Daphne Austin

Your ref: 
Our ref: 

07 October 2024 

PRIVATE AND CONFIDENTIAL 
Mr Robert Cohen 
Fairfield 
Station Road 
Cockermouth 
Cumbria  
CA13 9PT  

Via email only: 

Dear Mr Cohen 

Re: North Cumbria Integrated Care NHS Foundation Trust’s (“the Trust”) Regulation 28 
Response concerning the Inquest into the death of Ms Gillian Austin 

I write following the inquest that you resumed on 08/08/2024 into the death of Ms Gillian Austin 
at  the  Coroner’s  Court  in  Cockermouth.    You  concluded  that  Ms  Austin  sadly  died  on 
18/06/2023 at the Cumberland Infirmary in Carlisle with a medical cause of death as: 

1a Urosepsis and Acute Kidney Injury 
II Right cerebral Infarct 

A Narrative Conclusion was recorded, together with a finding of Neglect.   

During the inquest, you commended the excellent work the Trust had undertaken in improving 
fluid balance management and were reassured that your duty to issue a Regulation 28 Report 
in  this  regard  was  not  triggered.    The  Trust  remains  committed  to  ensuring  that  staff 
understand that the assessment and management of patients’ fluid and electrolyte needs is 
absolutely  fundamental  to  providing  good  patient  care.    Healthcare  professionals  need  to 
consider this as part of every review to reduce the potential serious impact of inadequate fluid 
balance on all our patients.  An urgent patient safety alert was therefore issued to all Trust 
staff on 30/08/2024 that as a minimum requirement, the following group of adult patients all 
have a Fluid Balance Chart completed, reviewed and acted upon as needed: 

• 
• 
• 

All non-elective inpatients 
Elective patients who have a length of stay >24 hours 
Patients who have an alteration in their NEWS score 

The cessation of this monitoring should only occur following a documented clinical decision.  
The  Nursing  Directorate  will  be  monitoring  compliance  with  this  notice.    In  addition  to  the 
urgent patient safety alert, a Trust wide improvement plan for fluid/hydration is being launched. 

Notwithstanding  this,  the  Trust’s  written  witness  evidence  set  out  that  one  Consultant 
(Consultant  A)  covered  25  patients  on  14/06/2023  during  Ms  Austin’s  admission,  during  a 
period of industrial action, and that due to the industrial action, Ms Austin did not receive any 
medical input on 14/06/2023.  The inquest also heard that another Consultant (Consultant B) 
who was rostered to ensure medical cover on the ward on 14/06/2023, may not have been on 
duty in line with the rota.  You were concerned that the Trust’s planning which seeks to ensure 
safe levels of cover during periods of industrial action, was insufficient to meet the need, and 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 that this may lead to future deaths if action is not taken by the Trust.  Your statutory duty to 
issue a Regulation 28 Report to the Trust was therefore engaged.   

I was extremely saddened to learn of the circumstances surrounding Ms Austin’s death and 
on behalf of the Trust, I wish to extend my sincere condolences to her family and friends.   

I am grateful to you for raising your concerns to me.  It is imperative to the Trust that safety 
issues are identified and rectified to ensure our services are safe and effective.  Please accept 
this letter as the Trust’s formal response to the Regulation 28 Report.   

To ensure a thorough review of Ms Austin’s care and the concerns raised within the Regulation 
28 Report, the Trust has reviewed the following: 

ICE system for requesting bloods and reviewing results 

  The Trust’s witness evidence to the inquest 
  Ms Austin’s medical records 
  WebV nursing documentation  
 
  Collaborative (formerly known as Care Groups) industrial action strike plan 
  Trust industrial action strike plan 
 
  June 2023 staffing rota, including industrial action confirmed staffing plans 
  Review  of  quarterly  weekend  staffing  at  that  time,  in  order  to  obtain  an  average 

Industrial action logs 

indication of weekend staffing 

Preparation for industrial action 

The  Trust  would  like  to  offer  assurance  of  the  planning  process  undertaken  before  the 
proposed industrial action on 14/06/2023 to 16/06/2023, which includes utilising the framework 
for managing industrial action.  The priorities were to maintain patient safety and access to 
services, and to identify the level of service disruption and risk.  An initial planning meeting 
was undertaken on 25/05/2023 which informed all Senior Managers and Clinical Directors of 
the confirmed industrial action and the impact that the Trust would be required to navigate, 
namely  the  lack  of  Foundation  Doctor  in  training  availability  during  this  period.    Staff  from 
across the Trust were contacted to ask if they would be able to support and Consultants from 
other  services,  including  in the  community  were  available to be  redeployed to other  areas. 
There  were  offers  of  clinical  skills  updates  if  required,  to  ensure  that  individuals  working 
outside their  usual  clinical  area  were confident.   The key services that  were  required to  be 
maintained were identified and risk assessments were undertaken for services that needed to 
be cancelled, in order to free up medical and support staff to work in other areas.  

Daily meetings were subsequently held for a two week period up to 13/06/2023, to effectively 
plan for this period of disruption.   Planning meetings were chaired by the Resilience  Team 
with  attendance  including  Executive  Directors,  a  senior  member  of  the  Medical  Directorate 
team,  Care  Group  Senior  Managers,  Support  Team  managers,  People  Services  and 
Communications.  Rotas were reviewed by each Care Group, with contingency plans in place 
to ensure service continuity; namely that Consultants were covering designated ward areas 
with  the  support  of  multi-disciplinary  team  (MDT)  members  such  as  Advanced  Clinical 
Practitioners  (ACPs),  and  Specialist  Nurses.  ACPs  are  highly  trained  individuals,  in  this 
instance, from a nursing background and have developed skills to allow them to offer clinical 
support in expanded roles.  ACPs are deployed across various settings within the Trust within 
the  composite  workforce  model  and  are  able  to  work  autonomously,  utilising  advanced 
practice and skills to support patients with complex clinical needs.   

The  planning  was  agreed  with  a  collaborative  approach  across  all  services,  including  the 
Executive  Medical  Director and   Executive Chief Nurse.   It  was understood that  due to  the 

 
 
 
 
 
 
 
 
 predicted impact of the industrial action, medical cover during this time would not be at usual 
weekday levels, but was representative of usual weekend cover. 

A daily situational report was expected to be completed which updated the Trust on the staff 
group  affected,  number  of  team  members  striking,  actions  taken  short  of  a  strike,  and  the 
impact on the service, for example any delays to diagnosis, treatment or discharge.  A risk 
assessment was also completed to support with risk identification and mitigation plans.   All 
Care  Groups  were  represented  at  the  below  meetings,  whereby  escalations,  updates  and 
situational reports were provided by all affected Care Groups: 

Situational updates during the period of Industrial Action were provided on: 

14/06/2023 

15/06/2023 

16/06/2023 

Tactical Co-ordination Group 08:15 and 13:00 
Strategic Co-ordination Group 10:00 and 16:00 
Tactical Co-ordination Group 08:15 and 13:00 
Strategic Co-ordination Group 10:00 and 16:00 
Tactical Co-ordination Group 08:15 and 13:00 
Strategic Co-ordination Group 10:00 and 16:00 

During this period of industrial action, as would be expected, there was reduced medical cover 
available, however, this was reflected throughout the medical wards and the Collaborative can 
confirm that no other incidents, other than the case of Ms Austin, were reported at this time, 
during the period of industrial action.  

To support with any escalations that may have required attention during the industrial action 
period, Operational Managers were assigned to dedicated areas and tasked to liaise with the 
ward teams (this would include the Consultants, ACPs, Specialist Nurses, and other members 
of the MDT covering the wards) on a daily basis, and to escalate any unresolved concerns 
raised through the Tactical Co-ordination Group.  The rota for this has been reviewed and we 
can confirm that no concerns were raised from any of the Elm A team during this period of 
industrial action.   

Following  the  period  of  Industrial  Action,  a debrief  was led  by  the  Resilience Team,  during 
which all Care Groups had the opportunity to share any learning from the period.  No concerns 
were escalated to the debrief regarding the planned staffing mitigation plan.  Had escalations 
been  made  to  the  Tactical  Co-ordination  Group  and/or  during  the  debrief,  this  would  have 
been acted upon. 

Detailed staffing plans for the Stroke Unit 

Specifically  focussing  on  the  provision  of  stroke  care  during  the  industrial  action,  as  an 
overview, the Stroke Unit at the Cumberland Infirmary comprises a 10 bedded Hyper Acute 
Stroke  Unit  (HASU)  and  a  33  bedded  Stroke  Rehabilitation  ward  (Elm  A).    Both  units  are 
staffed  separately  due  to  the  acuity  of  the  patient  cohort.    Although  staffed  separately,  the 
HASU is located within the same footprint as Elm A and staff are able to move between the 
departments as required.  

The usual medical staffing for the HASU from Monday to Friday is: 

  1 Consultant 09:00 – 17:00 
  Minimum of 2 Advanced  Clinical Practitioners (ACPs)/Trainee ACPs 09:00 – 17:00 
  1 Foundation Doctor in training also covering Elm A and Elm C (Elderly Care ward) 

  1 Foundation Doctor in training also covering Elm A, Elm C and Larch C (Elderly Care 

17:00 – 21:00 

wards) 21:00 – 09:00 

The usual staffing for Elm A ward from Monday to Friday is: 

 
 
 
             
             
             
 
 
 
 
 
 
 
 
   1 Consultant 09.00 to 17.00 
  1 Specialist Trainee Doctor Year 3 09.00 to 17.00 
  4 to 6 Foundation Doctors in training 09:00 – 17:00 
  1 Foundation Doctor in training also covering HASU and Elm C (17:00 – 21:00) 
  1 Foundation Doctor in training also covering HASU, Elm C and Larch C (Elderly Care 

wards) 21:00 – 09:00 

The usual weekend cover for Elm A and HASU (combined) is: 

  1 Consultant 09.00 – 15.00, based on HASU but available for Elm A should there be 

an escalation which requires expert decision maker review 

  1 Foundation Doctor in training on Elm A 
  2 ACPs on HASU 

During  the  period  of  industrial  action  (Wednesday  14/06/2023  to  Friday  16/06/2023),  it  is 
recorded  that  approximately  78%  of  Foundation  Doctors  in  training  rostered  to  work  on  a 
specialist  medical  ward  at  the  Cumberland  Infirmary  opted  to take  strike  action,  as  is  their 
right.  During the same period, 100% of the Foundation Doctors in training rostered to work 
on Elm A between the hours of 09:00 and 21:00 took strike action.  As a result, medical cover 
on Elm A during this period did not fully replicate the rota compared to when there are resident 
doctors present.   

An alternative rota was comprised of the composite workforce of individuals skilled and trained 
in the care of stroke patients.  The rota was agreed at the Trust tactical planning meeting and 
was felt to be safe.  The ward had Consultant cover between the hours of 09:00 – 21:00 on 
all days of the industrial action, therefore the Trust was assured of senior medical oversight, 
supported by Specialist Nurses and ACPs.  

There were no concerns regarding staffing levels overnight (21:00  – 09:00).  To note, other 
support services available to support if required or escalated to included wrap around services 
of Phlebotomy, Critical Care and the Hospital at Night Team.  

The staffing during the period of industrial action was as follows: 

Wednesday 14/06/2023 09:00 – 17:00 

  Consultant A on Elm A  (Stroke Rehabilitation patients) 
  Consultant B – carrying out an outpatient clinic for urgent patients (morning only) 
  Consultant C on Elm A  (Neuro Rehabilitation patients) 
  Consultant D on HASU with 1 Trainee ACP HASU 
  Consultants  A  and  C  were  supported  by  two  Trainee  ACPs,  a  nursing  team,  and 

Consultant B was available if required  

  The ACPs on duty during the strike period were in training, therefore were not qualified 
to work independently or carry out the full range of duties expected of a qualified ACP, 
however were under the supervision of a Consultant. 

Consultant B was on site on 14/06/2023 and was undertaking an urgent clinic in the morning 
assessing acute neurovascular cases who are required to be seen within 24 hours of symptom 
onset.  All other non-urgent clinics within stroke were cancelled in order to ensure Consultants 
were  available  for  ward  cover.    However,  Consultant  B  was  available  to  support  the  ward 
teams if concerns had been escalated.  We have been unable to evidence any escalations 
made on this day that would have necessitated  Consultant B to attend the ward to  provide 
support.   

 
 
 
 
 
 
 
 
 
 
 
 Between the hours of 17:00 and 21:00, Consultant D was on site providing medical cover to 
patients on Elm A and HASU. 

Thursday 15/06/2023 09:00 – 17:00 

  Consultant A on Elm A (Stroke Rehabilitation patients) 
  Consultant C on Elm A (Neuro Rehabilitation patients) 
  Consultants  A  and  C  were  supported  by  1  Trainee  Advanced  Clinical  Practitioner 
(ACP) and 1 Advanced Nurse Specialist in the afternoon (available if required in the 
morning) and a nursing team 

  Consultant D on HASU with 2 Trainee ACPs  

Between the hours of 17:00 and 21:00, Consultant C was on site providing medical cover to 
patients on Elm A and HASU. 

Friday 16/06/2023 09:00 – 17:00 

  Consultant A on Elm A  (Stroke Rehabilitation patients) 
  Consultant A was supported by 1 Trainee ACP and 1 Advanced Nurse Specialist in 

the afternoon (available in the morning) if required and a nursing team 

  Consultant D on HASU with 2 Trainee ACPs  

Between the hours of 17:00 and 21:00, Consultant A was on site providing medical cover to 
patients on Elm A and HASU. 

For  overnight  provision  throughout  the  period  of  industrial  action,  Elm  A  and  HASU  were 
covered by  1  Foundation  doctor  in training  and  1  contactable Medical  Registrar (Specialist 
Trainee).  In total, overnight provision across the 8 medical wards was 2 junior doctors and 1 
Consultant, which was greater than in normal circumstances when no industrial action was 
ongoing.  Usual overnight provision across the 8 medical wards is 2 Foundation doctors in 
training and 1 contactable Medical Registrar. 

The  staffing plans  were devised  with the  operational  teams  working closely  with the  senior 
clinical staff to determine what cover was needed.  The Emergency Care and Medicine Care 
Group’s  (subsequently  known  as  a  Collaborative)  confirmed  the  staffing  plan,  detailing  the 
staff rosters for 14 to 17/06/2023, was submitted to the Resilience Team, Associate Medical 
Director  and  Associate  Director  of  Operations  on  Monday  05/06/2023.    To  note,  the  plan 
initially detailed just 1 Consultant working on Elm A on 14/06/2023, however, as documented, 
the Care Group were able to provide 2 Consultants on this day.  

The  staffing  plan  was  discussed  throughout  the  tactical  planning  meetings,  led  by  the 
Resilience Team with attendance by a number of senior clinical and non-clinical managers in 
the weeks before industrial action took place.  Whilst it was recognised that medical staffing 
across all of the medical wards was anticipated to be significantly impacted by the industrial 
action, all wards were covered by at least 1 Consultant during the core hours of 09:00 – 17:00 
(with  usual  out  of  hours  Consultant  cover  in  place)  and  some  mitigations  from  other  staff 
groups (i.e specialist nurses and ACPs).  This was not deemed to be unsafe. 

Learning 

The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures 
safe levels of cover during periods of industrial action to meet need, and that this does not 
give rise to a risk of future deaths.  The process and plans will therefore be maintained during 
any  future  periods  of  industrial  action.    However,  despite  the  Trust’s  robust  framework  in 
ensuring appropriate medical cover during periods of industrial action, the Trust has identified 
areas of learning which could contribute to the Trust’s resilience: 

 
 
 
 
 
 
 
 
 
 
 
 
 1.  The Ward Teams to embed extraordinary safety huddles twice daily during periods of 
industrial action to allow  MDT members to attend and discuss concerns/escalations.   
2.  Operational Teams/Matrons to embed twice daily touch bases with each ward area, 
to  support  and  address  any  areas  of 

industrial  action, 

during  periods  of 
concern/escalation. 

Whilst the Trust already had robust systems in place for Operational Managers to visit areas 
affected by industrial action and groups for any concerns to be escalated to, the additional 
safety MDT huddles and twice daily visits from the Operational Teams/Matrons, provides an 
additional  forum/opportunity  for  concerns/escalations  to  be  made,  and  highlights  the 
importance to the MDT of doing so.  

In view of the Trust’s assurance that there is safe levels of cover during periods of industrial 
action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any 
missed opportunities within Ms Austin’s care.  However, the Trust unreservedly acknowledges 
that there is a need to establish what the causal and/or contributory factors were in Ms Austin 
not receiving medical input and basic, fundamental observations and interventions during her 
hospital admission.  The Trust will therefore carry out a review into this to identify any learning 
and take immediate action to embed the learning to prevent recurrence and ensure that the 
care we provide is safe, effective, and of a high quality.  

Once  again,  thank  you  for  bringing  your  concerns  to  my  attention.    I  hope  that  the  above 
provides assurance to you, Ms Austin’s family, and the public, that the Trust has taken them 
seriously and appropriate action is being taken. 

I appreciate not all of the actions are yet implemented and I would be happy to provide updates 
on these in the future, should you require this.  Please also let me know if you require clarity 
on any of the responses I have provided above. 

Yours sincerely 

Chief Executive 
For and on behalf of North Cumbria Integrated Care NHS Foundation Trust