Kenneth King

Clinical Governance and Quality Team 
Woodlands House 
Norwich Community Hospital 
Bowthorpe Road 
Norwich 
NR2 3TU 

Tel: 

Email: 

Website: www.nchc.nhs.uk 

Ref: 
Kenneth George Willard KING - Regulation 28 
Report 

23 January 2025 

Dear Senior Coroner, 

I am writing to you in response to the Regulation 28: Report to Prevent Future Deaths, relating to the 
death of Mr Kenneth George Willard King, dated 27th November 2024. Please find set out below the 
summary of actions taken, and those planned to be taken, in relation to your concerns. I have also 
enclosed a copy of the full Trust action plan including timelines for implementation.  We would like to 
apologise if information previously provided and presented during the inquest has not provided 
yourself or Mr King’s family with the necessary assurances that Norfolk Community Health and Care 
(NCH&C) are committed to the delivery of safe, effective and evidence-based care. We would also like 
to apologise for any additional distress this may have caused Mr King’s family and offer our sincere 
condolences for their loss once again.  

Following receipt of the report, a working group consisting of senior quality leaders, senior operational 
leaders and subject matter experts was commenced on 11th December 2024. The concerns raised 
within the report were reviewed and further areas for learning, improvement and development have 
been identified. These have been detailed in the attached action plan which is being regularly 
monitored by trust governance processes including risk group and quality committee. The action 
themes and focus areas include: 

•  Monitoring and Recognising the Deteriorating Patient in the Community  
•  Quality Assurance in Community Services  
•  Clinical Skills and Competencies  
•  Community Demand and Capacity Issues Impacting on Quality of Care and Patient Safety  
•  Temporary Worker Service 

In relation to your specific concerns (in bold), please find responses below. Full details and timelines 
can be found on the enclosed action plan. 

Concern 1: Evidence was heard that there is no formal structure in place as to when or with 
regard to the frequency of carrying out physiological observations on patients in the 
community. Observations are required to be taken if the attending clinician has any concerns 
about the patient's wellbeing or a deterioration in their condition, or at the request of a senior 
clinician or GP. 

  Norfolk Community Health & Care NHS Trust  
  Norwich Community Hospital, Bowthorpe Rd, Norwich, NR2 3TU 

LOOKING AFTER YOU LOCALLY 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 No specific questions are asked of the patient, such as if they are feeling unwell, have pain or 
localised heat, the attending practitioner relies on general conversation carried out at their 
attendance to help form a view as to whether observations are required to be taken. 
It was accepted in evidence that the decision to perform observations relies on the clinical 
judgment of the relevant clinician, which is a subjective decision which may be exercised 
incorrectly and at variance with other clinicians. 

In this case, evidence was heard that Mr King presented as feeling well but had high 
inflammatory markers, which may mask when observations are required to be carried out. 
Some patients may not be forthcoming about any symptoms unless specifically asked. 
Trust guidance was updated and disseminated to all clinical staff to mandate the completion of 
physiological observations on every initial patient visit with immediate effect. A community patient 
escalation plan has been published and cascaded to support staff in identifying patients at risk of 
deterioration and the escalation actions that are required which includes the completion of 
physiological observations.  

A community patient assessment guide is being created which will provide exploratory questions that 
community staff can use to ascertain any changes in the patient’s condition and identify if any further 
action is required. Both of these documents and how to use them will be included in the Deteriorating 
Patient training. 

Different clinicians carry out visits in the community and so have no overall view of a patient's 
presentation and any deterioration. Written records are available but evidence was heard that 
in this case, on the last visit, the record of the previous attendance was looked at and no 
history prior to that. 
Due to operational pressures and the need to work flexibly with staff allocation to ensure patients with 
priority and complex needs are seen in a timely manner, it continues to be very difficult to provide 
consistent staff allocation to individual patients. Whilst this would be best practice for continuity of 
care, escalation actions such as the movement of staff are sometimes required to minimise risk to our 
patients. Whenever possible continuity of care is maintained and patients most at risk or at end of life 
would be prioritised. Handovers are completed to share learning and patient updates and clinical 
leads are available to support with complex patient discussions and escalation of conditions. As a trust 
we recognise the importance of continuity of care and are currently piloting a named clinician and 
geographical area caseload approach which is being analysed and will inform the development of our 
future community nursing model. 

All community clinicians are given thirty minutes protected time each day for visit preparation, which 
includes reviewing of patient records prior to visits. We acknowledge that the record review can be 
variable across clinicians practice and that is an area of focus to understand why. It is also recognised 
that clinicians responding to urgent care visits may not have the ability to review the record at all prior 
to the visit. We are looking at ways to ensure more consistency with the senior operational and quality 
leadership team. 

Evidence was heard that Health Care Practitioners may have limited clinical training and rely 
on instructions and advice from trained nurses.  
The trust holds a clinical training programme that is open to registered and non-registered clinicians 
as per the competency matrix. Additional sessions are held, such as the Deteriorating Patient 
Training, which is open to all staff. From review of the attendance logs, it is acknowledged that there is 
lower uptake of this training by community staff, particularly podiatrists and non-registered clinicians 
including phlebotomists. The training sessions will have a targeted focus on those staff groups, and 
we are currently gathering information to understand the barriers and challenges to good attendance 
levels. It is also recognised that different staff groups will need different levels of training.  

 
 
 
 
 
 
 
 
 
 The current competency matrix has been under review and a newly developed community 
competency matrix has been out to consultation and is in the final stages of ratification. To support the 
competency management and sign off process, we have also developed competency passports 
aligned to each role. Each Place area will be completing a gap analysis of competency and training 
needs to ensure that our current clinical training programme is accessible and offers appropriate 
availability. 

Our non-registered clinicians do work under the delegation of registered staff who provide ongoing 
advice, support and review. Shadow and observational review shifts are completed to ensure 
competency of individuals in both practical skill and theoretical knowledge. This is an ongoing review 
process and will be supported with the competency passports. In addition to this monitoring and 
overview, there is an expectation that staff work within their limitations and escalate where further 
support and development is required. 

Concern 2: Mr King died a year ago and although there is a training programme which is being 
devised and rolled out it is not expected to be in place for a further eighteen months. 
We would like to apologise if information previously presented has not been clear or has caused 
yourself or Mr King’s family any confusion. NCH&C has a full clinical training programme and currently 
is and will continue to be delivered on a rolling basis across various locations. Whilst most of the 
clinical training is provided by our clinical education team, additional or enhanced sessions are 
provided by subject matter experts. One example of this is the wound care and tissue viability training 
package that is provided by the Tissue Viability Specialist Nurse. I have included the 2025 wound care 
and tissue viability training plan for information. As part of the action plan, we are currently scoping all 
clinical training to understand previous attendance levels and accessibility of sessions, so we can 
understand barriers or challenges to accessing the training. The tissue viability and wound care 
pathway has been a priority workstream within our community transformation programme, ‘Better for 
All’. The workstream has a number of quality improvement initiatives and focus areas such as the 
implementation of the National Wound Care Strategy guidance and the use of digital technology in 
wound care, which have different timeframes for completion. For clarity, the eighteen-month timeframe 
stated at the inquest was relating to the Better for all transformation programme duration and some of 
the individual initiatives, rather than the training programme which is on a rolling agenda.  

The policy to prevent bank staff applying for roles when they have not undergone the required 
training is not yet in place. 
We acknowledge that there is inconsistent and variable levels of clinical supervision and monitoring/ 
management of clinical competencies for this staff group. The majority of our bank staff are well 
known to the substantive teams and are supported with training and clinical supervision. The 
competency passports and matrix will provide a robust process for competency management moving 
forward. As part of the interim plan, restrictions are in place so that only temporary worker staff known 
to the local team and where competencies are signed off will be able to book community shifts. 

We hope that the information provided offers you full assurance that immediate learning and actions 
have been taken and further actions are planned to prevent recurrence. If you wish to discuss 
anything further following receipt of this letter and action plan, I would be very happy to meet you.    
Please do not hesitate to contact the Clinical Governance and Quality Team on the details at the top 
of this letter. 

Yours Sincerely 

Executive Director of Nursing and Quality 

Encs