Kevin Ince

Mr Christopher Long 
Area Coroner 
Lancashire and Blackburn with Darwen 

Via email: Coroner’s Officer 

14 January 2025 

Private and Confidential 

Dear Mr Long 

Mr Kevin Ince - Response to Regulation 28 report  

I write to you in response to the Regulation 28 report dated 18 November 2024. The report 
was issued following the Inquest touching the death of Mr Kevin Ince, which was heard on 
15 November 2024. The inquest concluded that Mr Ince died from natural causes.  

In the Regulation 28 report you raised two areas of concern for Priory to consider: 

1.  The  inquest  heard  clear  evidence  of  regular  refusals  of  necessary  and  appropriate  medical 
treatment  by  patients  detained  under  the  Mental  Health  Act  1983,  over  several  years  with 
insufficient  consideration  of  steps  that  were  then  appropriate  including  a  lack  of  steps  to 
persuade the patient, insufficient consideration of the powers under the Mental Capacity Act 
2005 and insufficient consideration of utilising s.63 of the Mental Health Act 1983. 

2.  Insufficient action was taken when patient detained under the Mental Health Act 1983 routinely 

declined food over a prolonged period. 

Priory response to matter of concern 1  

Following Mr Ince’s death, a ‘Management of Declined Physical Health Monitoring” flowchart 
was introduced at Kemple View. I understand the mechanics of this were explained by the 
Hospital  Director  during  the  inquest.  This  flowchart  sets  out  the  process  to  follow  when  a 
patient declines physical health checks, to include escalation to the Responsible Clinician and 
Primary Nurse for discussion at the next multi-disciplinary team (MDT) meeting. The patient’s 
capacity to decline physical health checks is to be assessed and where the patient is deemed 
to be without capacity, a best interest meeting is to be arranged. All decision making is to be 
documented.  

In  response  to  feedback  received  during  the  inquest  and  following  reflection  and  wider 
discussion, this flowchart has now been revised with input from Priory’s Head of Mental Health 
Act and Mental Capacity Act Operations. The flowchart now also includes consideration being 
given to the involvement of a patient’s family in discussions (where patient consent allows) 
and  to  ensure  powers  under  section  63  of  the  Mental  Health  Act  1983  are  also  taken  into 
account when considering a patient’s best interests if they decline physical health monitoring.  

The revised flowchart was presented at the Physical Healthcare Committee meeting, which is 
chaired by Priory’s Chief Medical Officer on 10th January 2025 for discussion and will be added 
to Priory policy “H100 Monitoring Physical Health of Inpatients” and cross referenced within 
relevant Mental Health Act or Mental Capacity Act policies, for use across all Priory Healthcare 
services.  It  is  proposed  that  consideration  be  given  to  implementing  a  focused  e-learning 
training module to support colleagues to understand the interface between the Mental Health 

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 Act and Mental Capacity Act decisions and the process to be followed by Priory colleagues 
when physical health checks are declined.  

A  database  has  also  been  created  at  Kemple  View  to  improve  the  recording  of data  about 
patients who have refused physical health monitoring using a clear RAG (Red, Amber, Green) 
rating system. This database is now reviewed weekly during the enhanced handover meeting, 
with actions documented where non-compliance is observed in accordance with the flowchart. 

Discussions have also been ongoing with Priory’s IT department to explore how the above 
monitoring could be captured within CareNotes (Priory’s electronic patient records system). 
Electronic monitoring of physical health observation checks and refusals by patients will be 
incorporated within CareNotes in January 2025 and a dashboard to enable monitoring of this 
will be built into CareNotes from February 2025.  

Priory response to matter of concern 2 

Following Mr Ince’s death, a ‘Management of Poor Diet and Fluid Intake” flowchart was also 
introduced  at  Kemple  View.  I  understand  this  was  also  explained  by  the  Hospital  Director 
during the inquest. This flowchart shows the process to follow when a patient has inadequate 
diet  and  fluid  intake,  to  include  escalation  to  the  Responsible  Clinician  for  discussion  and 
referral to the Dietician for advice. The patient’s capacity to refuse an adequate nutritional diet 
is  to  be  assessed  and  where  the  patient  is  deemed  to  be  without  capacity,  a  best  interest 
meeting is to be arranged. All decision making is to be documented. 

This  flowchart  has  also  been  reviewed  by  Priory’s  Head  of  Mental  Health  Act  and  Mental 
Capacity Act Operations and also includes consideration being given to the involvement of a 
patient’s  family  in  discussions  (where  patient  consent  allows)  and  to  ensure  powers  under 
section 63 of the Mental Health Act 1983 are taken into account. 

A database has also been created at Kemple View to capture data about patients who are 
monitored using food and fluid intake charts: this will facilitate a more thorough review as to 
whether adequate nutrition is being accepted by the patient. This database is now reviewed 
weekly  during  an  extended  hospital  handover  meeting,  with  actions  documented  in 
accordance with the flowchart where a nutritional diet is refused. 

A Priory dietician is scheduled to complete a briefing to Priory Hospital Kemple View staff in 
January 2025 on the topic of good nutrition and fluid intake. 

I trust that the actions outlined above will provide the assurances you seek in respect of this 
matter. 

Yours sincerely, 

Chief Executive Officer 
Priory  

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