Megan Williams

Trust Offices 
Kent and Canterbury Hospital 
Ethelbert Road 
Canterbury 
CT1 3NG 

20 September 2024 

PRIVATE & CONFIDENTIAL 

Your ref: 
Our ref: 

James Dillon 
HM Assistant Coroner 
Oakwood House 
Oakwood Park 
Maidstone 
Kent 
ME16 8AE 

Sent by email to:

Dear Sir 

Re: Ms Megan Ceris Williams 

I write to you following the concluded inquest into the death of  Miss Megan Ceris Williams on 20th 
June 2023.  At the outset, I would like to offer my sincere condolences to her family and I hope they 
have received answers to their concerns in relation to the care and treatment provided by the Trust. 

I refer to your request for further information following the conclusion of the inquest, namely the below 
points:  

1.  That  there  was  a  lack  of  knowledge,  among  clinical  staff,  of  the  Acute  Abdominal  Pain 

Pathway (AAPP). 

The reinforcement of the AAPP is a continuing process and has been happening throughout the 
last two years within the Trust.  The Trust have a monthly joined Emergency Medicine and Surgical 
teaching session. This is a platform for these Departments to present and discuss cases they face 
in order to improve patient safety continuously. It is important to note that cases surrounding acute 
abdomen are frequent and therefore often require discussion of the AAPP.  The AAPP is a feature 
of these discussions each time a relevant case is discussed.    

This  approach  forms  part  of  well-established  forums  in  which  clinicians  can  discuss  and  share 
insight into cases and share learning. The Trust considers the current training regime is sufficient 
to  ensure  that  all  staff  understand  the  appropriate  process  for  the  emergency  management  of 
patients with adult abdominal pain (explained further below). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Given what was said about how clear the AAPP was, that EKHT should provide evidence of 

what further work has been done make it clearer and accessible to clinicians. 

Enclosed with this letter is the Acute Abdominal Pain Pathway (AAPP) (Document 1). As explained 
above, the Trust have a monthly joined Emergency medicine and Surgical teaching session which 
involves clinical staff from both departments. The AAPP has been a constant part of the discussion 
to ensure that: 

a)  All clinical staff members understand the appropriate process for the emergency management 

of patients with adult abdominal pain.  

b)  All clinical staff know when the AAPP needed to be initiated.   
c)  All clinical staff know the teams they needed to escalate concerns to, and when these concerns 

need to be escalated.  

In addition, the Trust’s Updated Action Plan implemented a procedure whereby a copy of the AAPP 
needs  to  be  fully  completed  when  a  patient  is  admitted  to  the  Emergency  Department  with 
complaints  of  abdominal  pain.  This  process  was  implemented  on  07  September  2022. 
Furthermore, as of 13 September 2022, the AAPP has now been added to the My ED App, this is 
to ensure it is readily and easily accessible to clinical staff assessing patients with complaints of 
abdominal pain.  

3.  That the hospital SI process did not include information from family and other interested 

persons or parties as part its fact-finding exercise. 

Since the conclusion of the inquest, the Trust has changed the SI process to the new Patient Safety 
Incident Response Framework. The Trust Patient Safety Incident Response Policy (Document 2) 
and Plan (Document 3) have been agreed and are attached for information.    

Section 9 of the policy outlines how patients, families and staff are all to be involved following a 
Patient  Safety  Incident.  The  guiding  principle  of  the  policy  is  that  learning  and  improvement 
following a patient safety incident can only be achieved if supportive systems and processes are 
in  place.  These  systems  and  processes  focus  on  compassion  and  collaboration.  The  policy 
therefore promotes the Trust to work with those affected by Patient Safety Incident’s to answer any 
questions  they may  have,  signpost  them to support  and  include  their  comments  within the final 
report. As such, the Patient Safety Incident Framework unlike the SI process prioritizes obtaining 
information from the family and other interested persons as part of its fact-finding exercise.  One 
element of the principles of engagement for drafting a Patient Safety Incident Framework is that 
the  investigative  process  will  be  collaborative;  with  the  patient,  staff  and  investigators  working 
together to achieve learning that will ensure improvements are made. To ensure a collaborative 
approach the principle of patient and family involvement is threaded throughout the policy.  

The Trust transitioned to the Patient Safety Incident Framework on 10 June 2024 and incidents 
have been reviewed and managed in accordance with the Trust Policy and Plan from that date.   

To support implementation of the Patient Safety Incident Response Policy and Plan, the Trust has 
updated the governance structure to ensure the thorough review of incidents of concern or interest.  
Attention to the involvement of the patient and their family is incorporated into the incident review 
processes  via  the  Terms  of  Reference  for  the  Incident  Review  Panel  (Document  4  –  3.4)  and 
proforma which supports the review of incidents presented at the Incident Response Panel. 

In addition to the Policy and Plan, the Trust is adopting the NHS Engaging and involving patients, 
families and staff following a patient safety incident.  The Trust’s Incident Management Policy has 
been updated (pending ratification) to ensure that patient and family involvement is strengthened.  
Similarly,  the Trust’s  Duty  of  Candour  Policy  (Document  5)  will  be  reviewed  and  updated.    For 

 
 
 
 
 
 
 
 
 instance, to ensure that the Trust flowchart on page 10, is aligned to the requirements of the NHS 
engagement and involvement process (see below). 

The Patient Safety Incident Response Framework and our Trust plan requires the use of a Patient 
Safety Incident Investigation (PSII) methodology for certain incident types.  The Trust has adopted 
the national template for PSII reports (Document 6).  This includes recording of the patient and 
family involvement in the investigation process.  The other learning response reports that the Trust 
will be using e.g. After Action Review, Swarm, also prompt the inclusion of the patient and family 
perspective. 

Under the oversight requirements for the Patient Safety Incident Response Framework, the NHS 
Oversight  roles  and  responsibilities  specification  details  the  leadership  and  management 
requirements for oversight for providers, commissioners and regulators.  The provider executive 
lead responsibilities are to: 

•  Ensure the organisation meets the NHS National patient safety incident response standards 
(2024)  –  which include engagement  and  involvement  of those  affected  by  patient  safety 
incidents. 

•  Ensure PSIRF is central to overarching safety governance arrangements. 
•  Quality assure learning response outputs.  

The  Trust  will  be  replacing  the  previous  Serious  Incident  Approval  Panel  with  the  Learning 
Response Approval  Panel  to  approve  Patient  Safety  Incident  Investigations.    The  Care  Group 
Triumvirates will be responsible for oversight and approval of some learning responses.  In both 
instances  the  Trust  will  adopt  the  questions  to  guide  local  oversight  of  patient  safety  incident 
responses. 

The Trust  is  implementing  the  Learning  response  review  and  improvement  tool  to  enable  peer 
review  of  reports.    This  includes  the  descriptor,  “People  affected  by  incidents  are  meaningfully 
engaged and involved”.  This tool will be used by learning response leads and the Peer Review 
Panel described within the Trust Policy (section 12). 

In summary, the Trust has commenced implementation of Patient Safety Incident Framework and 
strengthened the processes to ensure the engagement of the patient, family and other stakeholders 
with the oversight of the Incident Review Panel.  The planned implementation of the Peer Review 
Panel  and  the  Learning  Response Approval  Panel  will  further  strengthen  the  oversight  of  the 
inclusion of information from the patient, family and other stakeholders.  In addition, the Trust also 
plans to consider how assurance of adherence to the patient safety incident response standards 
will be sourced and reported. 

4. 

There was not a clearly documented and recorded process for patients who self-discharge 
from hospital. 

As per the Updated Action Plan, the Trust have implemented a new process whereby all patients 
who re-attend the Emergency Department within 48 hours of discharge for the same complaint are 
seen by the discharging team, this review is documented, and forms  part of the patients records. 
This additional process is to ensure that the patient was not discharged when further investigation 
and/  or  treatment  was  required.  The  discharging  team  will  review  the  patient  on  re-attendance, 
ensure no additional investigations are required and either admit or discharge accordingly.  

To  ensure  a  repeat  of  similar  incidents  does  not  re-occur,  the  Trust  has  also  updated  its  policy 
relating to patients who self-discharge from hospital. Enclosed with this letter is the Trust’s updated 
Missing Persons Policy (Document 7) and the Discharge Criteria policy (Document 8). This has been 
through  3  separate  reviews  and  updates  since  May  2022  and  ensures  that  the  duties  of  staff 
members relating to missing patients and patients who are attempting to self-discharge are clearly 
established. It also now includes an updated Patient Risk Assessment so that staff members can 

 
 
 
 
 
  
 
 
 
 document if a patient is at high risk of going missing or if they will suffer harm from self-discharging. 
The updated policy has been approved by the Safeguarding Assurance Committee and the attached 
version was disseminated across the Trust on 30 May 2024.  

In addition, the Trust has updated the Hospital Discharge and Criteria to Reside Policy. The Policy 
was updated and issued to all staff at the Trust on 16 February 2023. The updated policy directs staff 
to always consider the following when a patient indicates that they want to self-discharge:  

a)  Does patient have capacity? Has this been evidenced by completion of an assessment under 

the Mental Capacity Act as appropriate? 

b)  Has a Deprivation of Liberty checklist been completed? 
c)  Inform and discuss with medical staff, matron, or care manager as required. 
d)  If out of hours, liaise with Operational Site Manager. 
e)  Inform and discuss with GP and any other relevant agency. 
f)  Ensure patient has prescribed medications to take away. 
g)  Inform next of kin, if known and appropriate. 
h)  Self-discharge form should be completed.  
i)  Document clearly within medical and nursing notes all actions taken. 

Of key importance is that patients are asked to review the Self Discharge Form which must then be 
filed within the patient’s case notes. The Self Discharge Form sets out the risks of discharging against 
medical advice and asks a patient to consider these risks before signing the form. This is to ensure 
that patients have weighed the risks of self -discharge and ensures that there is a recorded process. 
The Policy also mandates that following discharge, if on a ward, then a welfare check telephone call 
be made to ensure the patient has arrived home safely.  

I hope this letter provides you with the relevant clarification to your queries and I  would be happy to 
assist further. 

Yours sincerely 

Chief Medical Officer

Mr James Dillon 
Assistant Coroner 
 Mid Kent and Medway Coroner Service Team 
Oakwood House 
Oakwood Park 
Maidstone 
ME16 8AE 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

18 September 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Megan Ceris Williams 
who died on 5 May 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 July 
2024 concerning the death of Megan Ceris Willliams on 5 May 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Megan’s family and loved ones. NHS England are keen to assure 
the family and the Coroner that the concerns raised about Megan’s care have been 
listened to and reflected upon.   

I  note  that  you  have  also  addressed  your  Report  to  East  Kent  Hospitals  University 
NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the 
concerns raised by the Coroner, as these concerns do not fall under NHS England’s 
remit and are all local issues for the Trust to address.  

However, my regional colleagues in the South East are engaging with NHS Kent and 
Medway Integrated Care Board on the concerns raised, and NHS England has asked 
to be sighted on the Trust’s response to you. We will consider their response to the 
Coroner  once received  and  whether  any further  actions are  required.  We  would be 
happy to update the Coroner further if this is the case.    

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Megan, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
  
 
  
 
 National Medical Director

2nd floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

+44 (0)300 323 0140 

James Dillon  
Assistant Coroner  
Central and South East Kent Coroners  
By email: 

22 January 2025 

Your reference: 
Our reference: 

Dear Mr Dillon  

Re: Regulation 28 Prevention of Future Deaths Report in respect of Megan Ceris 
Williams  

I write in response to your regulation 28 report regarding the tragic death of Megan Ceris 
Williams. I would like to express my sincere condolences to Megan’s family and loved ones.  

We did acknowledge receipt of your report but, due to a miscommunication, we did not follow up 
with our formal response. I would like to apologise to you, and to Megan’s family, for our error.  

I, with colleagues in NICE’s patient safety oversight group, did review and reflect on the 
concerns raised within your report shortly after we received it.   

On this occasion, we do not consider that there are any actions from NICE that would address 
the issues raised.   

Once again, I am sorry for the delay in confirming NICE’s position.   

Yours sincerely  

Consultant Clinical Advisor  
Senior Responsible Officer for Patient Safety 

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