Paul Dunne

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 
Telephone: 03000 616161 
www.cqc.org.uk 

Car 

Mr Andrew Harris 
Assistant Coroner  
HM Coroner for London Inner South Coroners Court  
1 Tennis Street  
London  
SE1 1YD 

06 May 2025 

Dear Mr Harris,  

Care Quality Commission: 
Response to Regulation 28 Report to Prevent Future Deaths following the inquest into 
the death of Mr Paul Timothy Dunne.  

Thank you for your Regulation 28 Report to Prevent Future Deaths dated 18 February 
2022 about Mr Paul Dunne's death. I am replying on behalf of the Care Quality 
Commission.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mr 
Dunne’s death, and I offer my sincere condolences to his family and loved ones. Your 
report’s circumstances are concerning, and I am grateful to you for raising these 
matters.  

In the Regulation 28 Report to Prevent Future Deaths, the following concerns were 
raised to the CQC:  

1.  Individual mental health professionals appeared to have gaps in knowledge and 
judgment. The director, who was spokesperson for the Mental Health Trust, did 
not seem to appreciate the seriousness of these deficits. 

•  A mental health liaison nurse, who now is alarmingly manager of these nurses, 
did not recognise the patient as high risk, despite his having been persuaded to 
attend A&E by the police against his will, having just expressed suicidal ideation, 
made a previous attempt, with alcohol intoxication and absconsion, as at the time 
he denied suicidality. Even in retrospect, in court, she did not acknowledge her 
misjudgement. She also asserted incorrectly that a patient who has mental 
capacity cannot be assessed under the Mental Health Act. 

•  A mental health nurse of 9 years standing in the Home Treatment Team who 
acknowledged the risk to the patient’s life could hardly be higher, failed to 

 
 
 
 
 
 
 
 
 
 
 
 
 document his assessment, as he could not find anywhere to write it before going 
on his break. No staff acknowledged that he had informed them of the risk. He 
assumed the patient would get 1:1 monitoring, but did not direct anyone to the 
need. When asked what he would have done if he had known there were no staff 
to conduct 1:1 monitoring, he rather lamely said that he could perhaps hang 
around for a bit longer.  

2.  The Mental Health Trust. 
•  Staff and it appears the director, even at the time of the inquest, did not 

appreciate that the A&E policies (Missing Persons, Shared Care) which required 
risk assessment after an absconsion and alerting managers to the need for extra 
temporary staff if 1:1 monitoring was needed, also applied to MH staff. 
•  Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been 

trained on different risk assessment documents. Although meetings had been 
reinstated between departments, there had been no audit of absconsions or MH 
liaison in A&E. 

In response to the individual points raised: 

1.  We recognise the distress and concern these events have caused and 

acknowledge the importance of accountability where there are apparent shortfalls 
in professional conduct or decision-making. However, it is important to clarify that 
the Care Quality Commission’s regulatory remit, as established under the Health 
and Social Care Act (2008) and the associated Regulated Activities Regulations 
(2014), is focused on assessing and holding providers rather than individual staff 
accountable for meeting fundamental standards of care. While we do not have 
the authority to investigate or act against individual healthcare professionals, we 
expect providers to ensure that their staff are competent, appropriately trained, 
and supported to deliver safe and effective care. Where there are indications that 
individual knowledge gaps or lapses in professional judgment reflect broader 
systemic or cultural issues within a provider, such as inadequate supervision and 
training, poor risk management protocols, or ineffective governance, we may 
examine these as part of our regulatory activity.  

Concerns such as those described contribute to our ongoing monitoring of the 
provider’s performance. Where patterns might suggest systemic failings, we 
carry out further monitoring, engagement and assessment activities and/or 
require the provider to take specific actions to address risk and improve quality. 

2.  Our regulatory focus is on the systems and governance arrangements providers 
have to deliver safe, effective, and coordinated care. Concerns regarding the 
apparent misunderstanding or inconsistent application of key policies, such as 
those related to missing persons or staffing for 1:1 monitoring, fall within this 
remit when they indicate potential provider-level failings. In particular, any 
indication that staff and senior leaders, including directors, did not recognise the 
applicability of trust-wide risk and safety policies is a matter of concern. We 
expect all providers to ensure that relevant policies are clearly communicated, 
understood by staff, and implemented consistently across services and that staff 
from different NHS trusts are supported to work together and understand how 
their policies and procedures support joint working to deliver safe and effective 
care.  This includes ensuring that staff working in shared care environments, 
such as mental health liaison teams in acute settings, operate under a coherent 

 
 
 
 
 
 
 and aligned set of standards. We also note your concerns about using different 
risk assessment tools by staff from different trusts (King's College Hospital NHS 
Foundation Trust and Oxleas NHS Foundation Trust) and the lack of audit or 
oversight of absconsions or mental health liaison activities.  

We will take these concerns into account as part of our ongoing monitoring of the 
providers. We may consider them alongside other intelligence to assess whether 
further regulatory action is warranted through monitoring, engagement and 
assessment activities. Where there is evidence of systemic risk or breaches of 
the fundamental standards of care, CQC may take steps including assessments 
and enforcement action, or require provider improvement plans. 

Currently, information shared from members of the public, providers, system partners 
and stakeholders feeds into our provider monitoring system. The Care Quality 
Commission local integrated assessment and inspection teams are monitoring and 
engaging with Oxleas NHS Foundation trust and King's College Hospital NHS 
Foundation trust through continuous monitoring, regular engagement, and risk-based 
assessments. We gather intelligence from various sources, including patient and 
service user feedback, notifications,  incident reports, and information from partner 
organisations, to assess the quality and safety of care. Regular engagement meetings 
with trusts provide opportunities to review performance, discuss concerns, and seek 
assurance on improvements. We also attend relevant committee meetings such as 
Oxleas NHS Foundation trust’s mortality surveillance committee, where the trust 
reviews patient and service user deaths to improve patient safety and learning from 
incidents.  

Internally, at the CQC, we will incorporate any proposed trust actions and information 
from incidents, notifications, and Regulation 28 Prevent Future Deaths reports into our 
ongoing monitoring with the service and any subsequent engagement work or 
assessment planning. We will ask Oxleas NHS Foundation trust for the action they 
intend to take because of this Prevent Future Deaths Report and monitor those actions 
as part of our ongoing monitoring and engagement with them. Information such as this 
will be reviewed via our internal Specific Incidents Guidance (SIG), which requires and 
identifies the process for the initial assessment of information relating to specific 
incidents of potential avoidable harm based on the details of the incident. The SIG 
guidance refers to Regulation 28 Prevent Future Deaths reports and other 
correspondence from providers and system stakeholders, such as coroners, as being 
capable of amounting to information requiring an initial assessment under the SIG 
process. Inspectors supported by operations managers assess if the incident gives rise 
to potential further monitoring, assessment and/or enforcement functions as appropriate 
and if the incident suggests the harm sustained was avoidable, may have resulted from 
a breach of a prosecutable fundamental standard and was the result of the registered 
person.  

Where the information, such as a PFD report, triggering the initial assessment, does not 
provide sufficient evidence to inform a reliable answer to these questions under SIG, we 
may undertake further enquiries. When risks are identified, the CQC may carry out 
targeted or unannounced assessments and, if necessary, take regulatory action such as 
issuing requirement notices or enforcement measures to ensure the trust meets 
fundamental standards of care and drives improvement. 

 
 
 
 
 
 
 
 We are grateful for the information you have shared. It is invaluable in helping us 
monitor the quality of care provided across services and to ensure that providers are 
meeting the standards expected under the Health and Social Care Act (2008) and the 
associated Regulated Activities Regulations (2014). We appreciate the coroner raising 
these concerns with us. We will continue to monitor the trusts and any information we 
receive in line with our internal processes and methodology. If you have any further 
queries, please do not hesitate to contact us further. 

Yours sincerely,  

Deputy Director of Operations

Mr Andrew Harris 
HM Assistant Coroner 
South London Coroner’s Service  
2nd Floor House 
Robert Street 
Croydon 
CR0 1QQ 

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

4 June 2025  

Dear Mr Harris, 

Re: Regulation 28 Report to Prevent Future Deaths – Paul Timothy Dunne who 
died on 2 January 2020.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  13 
March  2025  concerning  the  death  of  Paul  Timothy  Dunne  on  2  January  2020.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Paul’s family and loved ones. NHS England are keen 
to assure the family and yourself that the concerns raised about Paul’s care have been 
listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  Paul’s  family  or  friends.  I  realise  that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them.  

Your  Report  raised  concerns  around  mental  health  staff  and  hospital  staff  in  the 
Accident  and Emergency  (A&E) department  writing  their  clinical  records  in different 
systems and hospital staff not having access to mental health records. You raised that 
this meant mental health staff attending A&E are asked to make a double entry in the 
A&E records which, if not completed, as was the case  during Paul’s care, can have 
fatal consequences. You heard evidence that the introduction of a combined electronic 
health  record  system  (known  as  EPIC)  has  been  very  slow.  My  response  to  you 
focuses on the areas of concern within NHS  England national policy or programme 
remit.   

NHS England is committed to improving the maturity and quality of Electronic Patient 
Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure 
all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts 
to  effectively  procure  and  implement  their  chosen  EPR  system,  and  to  agree  and 
progress any convergence of EPR systems within their local systems.  

NHS England is also committed to supporting the sharing of critical clinical information 
across NHS organisations. Since 2021, all primary and secondary care organisations 
have been able to share a subset of the patient information they hold  (known as the 
core information standard) between providers within their own Integrated Care System 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 footprint,  through  their  local  Shared  Care  Record  (ShCR).  ShCR  supplies  must  be 
assured against the Professional Record Standards Body’s (PRSB) Core Information 
Standard, which has been specified by NHS England. Where local ShCRs are used 
therefore,  the  core  information  standard  will  be  available.  Building  on  this  and 
recognising  the  clinical  need,  an  initiative  has  been  set  to  achieve  national 
interoperability between SHCRs across England. This initiative has been commenced 
but does not have a defined timeframe as it is dependent on funding which has not yet 
been  confirmed.  It   aims  to enable  any  authorised health and  care  professionals to 
have access to safe, reliable and accurate records, regardless of the patient’s location 
or where care is provided. It is, however, up to local care record organisations and 
participating NHS Trusts to agree what information, in addition to the core information 
standard, is held and shared through the local ShCR. It is also up to individual NHS 
Trusts  to  negotiate  data  sharing  protocols  and  agreements  to  enhance  localised 
information sharing outside of the local ShCR.   

NHS England’s Frontline Digitisation Team advise that the Princess Royal University 
Hospital implemented the EPIC Electronic Patient Record (EPR) on 6 October 2023 
(as part of the King’s College Hospital NHS Foundation Trust’s implementation of the 
EPR). Oxleas NHS Foundation Trust use the Rio EPR system. 

Integrated  Care  Boards  (ICBs)  /  Systems,  the  responsible  commissioners  for  the 
majority  of  services  administered  by  NHS  Trusts,  should  have  in  place  a  digital 
strategy.  This  would  usually  recognise  and  acknowledge  the  requirement  to  share 
information across frequently used patient pathways. The responsible system in this 
matter, South East London Integrated Care System (SEL ICS), has a digital strategy 
in  place  which  includes  the  sharing  of  health  information  across  health  and  care 
pathways. Currently, the London Care Record is the key solution that can be used to 
access a shared care record. Further details on SEL ICS’s digital strategy can be found 
here.  

My colleagues from the London region have been in contact with South East London 
Integrated  Care  System,  who  have  informed  us  that  King’s  College  Hospital  NHS 
Foundation Trust (KCH) conducted a Serious Incident review of Paul’s care, with the 
final report dated 12 January 2021. Within the report,  KCH made recommendations 
including  the  following:  ‘The  Trust  must  discuss  a  process  whereby  Oxleas  team 
record their assessments on Electronic Patient Records (EPR) going forward so that 
the King’s team have access to their notes and decisions.’  

Oxleas NHS Foundation Trust have also informed us that, in order for them to have 
access to KCH’s EPIC EPR, their staff would need to have an honorary contract with 
KCH. At present, 16 of the 21 staff within Oxleas’ Mental Health Liaison Team (MHLT) 
have access to EPIC, and those who do not currently have access are in the process 
of obtaining access. The mitigation for this is that the MHLT will always have someone 
on  shift  who  has  access  and  can  assist  with  uploading  the  required  information  to 
EPIC.  

The recently updated MHLT policy outlines the required documentation the MHLT will 
provide to acute trusts, as set out below:  

‘5.3 Documentation on Acute Trust electronic systems 

 
 
 
 
 
 
 5.3.1 The MHLTs will transfer appropriate clinical documentation to the Acute 
Trust electronic recording system. This is to ensure all clinicians involved in the 
patient’s  care  [are]  aware  of  key  information  relating  to  presentation, 
formulation and plan and is crucial for sharing and minimising risk.  

5.3.2 For iCare (QEH) – the ‘Clinical Notes’ section will be updated throughout 
the person’s admission to QEH and the ‘depart’ section will be updated at the 
point of discharge from MHLT as this contributes to the GP Discharge Letter. 

5.3.3 The MHLTs will ensure there is clear documentation on:  
impression/formulation and management plan  

• 
•  current risk status and risk management plan, including advice regarding 
contingencies,  as  well  as  advice  regarding  any  requirement  for 
enhanced nursing observations, secure staff supervision and actions to 
take if [a] person expresses [an] intention to leave the department  
legal status  

• 
•  diagnosis. 

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 Paul, 
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,  

Co-National Medical Director  
(Secondary Care)