Chloe Every

Private and Confidential 
Mr G Irvine 
HM Area Coroner 
Walthamstow Coroner’s Court 
Queens Road 
London 

Date: 18 December 2024 

Legal Services 
Queen's Hospital 
Rom Valley Way, Romford, RM7 0AG 

Phone: 01708 435 000 
www.bhrhospitals.nhs.uk 
@BHRUT_NHS 

Regulation 28 Report on the death of Miss Chloe Every- Reference: 

Dear Mr Irvine, 

Thank you for your Regulation 28 Report of 25 October 2024. Barking, Havering and Redbridge 
University  Hospitals  NHS  Trust  (the  Trust)  has  carefully  considered  the  matters  of  concern 
raised  by  the  learned Coroner in  the  Regulation  28  Report,  and  guidance  has  been  sought 
from specialists within the Trust to address them. 

The matters of concern identified in the Regulation 28 report and the Trust`s responses are set 
out below 

•  The Trust does not provide nursing cover during weekends and holiday periods 

of staff with relevant learning disability training. 

It was submitted in evidence at the hearing that the Trust has made efforts to recruit qualified 
Learning Disability nurses to provide cover during weekends and holiday periods. The absence 
of nursing cover at these times is not a matter of a lack of resource, but an issue with having a 
cohort of available, recruitable nurses with this specific qualification. Our review identified that 
no acute Trust in London has Learning Disability nurses on a 24/7 basis.  

In  recognising  this  limitation,  the  Trust  has  put  mitigations  in  place.  The  Trust  provides 
mandatory training for all staff including both nursing and medical staff related to the care of 
patients with a Learning Disability. The training covers a broad range of topics which include 
diagnostic  overshadowing,  the  importance  of  reasonable  adjustments  and  how  to  access 
resources to support patients with a Learning Disability whilst they are under the care of the 
Trust. The aim of the training is to alert staff to understand the requirements of patients with a 
Learning Disability and to be aware of the reasonable adjustments required that will support 
patients and ensure that they receive the care that they need. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All staff are expected to complete the Oliver McGowan training which is a national standardised 
training requirement. The training is designed to provide staff with better skills, knowledge and 
understanding of the needs of autistic people and people with a Learning Disability. The Trust 
implemented internal face to face level 3 Learning Disability training for staff including sharing 
the experience  of  a patient  with Learning  Disability  and  their  interaction  with  clinical  staff  to 
promote best practice. 

The Trust’s Learning Disability Team (LD team) review patients in the wards and ensure that 
staff have the required support to deliver care to patients. This team operates across both sites 
and are accessible by telephone and email.  

The hospital IT system is able to identify when patients with a Learning Disability have been 
admitted or are being cared for within the hospital. The team produces a report daily via the 
Trust IT system which identifies if new patients with a Learning Disability have been admitted. 
They  then  review  the  patient  in  person  on  the  ward  the  next  working  day  ensuring  that 
appropriate  clinicians  and  professionals  are  informed  of  the  admission.  Daily  follow  ups 
continue throughout a patient’s stay to ensure that appropriate support is provided to the ward 
area, the patient, and their carers. 

There is a practice development nurse who supports the training needs of staff on the ward. 
The  needs  are  identified  by  feedback  from  the  Ward  Accreditation  assessment  process, 
information from the Senior Nurse for Learning Disability and from audits completed. The ward 
accreditation is a process by which ward areas are assessed by Subject Matter Experts across 
11 standards which include reviews by the Learning Disability teams. 

There are ongoing plans to employ more nurses with Learning Disabilities qualifications in the 
Trust which will include the acute ward and emergency department (ED) areas; the recruitment 
process is underway. The nurses will work in the clinical areas as part of the workforce and will 
be allocated to care for patients with Learning Disabilities within their area. 

•  The investigation of this inquest was prejudiced by the absence of contemporary 
nursing and medical notes from various stages of Chloe's treatment. The extent 
of these lapses meant staff who made important treatment decisions could not be 
identified, and where staff could be identified, no contemporary account of their 
rationale for making treatment decisions could be located. 

The Trust currently remains on part electronic and paper records.  However, there has been 
significant progress towards a more integrated system. The Trust is in the planning stages of 
implementation  of  a  full  Electronic  Patient  Care  Record  (EPR)  with  the  planned  date  for 
implementation  of  June  2025.  Implementation  is  supported  by  a  team  of  clinical  and  digital 
staff, with progress monitored through the Trust Executive Committee and the Trust Board. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As a practical response to this concern, the Trust’s Legal Services Department now routinely 
deliver  training  sessions  on  “The  importance  of  Good  Record  Keeping”.  The  training  puts 
particular focus on the importance of good medical documentation being a fundamental aspect 
of  clinicians’  duty  in  providing  patient  care;  ensuring  patient’s  needs  are  met;  ensuring 
continuity  of  care;  ensuring  effective  evidence  of  the  standard  of  care  and  decision-making 
process.  

Good Medical Record training is being delivered in December 2024 and January 2025 as part 
of the junior doctors’ induction in ED. Consideration is being given to adding this training to all 
junior doctors’ inductions, and as part of the Trust’s Statutory and Mandatory training for clinical 
staff. 

In August 2024, the Medical Directorate established a Quarterly Health Records Group where 
both best practice and learning opportunities will be presented and reviewed with action plans 
as appropriate. 

The Trust lead for mortality  and Caldicott Guardian is in the process of organising  CRABEL 
audits (an audit tool designed by CRAwford – BEresford – Lafferty) as a tool for the assessment 
of the quality of medical record keeping, with the ability to standardise audit and improvement 
across  areas.  A  paper-based  CRABEL  audit  is being  undertaken within  different  specialties 
and results will be shared trust wide.  

An online audit tool has been developed (it is currently at the ready for testing stage to ensure 
data is captured and reported correctly using an electronic risk management system) and the 
Trust is aiming to commence auditing across all specialties from February 2025. 

•  The regularity of Chloe's clinical observations fell well below the expected level. 
The  lapses  included  a  period  of  over  10  hours  in  which  no  observations  were 
undertaken. 

There is live data in the format of a dashboard showing compliance with expected observation 
frequency  available  to  senior  staff  within  clinical  areas  (ward  managers,  matrons,  practice 
development nurses and clinical group directors). Additional monthly performance reports have 
been sent to the same staffing groups since December 2023. Vital signs recording and actions 
form  part  of  the  Ward  Accreditation  Framework  process  and  clinical  areas  work  with  the 
VitalPac team to continue to improve the timings of observations. 

The  wards  areas  in  the  Trust  are  subject  to  assessment  utilising  the  Ward  Accreditation 
Framework (WAF) which monitors metrics related to patient care and safety, as well as how 
the wards are operated. Audits are completed annually by subject matter experts and any areas 
in  which  the  ward  falls  below  70%  compliance  is  addressed  with  an  action  plan.  The  WAF 
framework  assesses  the  nursing  staff  knowledge  of  the  escalation  process  for deteriorating 
patients. The Ward Accreditation assessments started in 2020 and since then all wards in the 
Trust  have  completed  and  have  achieved  a  minimum  of  a  bronze  standard  for  ward 
accreditation with many at Silver and working towards gold. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Monthly  deteriorating  patients’  audits  are  carried  out  by  ward  areas  and  are  discussed  at 
governance meetings within the Clinical Groups. The Trust also undertakes regular audits of  
NEWS recording and escalations in compliance with NHS England Commissioning for Quality 
and Innovation (CQUIN) framework for NEWs escalation and response. 

The Trust has funded and implemented a 24 hour a day Critical Care Outreach Team (CCOT) 
and the team reviews observations using a tracking process on the Clinical Vitals App in all 
ward areas to ensure that patients who have raised NEWS 2 score have been escalated and 
reviewed. CCOT monitors patients across the Trust and reviews the Clinical Vitals app within 
CareFlow to identify patients with elevated NEWS 2 scores (a national early warning system 
for identifying patients at risk of deterioration). These reviews are undertaken a minimum of 
three times a day. This is alongside the prompts for escalation that are raised at the time that 
an elevated NEWS 2 score is entered into the Clinical Vitals system. 

•  Chloe underwent an enema on 08 May 2019 without informed consent being 
taken. The court found that Chloe was unconscious, before, during, and after 
the procedure, it is possible this procedure contributed to her death. 

The Trust’s Consent to Examination and Treatment policy section 4.1.4 'Procedures to follow 
when patients lack capacity to give or withhold consent' includes guidance on when and how 
to apply. The policy will be updated by February 2025 to include guidance on implied consent. 

An Easy Read leaflet on Information about Consent for patients with Learning Disabilities has 
been  drafted  and  is  currently  going  through  review  and  approval  processes  with  expected 
completion in February 2025. 

The Legal team will deliver training about informed consent including Montgomery Law and 
GMC and NMC requirements in January 2025. 

•  Nursing staff were incapable of explaining to the court the appropriate criteria 
that would have to exist before commencing CPR on an unresponsive patient. 

All  staff  are  required  to  complete  annual  mandatory  resuscitation  training  at  different  levels 
depending on their job roles. Trust staff statutory mandatory resuscitation training aligns with 
NHS England, UK Core Skills Training for Health Framework and 2021 Resuscitation Council 
UK guidelines. The Training Needs Analysis can evidence cross-Trust resuscitation training, 
logistical  and  financial  demands,  and  more  accurate  monitoring  of  mandatory  compliance 
metrics in resuscitation training levels 1-3. 

In addition, the Trust have introduced mandatory training related to identification and escalation 
of the acutely deteriorating patient for all patient facing nursing staff in October 2024. Training 
needs analysis for medical staff is in progress. CCOT provides a deteriorating patient session 
during Trust induction and on Keeping in Touch (KIT) days, as well as targeted local training 
in clinical areas on request and when learning is identified following incidents. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  Trust’s  Resuscitation  Service  has  an  audit  programme  to  ensure  compliance  against 
published standards. NCEPOD recommends that every CPR attempt is reported through the 
organisation’s incident reporting system; the Trust is compliant with this recommendation and 
an ongoing audit on reported incidents for cardiac arrests and medical emergencies is being 
undertaken. The Trust is taking part in  the National Cardiac Arrest Audit.  Audit of DNACPR 
policies is mandated as per Health Services Circular and is being undertaken as a part of the 
Ward Accreditation programme.  

In addition, test bleep/dect calls audits are ongoing and help to ensure only relevant personnel 
receive emergency calls. All audit results are presented at the Resuscitation Committee and 
reported quarterly to Quality Governance Steering Group.  

•  Governance processes at the Trust failed to identify that Chloe's death 

constituted a patient safety incident until months after her death. A mortality 
review authored by the Associate Medical Director on 17 May 2019 assessed 
Chloe's care as good or excellent. 

The incident form was completed on 08 May 2019 following the cardiac arrest as per NCEPOD 
recommendations. The mortality review was performed in accordance with the RCP Structured 
Judgement  Review  guidance.  That  guidance  is  reflected  in  the  Trust  Learning  from  Deaths 
policy which was adhered to in this case. The mortality review is a desktop case note review 
to identify quality judgments over phases of care. It is not, and is not intended to be, a detailed 
or final review of care. 

The  Trust  commissioned,  from  external  experts,  a  review  of  the  Resuscitation  Services 
provided  by  the  Trust.  As  a  result  of  the  review,  the  Trust’s  Resuscitation  Services  was 
established in March 2022. The service reviews all Cardiac and Emergency calls and mandates 
the reporting of all calls on the incident reporting system. The service comprises a team of 6 
members of staff who are able to support both the teaching and review of deteriorating patients. 

There  is  a  Medical  Lead  for  Resuscitation  and  there  are  regular  Trust  wide  resuscitation 
meetings. All cardiac arrests are attended by the Resuscitation team and debriefs are offered. 

The  Resuscitation  team  receives  the  switchboard  calls  list  (one  day  retrospectively  or  post 
weekend Fri-Sun). This information is collated within a database for an understanding of time, 
date and location; it presents an opportunity to review thematic trends. Identified cardiac arrest 
calls  are  triangulated  using  clinical  presence,  documentation  on  CareFlow  (the  Trust  IT 
system), incident forms submission or retrospective review, if out of hours (this also supports 
legitimate submission to the National Cardiac Arrest Audit). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Deteriorating Patient proforma is sent to colleagues at the incident location and following 
a review by CCOT and Resus, this is presented at the Deteriorating Patient Group to analyse 
the  process  of  deterioration  and  identify  any  learning  opportunity.  Invites  are  shared  with 
colleagues who submitted the incident form to present the case, receive feedback and cascade 
any identified learning within their place of work. If significant learning is identified, this is shared 
with Incident Oversight and Learning Group and may require a prospective learning response 
in line with PSIRF (Patient Safety Incident Response Framework). 

•  A Serious incident report completed by the trust in the second half of 2019 failed 
to  identify  a  series  of  healthcare  failings  in  Chloe's  treatment.  Management 
failings at the Trust meant that Chloe's death was not reported to a Coroner until 
August 2023, by which time Chloe's body had been cremated denying the court 
an opportunity to gather relevant evidence through autopsy. 

The Trust informed the Coroner that family concerns were expressed from the 17 May 2019 
which led to a case review that followed the Learning from Deaths RCP guidance.  The Trust 
advised in the referral form from 2019 that they did not see any reason to delay the funeral and 
had not found significant events relating to cause and mechanism of death. The cause of death 
offered by the Trust was 1a) Advanced Cancer and part 2) Myotonic Dystrophy. 

Since September 2024 all deaths have been reviewed by the Medical Examiner Office. The 
role of these offices is to examine deaths to: 

•  agree the proposed cause of death and the overall accuracy of the medical certificate 

of cause of death (MCCD) with the doctor completing it 

•  discuss the cause of death with bereaved people and establish if they have questions 

or any concerns with care before death 

•  act as a medical advice resource for the local Coroner 
• 

identify  cases  for further review under local mortality arrangements  and  contribute  to 
other clinical governance processes. 

The SI investigation found care and service delivery problems but did not identify that any of 
these contributed to Chloe's death. It did not explore the cause of Chloe's cardiac arrest nor 
the prescribing of morphine, cornerstones of the family's complaints. Due to how significantly 
unwell Chloe was during this admission, it was not felt that the cardiac arrest was unexpected 
which may have impacted on the lack of focus on this within the initial investigation. 

In  July  2024,  the  Learning  Review  Group  was  established.  The  Learning  Review  Group 
undertakes an oversight function to assess the quality of learning responses and adherence 
with PSIRF methodology. This multi-professional group ensures an appropriate systems-based 
approach  has  been  used  to  extract  learning  from  learning  responses  and  develop  robust 
improvement  actions,  as  well  as  ensuring  that  compassionate  engagement  with  patients, 
families and staff has been central to the learning response. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust is monitoring implementation of the safety actions arising from learning responses 
via the Improvement Oversight Panel (IOP) which was implemented in July  2024. This panel 
oversees  the  effectiveness  of  safety  actions  and  wider  safety  improvement  plans  to  ensure 
they  are  delivering  the  required  improvement.  The  panel  will  consider  whether  sufficient 
evidence is available of sustainable improvement, prior to closure of the relevant patient safety 
incidents, or where it is absent, consider what further improvement actions are needed. 

All  Patient  Safety  Incident  Investigations  (PSII)  will  be  scheduled  for  review  of  action 
progression at the IOP three months post report approval, regardless of expected completion 
date of individual actions. 

The Trust has taken the issues identified by the Learned Coroner very seriously and has taken 
positive action to address those issues. 

I would be happy to meet you to discuss this response if that would be helpful. 

Yours sincerely, 

Chief Executive 

,

Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London  SW1H 0EU   

07 January 2025  

Our ref: 

Mr Graeme Irvine  
East London Coroner’s Court  
Queens Road  
Walthamstow  
London   
E17 8QP  

By email: 

 Dear Mr Irvine,   

Thank you for the Regulation 28 report of 25 October sent to the Secretary of State about 
the death of Chloe Every. I am replying as the Minister with responsibility for Patient Safety.        

Firstly, I would like to say how saddened I was to read of the circumstances of Chloe’s death, 
and I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to my 
attention.   

In preparing this response, my officials have made enquiries with NHS England and the Care 
Quality Commission (CQC) to ensure we adequately address your concerns.   

The report raises concerns over several failings at the Barking, Havering & Redbridge NHS 
Foundation Trust (BHRUT), which are summarised below:   

Inadequate nurse cover;  

- 
-  Absence of medical notes which prejudiced the inquest;  
-  Below par clinical observation;  
-  Process of informed consent and nurse CPR training;  
-  Governance processes failure to identify patient safety incident.  

NHSE have informed us that BHRUT is preparing a response to address your concerns in 
full. This  is  entirely  appropriate  due  to  the  nature  of  the  concerns  raised  and  as  a  direct 
recipient  of  this  report.  I  look  forward  to  their  response  with  interest  and  do  not  wish  to 
duplicate it. However, I will highlight some points from the information shared with us, of the 
actions taken to improve matters in relation to the care of patients with learning disabilities 
since Chloe’s death in 2019:   

•  Daily  checks  are  conducted  by  the  Learning  Disability  Team  at  the  Emergency 
Departments and the wards for any learning disability patients that are being cared 
for.   

•  BHRUT introduced the Emergency Department (ED) care pathway in June 2021, and 
they  have  an  Inpatient  Learning  Disability  Good  Practice  Care  Pathway  in  place, 
including  out  of  hours  for  both.  Other  resources  such  as  safe  toilet  facilities,  Easy 
Read appointment letter and guidance is also available.  

  
    
  
  
  
  
  
  
  
 •  The  Learning  Disability  &  Autism  Training  for  all  staff  was  first  implemented  and 
mandated  in  January  2022  and  further  updated  in  2024  with  the  government 
preferred Oliver McGowan Mandatory training.   

•  A Learning Disability Policy and a Transition Policy (the transfer from child health to 

adult health) is in place.   

•  A learning disability champion has been introduced – as a key contact for patient with 

learning difficulties, their families and staff.   

•  Crucially, structured reviews are held that provide feedback to Learning from Lives 
and  Deaths  –  people  with  a  learning  disability  and  autistic  people  (LeDeR)  –  to 
improve the care and treatment of people with a learning disability in their area.  
•  BHRUT  plan  to  recruit  more  learning  disability  nurses  in  2025. They  have  created 
pathways to encourage and upskill existing staff due to the shortage of nurses going 
into learning disability training (RNLD).   

I  have  been  informed  by  CQC  that  the  latest  inspection  from  2023  supports  BHRUT’s 
narrative on improvements made since 2019, including several changes at leadership  

level, the updating of governance processes and focused support to patients with learning 
disabilities. The full inspection report can be viewed here: 
https://www.cqc.org.uk/provider/RF4/reports.   

As  the  Minister  for  Patient  Safety,  I  fully  appreciate  your  concern  around  patient  safety 
failures,  which  resulted  in  denying  the  court  an  opportunity  to  gather  relevant  evidence 
through autopsy. CQC acknowledge that the lateness in actions of informing the Coroner 
and CQC are not in line with their expectations. This will be a key point of discussion in the 
upcoming  meeting  in December where they  will  also  focus  on BHRUT’s  response  to  this 
report. The aim is to underpin actions to embed learning from this death, as well to ensure 
that people using their services are kept safe.    

I  understand,  that  BHRUT  undertook  a  Serious  Investigation  review  in  2019  prior  to  the 
introduction to PSIRF, alongside an Independent Investigation. As you may be aware, the 
Patient  Safety  Incident  Response  Framework  (or  PSIRF),  removes  the  Serious  Incident 
threshold for investigation enabling organisations to respond much faster to safety events 
where there’s the greatest potential for learning and improvement. All NHS trusts in England 
have now transitioned to PSIRF and an evaluation of the implementation and impact of the 
framework  is  ongoing.  Early  indications  suggest  (aligned  with  the  findings  from  the  early 
adopter  programme)  that  PSIRF  supports  more  effective  learning  and  improvement  and 
provides the foundation for the development of an effective safety culture.   

Learning lessons is essential to ensure that NHS provides the care and respect to everyone 
who needs it. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH