Anne Taylor

Mr Michael James Pemberton  
HM Assistant Coroner  
Manchester West  
First Floor 
Paderborn House 
Howell Croft North  
Bolton  
BL1 1QY  

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

24 December 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Anne Taylor who died on 
31 July 2024   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  8 
November 2024 concerning the death of Anne Taylor on 31 July 2024. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Anne’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that  the  concerns  raised  about  Anne’s  care  have  been 
listened to and reflected upon.   

I note that your Report has also been sent to Salford Royal Hospital Foundation Trust, 
who are the appropriate organisation to respond to the concerns raised. NHS England 
has asked to be sighted on the Trust’s response to the Coroner and will review this 
once received.  

The matters of concern in your Report relate to Anne electing to leave hospital on 19 
July 2024 due to waiting times, before being clinically assessed. You raised that there 
was  no  consideration  of  whether  secondary  investigations  could  have  been 
undertaken  during  the  waiting  time  (e.g.  a  CT  scan),  which  would  have  likely  been 
required to make a diagnosis.  

My  regional  colleagues  in  the  South  West  have  engaged  with  Greater  Manchester 
Integrated  Care  Board  (GM  ICB),  the  responsible  commissioner  for  the  services 
provided by Salford Royal Hospital Foundation Trust.  

They  advise  that  in  line  with  quality  oversight  and  governance  arrangements  as 
defined  by  GM  ICB,  the  Salford  Locality  Quality  Team  continue  to  have  fortnightly 
relationship meetings with Salford Care Organisation Clinical Governance Team. In 
addition, the Quality Team attend the Salford Care Organisation weekly safety summit 
meetings where quality assurance and improvement is overseen. The purpose of the 
local relationship meetings is to: 

• 

Support  and  promote  the  quality  and  safeguarding  agendas  so  that 
Salford  residents  receive  safe  effective  care  that  results  in  a  positive 
experience of services. 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
              
 
  
 •  Maintain  an  open  and  transparent  relationship  between  the  NHS  GM 

• 

• 
• 

Salford and Provider Quality and Safeguarding Teams. 
Promote  and  support  the  delivery  of  national,  GM  and  local  quality 
improvement initiatives.  
Review and discuss the areas of focus and escalation. 
Review any additional reports as requested/put forward by Salford Care 
Organisation. 

In addition to this, the ICB will be undertaking a quality assurance visit to Salford Care 
Organisation.  This  will  include  oversight  of  patient  pathways  including  discharge 
planning. 

NHS England recognises the significant pressures on all NHS services and, in January 
2023, published a two-year Delivery plan for recovering urgent and emergency care 
(UEC)  services.  The  plan  prioritised  improvements  to  four  hour  performance  in 
Emergency Departments and outlined key actions to recover and improve urgent and 
emergency  care  services.  Despite  significant  challenges,  including  higher  than 
anticipated demand, there has been a marked improvement in the headline ambition, 
with over 2.5 million more people completing their Accident & Emergency treatment 
within four hours in 2023/24 compared to 2022/23. 

NHS  England  is  working  to  support  its  regions  to  support  providers  to  eliminate 
crowding  in  Emergency  Departments  in  the  longer  term. Improvements  are  being 
demonstrated  through  NHS  England’s  operational  planning  guidance  where  health 
systems were asked to focus on areas to deliver improved patient flow and this has 
included  increasing  the  productivity  of  acute  and  non-acute  hospital  services, 
improving flow as well as clinical outcomes.  

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 Anne, 
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

Chief Executive Office 
NCA Headquarters 
3rd Floor 
Mayo Building 
Stott Lane 
Salford 
M6 8HD 

Telephone: 

Email : 

31 December 2024 

Mr M J Pemberton 
His Majesty’s Assistant Coroner 
HM Coroners Court 
First Floor Paderborn House 
Howell Croft North 
Bolton 
BL1 1QY 

Dear Mr Pemberton 

Re: Inquest into the death of Anne Taylor – Regulation 28 Report 

I write following receipt of your report to prevent future deaths and to hopefully assuage your concerns 
that prompted it. At the outset I would like to take this opportunity to offer my sincere condolences to 
Mrs Taylor’s family for their loss.  

Thank you for bringing the concerns raised in the Regulation 28 report to my attention. Your concerns 
were as follows: 

1.  During evidence, it was heard that the deceased had elected to leave the Hospital on Friday 19 

July because of waiting times, before being clinically assessed. 

2.  There was no consideration of whether secondary investigations could be undertaken during the 

waiting time for example CT scan which would likely be required by a clinician to make a diagnosis. 
3.  No evidence was provided that the deceased’s mental capacity to decide to leave the hospital was 

assessed given the history of suspected head injury. 

4.  Reference was made to a new standard operating procedure being developed relating to patients 
leaving the hospital before a clinical assessment occurs, but it was unclear what this will include. 

I understand that following Mrs Taylor re-attending hospital on 20th July 2024, and the diagnosis of 
acute subdural haematoma being made, a clinical incident was immediately reported by a nurse in the 
Emergency Department regarding the ED attendance the previous evening. This incident was triaged 
via our usual governance systems, and it was felt that although an earlier diagnosis would sadly not 
have changed the outcome for Mrs Taylor, there was an opportunity for learning and improving our 
systems and so an After-Action Review was undertaken under the Patient Safety Incident Response 
Framework (PSIRF). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The review determined that going forwards secondary investigations (such as a CT scan) should be 
considered and frontloaded for patients who are identified as meeting NICE guidelines criteria for CT 
scan in head injury, whilst they await clinical review. The new NHSE Acuity tool process described 
below will support this. 

Additionally, it was highlighted that at the time of Mrs Taylor’s attendance there was no formalized 
Standard Operating Procedure within Salford Royal’s Emergency Department defining the actions to 
take when a patient leaves before clinical assessment. Salford site has an electronic self-discharge 
checklist designed for ward-based use, but no guidance or policy to describe the appropriate 
completion of this, or relevant steps to take, in the emergency department setting. 

A Standard Operating Procedure (SOP) for patients who leave the emergency department whilst 
waiting to be seen has now been drafted and is going through NCA approval processes, with an 
estimated approval date of 6th February 2025. We append the working draft for your information. This 
guideline sets out the responsibilities of clinical and nursing staff when an adult leaves an emergency 
care setting prior to being assessed or receiving treatment, so that the patient is safeguarded 
appropriately with the aim of: 

•  Ensuring patients receive appropriate healthcare.  
•  To help identify patients who are at risk of coming to harm.  
•  Ensuring patients have the mental capacity to and are supported to make their own decisions 

regarding their care. 

Once approved the SOP will be shared with all urgent and emergency care areas for dissemination. In 
the interim, learning from the incident and draft SOP will be circulated through safety messages and in 
the directorate governance meeting.  

Within this new SOP, it is made clear to nursing and clinical staff that it is their responsibility to assess 
mental capacity for patients stating they want to leave and to escalate any concerns appropriately. 
Patients who wish to take their own discharge and are assessed to have the mental capacity to do so, 
should be safety netted, with NCA leaflets related to their presentation and verbal advice as indicated. 
The documentation review, actions taken, and record of discussions, should be clearly documented in 
the patient’s notes. 

In addition to the above, as of 25th November 2024, Salford Royal Hospital has become an early 
adopter of the NHSE Acuity Tool, an initial assessment model which aims to standardize the 
measurement of acuity in Emergency Departments and Urgent Treatment Centres. Patients who attend 
the ED at Salford Royal now receive an initial, primary assessment to identify patients with an acuity 1, 
2 or 5 which will allow them to either be directed immediately to a receiving location or be directed to an 
alternative provider such as primary care. Acuity 1 patients are those with immediate life/limb 
threatening illness/injury, acuity 2 are those with imminent life/limb threatening illness/injury and acuity 
5 denotes no threat to life or limb, no ED specific resource necessary. Patients who do not meet an 
acuity 1, 2 or 5 will then go on to receive a secondary assessment. The target time for secondary 
assessment is 15 minutes, Salford Care Organisation are on track to achieve this. Progress of the early 
adopter programme is being shared with NHSE at regular intervals. Patients receiving a secondary 
assessment can be identified for early clinical intervention and front loading of essential investigations 
such as, CT scan. Work is ongoing to meet the NHSE secondary assessment target to provide the 
significant benefits it offers of reducing the risk of patients with serious conditions sitting in the waiting 
room for a long time undiagnosed. In addition, the new acuity tool, has a specific question regarding 
mental capacity assessment relating to a patient’s decision to leave the department.  

 
 
 
 
 
 
 
 
 
 The Trust is always open to the opportunity to review, and where possible, strengthen our processes. I 
hope this response offers assurance to you that the Trust has continued to take these concerns 
seriously and has put in place a number of steps and actions since the tragic death of Mrs Taylor. 

Yours sincerely  

Chief Executive Officer