit -25.09.2024.xlsxA20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Operational 

of three months, until 
assurance is gained 
that this practice is 
embedded. The 
outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 
Clinical Governance 
report from October 
2024.  

Area for improvement 6: MDT documentation is to be completed in full and with adequate detail 

Implementation actions  

Person 
responsible 

Evidence of actions taken 

, 

DoCS  

An email was sent to the MDT by the 
DoCS on 29.08.2024 outlining 
expected standards and quality of 
completing MDT forms during the ward 
round, covering all aspects reflected in 
the implementation actions column: 

This email has been followed up with 
staff during safety huddles and 
discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff. 

Issue a reminder to all staff 
regarding the expectations 
about the quality and 
completeness of Multi-
Disciplinary Team (MDT) 
documentation, to include the 
requirement to complete:  

  The MDT feedback  
  A clear and accurate 

record of the discussion 
had  

  Evidence of mental 
state examination  

  Patients views 
  Family/career/external 
professional feedback  

  A clear plan following 

the MDT  
Discharge planning is to be 
documented 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

Details of how 
implementation will 
be/has been tested 

An audit of five patient 
records was conducted 
by the DoCS on 
05.09.2024, which 
evidenced 100% 
compliance in respect 
of complete and good 
quality MDT 
documentation: 

Monthly audits will 
continue for a minimum 
of three months, until 
assurance is gained 
that this practice is 
embedded. The 

Implementation 
category and 
target date for 
completion 
4 - Complete 

Completion 

01/10/2024 
(audit will 
continue) 

OP Form: 46L 
Page 8 of 10 

Area of Improvement 2 - Quality of MDT documentation.msgArea Of Improvement 2,  3  & 4 -Priory Dorking MDT Audit Log 2024.xlsxA21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Operational 

outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 
Clinical Governance 
report from October 
2024.  

Area for improvement 7: Ensure that a patient’s family and carers are involved in discharge planning  

Implementation actions  

Person 
responsible 

Evidence of actions taken 

Details of how 
implementation will 
be/has been tested 

Issue a reminder to all staff 
regarding the expectations 
about involving a patient’s 
family/carer in discharge 
planning (with patient consent). 

, 

DoCS 

An email was sent by the DoCS on 
11.09.2024 reminding all staff to ensure 
that a patient’s family and carers are 
involved in a patient’s care, by routinely 
inviting them to the patient’s MDT 
meeting (with patient consent) where 
discussions regarding discharge 
planning are had: 

A sample of five patient 
records were audited by 
the DoCS on 
10.09.2024. In all 
cases, the patient’s 
family/carer had been 
invited to participate in 
the MDT meeting: 

Implementation 
category and 
target date for 
completion 
4 - Complete 

Completion 

01/10/2024 
(audit will 
continue) 

This email has been followed up with 
staff during safety huddles and 
discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff. 

Monthly audits will 
continue for a minimum 
of three months, until 
assurance is gained 
that this practice is 
embedded. The 
outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 9 of 10 

Areas of Improvement 4- The service to ensure that patients family and carers are involved in discharge planning.msgArea of Improvement 3, 5  &  6  -Priory Dorking Discharge Process Audit Log 2024 reviewed.xlsxA22 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Operational 

Clinical Governance 
report from October 
2024.  

Area for improvement 8: All patient referral information is to be uploaded to CareNotes 

Implementation actions  

Issue a reminder to all 
administration staff of the Priory 
requirement to ensure all 
referral information is uploaded 
to CareNotes. 

Implementation 
actions  

, Ward 

Clerk  

Implementation actions  

Implementation actions  

An email was sent to all administration 
staff by the DoCS on 11.09.2024 to 
remind the team that all referral 
information is to be uploaded onto 
CareNotes within 72 hours of 
admission: 

A sample of three 
patient records were 
audited by the DoCS in 
September 2024. In all 
cases, the referral 
notes had been 
uploaded to CareNotes: 

Implementation 
actions  

Implementation 
actions  

4 - Complete 

01/10/2024 
(audit will 
continue) 

` 

This email has been followed up with 
staff during safety huddles and 
discussion during the daily flash 
meetings to ensure it reaches and is 
understood by all relevant staff. 

Monthly audits will 
continue for a minimum 
of three months, until 
assurance is gained 
that this practice is 
embedded. The 
outcomes of the 
monthly audits will be 
shared with the MDT as 
part of the monthly 
Clinical Governance 
report from October 
2024.  

© Priory – Confidential    
Operational – v06 – OP04 – March 2024 

OP Form: 46L 
Page 10 of 10 

Area of Ipmprovement  1- Referrals to be uploaded onto care notes.msgArea of Improvement 1 - Priory Dorking Referral Log with referal upload audit- September 2024.xlsxA23