Stephen Dulling

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

6 December 2024 

Private and Confidential 
Catherine Cundy 
Area Coroner for North Yorkshire and York 
By email: 

Inquest into the death of Stephen Dulling  

I am writing to you in response to the Report to Prevent Future Deaths (PFD), dated 
14 October 2024, following the sad death of Mr Dulling.  I note that the PFD is directed 
to  both  Tees,  Esk  and  Wear  Valleys  NHS  Foundation  Trust  (TEWV)  and  York  and 
Scarborough Teaching Hospitals NHS Foundation Trust.  This response is provided 
on behalf of TEWV.  

I understand that your concern in relation to TEWV is the management of a phone call 
to the All Age Crisis Line and the advice which was provided to contact the Police.  

The  Crisis  Team  are  not  an  emergency  service  and  when  there  is  felt  to  be  an 
immediate and significant risk, the correct advice is for the emergency services to be 
contacted,  which  depending  upon  the  nature  of  the  call  will  either  be  done  by  the 
person  contacting  emergency  services  themselves  or  the  Crisis  Team  agreeing  to 
contact  on  their  behalf.    This  will  then  result  in  a  decision  being  made  by  the 
emergency  services  as  to  whether  there  will  be  a  response  from  the  Police  or 
Ambulance Service.  

In this case, due to the concerns of violence and aggression, the correct advice was 
provided for the Police to be called.  This is because the Police can provide an urgent 
response and have additional powers, such as the ability to enter a person's home, or 
in certain situations, take a person to a place of safety, such as a hospital for a Mental 
Health Act assessment, under S136 of the Mental Health Act.  

Had  the  advice  been  followed  and  the  Police  contacted,  the  Police  would  have 
provided an emergency response in relation to the threat of violence, whilst liaising 
with the Crisis Team and any other services required, such as the ambulance service, 
to ensure that there was an appropriate assessment of Mr Dulling's mental state and 
risk, either via an assessment from the Crisis Team or through a Mental Health Act 
assessment.  

 
 
 
 
 
 
 
 
 I am sorry to hear that the role and rationale for contacting the Police was not clearly 
communicated to Mr Dulling's wife.  The case will be presented at the Trust Urgent 
Care Board which takes place on the 23 January 2025.  Learning from this incident 
will also be shared at the all the Trust's Specialty Clinical Networks meetings on 19 
December 2024, 20 December 2024, 7 January 2025 and 22 January 2025 via the 
service  development  managers  for  adult  mental  health,  mental  health  services  for 
older  people,  child  and  adolescent  mental  health  services  and  adult  learning 
disabilities to highlight the importance of clear communication and the impact of it and 
to the Trustwide Organisational Learning Group on 5 December 2024.  The meetings 
are  attended  by  specialist  practitioners,  service  development  managers,  consultant 
psychologists, associate medical and nursing directors from across the Trust, who will 
disseminate the learning.  

I  hope  that  the  above  clarifies  your  concerns,  but  should  you  have  any  additional 
queries please do not hesitate to contact me.  

Yours sincerely 

Chief Executive

Chief Executive Office 
                                                                                                                                      York Hospital 
Wigginton Road 
York 
YO31 8HE 
, Chief Executive 

Direct Line: 
Email:  

18 December 2024 

Ms C Cundy 
HM Coroner for York & North Yorkshire 
By email: 

Dear Madam 

Thank you for raising your concerns as a result of the inquest into the death of Mr Stephen 
Dulling, following his admission to York District Hospital. York & Scarborough Teaching 
Hospitals NHS Foundation Trust (the Trust) recognises the seriousness of these findings, and 
I write to outline the actions we are taking to address the lapses identified. These measures 
are intended to reduce the risk of recurrence and improve the quality and safety of care 
provided to our service users. 

Coroner’s concern:  

a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in 
respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity 
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, 
despite a) above 
c) No food chart being implemented and maintained despite the outcome of Mr 
Dulling’s malnutrition risk assessment 

It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not 
detailed enough and that a food chart was not instigated/completed when it should have 
been.  
The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in 
November 2024. There are currently several assessments, relating to eating and drinking and 
nutrition, that nursing staff undertake when a patient is admitted. These assessments are not 
all located in the same place and not as intuitive as they could be. We recognise that this is 

 
 
 
 
 
 
 
 
 
 not optimal and are in the process of bringing these assessments together into one section of 
Nucleus (electronic digital nursing record) and this is due to go live in January 2025. We are 
confident that this will significantly reduce the risk of essential information being overlooked.  
The Trust recognises the previous poor compliance in this area, as identified in Mr Dulling’s 
case, and this is a focus of current quality improvement project work. The Trust has 
completed a Patient Safety Incident Investigation (PSII) cluster review of Speech and 
Language Therapy (SLT) and swallow related incidents. This was presented to the Trust’s 
Serious Incident Group in December 2024 with an associated action plan.  

The PSII identified themes around lack of or delayed referral to SLT as well as food and drink 
given to patients that is not the IDDSI (International Dysphagia Diet Standardisation Initiative) 
level advised by SLT. The identified actions are incorporated into ongoing improvement work 
and monitored by the Trust Food, Nutrition and Hydration Steering Group.  

Speech and Language Therapists have also led on development of a Sip Testing Standard 
Operating Procedure (SOP) which was published in November 2024 along with a training 
video on Nucleus. This identifies patients who should be considered for a sip test and those 
for whom this is contraindicated, such as those with pre-existing swallowing difficulties. 

d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids 

Since this incident occurred there is a new fluid assessment, as part of the Nucleus digital 
patient record, which is completed for all patients. This then prompts appropriate hydration 
monitoring dependant on the level of clinical need. The Food, Nutrition and Hydration Policy 
clearly states that when a patient lacks capacity a best interest’s decision should be made 
about ongoing fluid management, in consultation with family or carers.  

e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling 
was choking 

It is noted that the HCA (health care assistant) statement said the nurse looking after the 
patient had a delayed response, but that nurse was in the middle of giving another patient 
medication and said there was only a brief moment of delay until the patient swallowed their 
medication before they attended Mr Dulling.   

f) The absence of a de-brief of staff involved in the choking incident by a nurse of the 
requisite level within the period of 72 hours after the event. This, together with the 
subsequent delay in undertaking and completing the patient safety investigation 
review, resulted in important gaps in the evidence supplied both to the review and the 
inquest. 

It is to be noted that at the time of the incident the Trust followed its previous policy on 
incident management. The Trust moved to the new Patient Safety Incident Response 
Framework (PSIRF) in December 2023. Since that time revised systems and processes have 
been put in place to record, monitor, review and learn from incidents across the Trust. It is 
acknowledged the investigation undertaken following this incident was not timely nor optimal. 
This has been reviewed with the Medicine Care Group and the new policy requiring either hot 

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 debrief or other form of incident response is now in place and is being used to proper effect. 
The Medicine Care Group has a dedicated Clinical Governance Team who review all reported 
patient safety events on a daily basis, appropriate learning responses identified and 
requested, and any severe or moderate harm patient safety events escalated to the Care 
Group quadrumvirate. 

Conclusion 

We hope that this information provides you with assurance that the Trust has learned from 
this incident and have refined our procedures as a result. This will continue to be monitored 
carefully through our governance and assurance structures.  

Yours sincerely 

Chief Executive  

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