Shaun Hall

CHAIR AND CHIEF EXECUTIVE’S OFFICE 
Berrywood Hospital 
Berrywood Drive 
NORTHAMPTON 
NN5 6UD 

Tel: 03000 271717 
Web: www.nhft.nhs.uk  

PFD Shaun Hall (v1) 20250327 

Ref:  
Date:   27 March 2025 
Email:  

Mrs A Pember 
Senior Coroner for Northamptonshire 
The Guildhall 
St Giles’ Square 
NORTHAMPTON  
NN1 1DE 

BY E-MAIL ONLY TO:

Dear Mrs Pember 

RE: Regulation 28: Report to Prevent Future Deaths – Shaun Kenny Hall 

Thank you for your Report to Prevent Future Deaths (‘Report’) dated 30 January 2025 concerning the death of 
Shaun Kenny Hall on 14 December 2023.  Before responding to the matters of concern you have included 
within your Report, I would like to express my condolences to Mr Hall’s family and loved ones.  We have 
carefully reflected on the circumstances surrounding Mr Hall’s death and have identified the specific actions we 
will take . 

Your Report expresses concern about the decision made by the Trust’s Urgent Care and Assessment Team 
(UCAT) not to accept the referral made by NHS Northamptonshire Talking Therapies considering the 
information available to UCAT on ‘escalating factors’ and a statement made by Mr Hall that he ‘would take his 
own life’.  Your Report also expresses concern that the identity of the person receiving the referral for UCAT is 
unknown and that no notes were made of the referral.  Responses to each point are taken in turn. 

1.  UCAT assessments on referral 

In response to several national drivers and as part of our Trust’s commitment to continuous improvement and 
learning from incidents, we are developing a range of new risk management processes, including policy 
updates, changes to risk management documentation and the commissioning of new training modules. 

Cont’d/… 

Trust Headquarters: St Mary’s Hospital, London Road, Kettering NN15 7PW   Tel: 0300 027 1717 

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 Together, these new ways of working will strengthen our approach to the assessment of patients referred to 
the UCAT and all our crisis and community services.  Our new approach will focus on risk formulations that seek 
to understand the drivers and context behind a service user’s risks, which is a change from our previous risk 
processes that focused on indicating a level of risk such as ‘low, medium or high’.  These changes will provide 
staff and service users with a better understanding of an individual’s fluctuating risks.  As a result, there can be 
a focus on the development of co-produced safety plans with service users and carers.  These safety plans will 
be owned by the service user and will be responsive to the individual’s own needs and challenges when 
managing risk.    

To support the transition to our new approach to risk formulation, we commissioned a training module from a 
leading, external provider that brings in national best practice and core skills around formulation and safety 
planning.  To date we have trained more than 140 of our community staff and continue to roll this out across 
our teams.  This represents 80% of the community workforce at this time. 

2.  The duty of candour of all staff 

We take our legal duty to be open, honest, and transparent with the people who use our services extremely 
seriously.  We expect all staff to comply with our ‘Being Open / Duty of Candour Policy’ and all clinical staff 
must complete a Duty of Candour training module.  At the time of the incident, we arranged group supervision 
and spoke with members of the teams involved.  We reiterated their responsibilities with regards to the duty of 
candour.  The staff were able to participate in this reflective discussion acknowledging their responsibility and 
accountability.  Additionally, we continue to monitor compliance with Duty of Candour training requirements 
via our mandatory training programme.   

We have heard the concerns you raised and have elected to expand the use of call handling and recording 
systems within the Trust to our Crisis Services.  We currently use a web-based call handling product within our 
response hub and have begun the process of extending the product into the UCAT services.  By the end of July 
2025, we anticipate that we will have trained all staff in the use of this product. This product will improve the 
accuracy of our record keeping and our ability to provide reflective interventions with staff. 

3.  Record keeping standards within the Trust 

We expect all clinical staff to adhere to the record keeping standards of their respective professional body and 
to comply with our ‘Health Records Management and Keeping Standards Policy’.  We emphasised the 
importance of record keeping at the time of the incident to all staff in the UCAT team as a result of our initial 
learning.  We continue to track the team’s compliance with mandatory information governance training and 
have developed a new record keeping audit tool that ensures governance over the quality and content of 
records. 

Cont’d/… 

 
 
 
 
 
 
 
 
 
 
 
 Having further examined the circumstances surrounding Mr Hall’s death, we have understood the need for a 
greater level of patient records visibility between UCAT and Talking Therapies staff.  We have now enabled 
both UCAT and Talking Therapies staff to have full visibility of all records relating to the treatment of service 
users in their care.  

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 

Chief Executive 
Northamptonshire Healthcare NHS Foundation Trust 

Cc 

, Trust Chair 

, Managing Director and Deputy Chief Executive 

, Chief Operating Officer 
, Chief Nurse 
, Chief Medical Officer 

, Director of Corporate Governance