Mark Fernandez

E: 

Date: 22nd 2025 

Private & Confidential 
Joanne Kearsley 
Senior Coroner for the area of Manchester North 
Manchester City Coroner’s Office and Court 
Exchange Floor 
The Royal Exchange Building 
Cross Street 
Manchester 
M2 7EF 

Sent by email to: 

Dear Ms. Kearsley 

Re: Regulation 28 Report to Prevent Future Deaths – Mark Anthony Fernandez  

Thank you for your Regulation 28 Report dated 4th March 2025 regarding the sad death of Mark Anthony 
Fernandez. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin 
by offering our sincere condolences to Mr. Fernandez’ family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 17th of February 
2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our 
attention. We recognise it is very important to ensure we make the necessary improvements to the 
quality and safety of future services.   

During the inquest you identified the following matters of concern for investigation and response by NHS 
Greater Manchester (NHS GM): - 

The referral to the specialist service did not provide adequate information as to his level of 
care needs to help assist the service conduct an appropriate examination. 

An investigation into this matter of concern has been undertaken by 
, Assistant Director Patient Services, 
Associate Director Quality & Safety (Oldham) and 
both of NHS GM. I understand that separate matters of concern have been directed to Northern Care 
Alliance, Oldham Social Services and Oldham Independent Mental Health Advocate and that they will be 
provided their responses. 

,  

To ensure learning and service improvements have been put into practice: 

  A locality practice review process has begun in partnership with key stakeholders to lead forward 
improvement work in Oldham for patients who have a learning disability and complex needs to 
improve the care experience for our most vulnerable patients and residents. Learning from the 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

A16 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 review will be shared across Greater Manchester.  

  Staff have been reminded via a Take 5 Briefing (attached with this letter) of their responsibilities 

towards patients with learning disabilities and complex needs. 

  Staff have been reminded via a Take 5 Briefing (attached with this letter) of the importance of 

Safeguarding vulnerable patients and the responsibilities and mechanisms of making referrals. 

  As a health and care system, we recognise the importance of Hospital Passports. Staff have 
been reminded to be immediately aware of and seek out whether a Hospital Passport is held, 
regardless of whether or not one is noted on the patient records, Trust or community systems or 
is available at any given presentation to services for care.  

  Compliance with the Oliver McGowan mandatory training and completion rates are being 

monitored at Directorate and Trust levels.  

Learning from this PFD will be shared specifically with the GM acute hospitals and the wider health and 
care system through the NHS GM Assistant Directors of Quality networks.  

I hope that the above actions and the outline of the locality review show that NHS Greater Manchester is 
taking appropriate action to learn from the sad death of Mr. Fernandez.  

Please contact me if I can be of further help/ 

Best wishes 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

A17

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

Telephone: 0161 206 5186 

Email : 

29 April 2025 

Ms Joanne Kearsley  
HM Senior Coroner for Manchester North  
Rochdale Coroner’s Court  
Floors 2 and 3 
Newgate House 
Rochdale  
OL16 1AT 

Dear Ms Kearsley 

Re: Inquest into the death of Mr Mark Anthony Fernandez   

I write with regard to the inquest into the death of Mr Mark Anthony Fernandez which concluded on 17 
February 2025 in which you issued a Regulation 28 report to Prevent Future Deaths.  

As you recorded in the Record of Inquest, Mr Fernandez sadly died at the Royal Oldham Hospital 
(“the Hospital”) on 18 April 2024, which falls under the Northern Care Alliance NHS Foundation Trust 
(“the Trust”), following admission on 1 February 2024. May I take this opportunity to express my 
sincere condolences to the family of Mr Fernandez and to his long-term carers.  

The Trust is always open to the opportunity to review, and where possible, strengthen its processes. I 
hope the below offers assurance to both you and Mr Fernandez’s family and carers that the Trust 
takes these concerns seriously and has put in place a number of steps and actions since Mr 
Fernandez’s death.   

I will address your concerns raised in the Regulation 28 report in turn as below: 

1.The referral to the specialist service did not provide adequate information as to his level of 
care needs to help assist the service conduct an appropriate examination  

The referral / Hospital Passport 

On 16 January 2024, a referral was made from 
Rochdale Infirmary, to the Sarcoma Service at Manchester Royal Infirmary. The referral related to a 
suspicious mass in Mr Fernandez’s left groin.  

, Consultant Orthopaedic Surgeon at 

 made the referral following Mr Fernandez’s attendance at the Emergency Department on 
14 January 2024. A suspected cancer upgrade referral was sent by the Emergency Department to the 
orthopaedic team and was virtually reviewed by 

 before he sent the referral to the 

A3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Sarcoma Service. A Hospital Passport was not included with the referral nor was reference made to 
its content. Mr Fernandez had arrived at the Emergency Department on 14 January 2024 
unaccompanied and there is nothing in the documentation to suggest that he came with his Hospital 
Passport. Consequently, 
 was not aware as to its content and potential assistance to the 
Sarcoma Service in accommodating their examination of Mr Fernandez on 1 February 2024.  
The Trust acknowledges that the referral did not provide sufficient information regarding Mr 
Fernandez’s presentation and the accommodations that would be required to ensure a full 
examination could take place. It was evident however that the lack of information regarding Mr 
Fernandez’s presentation within the referral indicated the need to increase the awareness amongst 
Trust staff regarding the adjustments and support required by patients with a learning disability. The 
Trust has improved its processes about the utilisation and awareness of Hospital Passports as I 
describe below. 

Review of the Learning and Disabilities and Autism policy and Enhanced Patient Observation (“EPO”) 
policy 

There is a Learning and Disabilities and Autism Policy available on the Trust Policy Hub providing 
guidance including a Summary Sheet and Emergency Care and Admission Pathway. The Policy also 
references Hospital Passports in its advice regarding reasonable adjustments required in triage and 
on admission. The Trust will review this Policy with reference to your concerns and in particular 
regarding how additional guidance can be provided with regard to specialist referrals.  
A review of the policy will be undertaken by the Lead Nurse for the Learning Disability Acute Liaison 
service within 3 months of the date of this letter, incorporating a review of the Enhanced Patient 
Observation (“EPO”) policy to provide assurance that the policies are equally cognisant of the needs 
of people with learning disabilities and the requirement of active use of Hospital Passports, and 1 
Page Profiles (e.g. Traffic Light Hospital Passport, My Health Passport, What Matters to Me 1 Page 
Profile, This is Me). 

Share Learning Take 5 

An educational Share Learning Take 5 has also been prepared to increase awareness regarding 
patients with learning disabilities. This was presented to the Oldham Care Organisation patient safety 
summit on 9 April 2025 and divisional governance meetings in the month of April 2025. It was also 
shared with the other Care Organisations within the Trust on 10 April 2025.  
The Take 5 highlights the need to avoid diagnostic overshadowing and encourage those caring for a 
patient with a learning disability to have regard to their unique needs. It reinforces the current policy 
about the importance of communication with patient’s carers and family and how to adapt 
communication with the patient themselves. The Take 5 also signposts to the Trust Learning Disability 
Acute Liaison team which is on hand to offer guidance and support with regard to all aspects of care 
and support required for patients in this cohort.  

Oliver McGowan training 

The Oliver McGowan Mandatory Training on Learning Disability and Autism aims to save lives by 
ensuring the health and social care workforce have the right skills and knowledge to provide safe, 
compassionate and informed care to autistic people and people with a learning disability (NHSE, 
2025). The Trust has mandated the part 1 e-learning programme to all staff with 97% compliance 
across the organisation to date. Ongoing development is in progress to complete training of the 
trainer for Tiers 1 and 2 of the programme during 2025. 

A4 
 
 
 
 
 
 
 
 
 2. The Hospital Passport was not utilised 

Provision and use of Mr Fernandez’s Hospital Passport 

The Trust acknowledges the importance of Hospital Passports in informing the care and treatment of 
patients with a learning disability.  

The Trust is aware of the evidence of 
 that a Hospital Passport accompanied Mr Fernandez 
into hospital on 1 February 2024. From its review of the notes the Trust found nothing to suggest that 
Mr Fernandez did, in fact, arrive with this document. He arrived unaccompanied via ambulance and 
following his transfer from the Emergency Department to the Acute Medical Unit all notes were 
scanned into the symphony system. The Hospital Passport was not included within these notes. 

From its review of the notes the Trust concludes that the Hospital Passport must have been provided 
at some point within the next 4 days as contact was made to his care home residence on 5 February 
(the Hospital Passport being the only documentation containing these contact details).  The Hospital 
Passport was scanned on Mr Fernandez’s transfer to ward F8 and would have been located in his 
‘end of bed’ notes in accordance with the Trust Learning Disability and Autism Policy as it would be 
accessible to all members of the MDT.  

The Learning Disability team documented five attendances on Mr Fernandez during his admission 
and the Trust’s review of the notes confirms that this input was appropriate, informing the treating 
team as to Mr Fernandez’s normal baseline, communication preferences etc. It was however, noted 
during this review that there was not enough contact with Mr Fernandez’s care provider. This was 
most likely as a consequence of the initial absence of the Hospital Passport and these contact details 
being unknown until its arrival to the Hospital. 

The Trust’s review determined that Mr Fernandez’s care was not impacted by the initial absence of 
the Hospital Passport. Notwithstanding this however, the Trust recognises that it’s proper utilisation 
depends on hospital staff being immediately aware as to the need for this document to accompany a 
patient with a learning disability or if one is not available to create one.    

Patient Care Alert (“PCA”) 

The Trust therefore prepared a Patient Care Alert (“PCA”) for immediate learning, which was 
circulated amongst clinical and non-clinical staff on 17 April 2025 and was also shared at the PSIRF 
(patent safety incident response framework) Assurance Group on 24 April 2025, covering the 
following actions: 

1.  Hospital systems containing next of kin contact details must be checked for accuracy and updated 
on a patient’s arrival to the hospital. The Emergency Department Lead Nurse will raise this at an 
Emergency Department reception team meeting so that patient contact details are confirmed and if 
a patient has arrived by ambulance, cross referenced with the PRF (patient report form) on arrival.  
a.  Where any demographics/next of kin details have been updated, the reception team must 

leave a comment to highlight the details which have been updated; 

b.  Where it has not been possible to confirm demographics/next of kin details, the reception 
team must put a note within the record with a request for the details to be checked by the 
nursing team. This will enable omissions to be picked up in real time and actioned by the 
nurse in charge; 

c.  A monthly audit will be undertaken for patients presenting by ambulance and via the waiting 

room, to ensure compliance with the above process.  

A5 
 
 
 
 
 
 
 
 
 
 2.  Hospital staff to make contact with care providers and ensure a Hospital Passport is available as 

soon as possible  

3.  A prompt will now appear on the ‘patient status at a glance’ board (the bed board) when a Hospital 
Passport is available and in use. This will reiterate the policy provision with regard to the visibility 
and prominence of Hospital Passports. The board features a learning disability symbol and staff 
can include written confirmation of “Hospital Passport in place”. 

Daily safety huddles 
Further to the PCA, any patient with a learning disability/Hospital Passport will automatically be ‘red 
flagged’ during daily safety huddles for nursing staff. This adds a further layer of awareness of this 
cohort of patients and their specific needs. The senior nurse (ward manager) will have oversight of 
vulnerable patients.  

In Patient Assessment and Accreditation System (“IPAAS”)  
Nursing teams’ adherence to Safeguarding / Learning Disability Policy is assessed part of the In 
Patient Assessment and Accreditation System (“IPAAS”) and mini IPAAS. Action plans are 
implemented for any areas that do not achieve green status. IPAAS includes:  

•  Evidence of active safeguarding champions, covering dementia, learning disability and fall/EPO in 

safeguarding IPAAS file; 

•  All elements of safeguarding mandatory training compliance equal to or greater than 90%, 

(evidence provided in mandatory training data base and local records); 

•  Safeguarding Adults Level 1, Level 2, Level 3; 
•  Safeguarding Children Level 1, Level 2, Level 3; 
•  Prevent Basic, Prevent WRAP, Oliver McGowan; 
•  Robust documented evidence of relevant relative/carer/patient/IMCA involvement in best interest 
discussions and meetings in accordance with the Mental Capacity Act 2005 (“MCA”). Outcomes 
and actions from these are clearly recorded, evidenced by review of documentation and 
discussions with staff.  

•  Patients with a learning disability or autism, cognitive impairment, dementia etc. have had a 
relevant Passport of Care completed within 48 hours of admission (Traffic Light, My Health 
Passport, This is Me). If not required, this is clearly documented within the patient’s notes. Staff 
can call significant others and complete over the phone if unable to visit.  This is evidenced by 
review of documentation and discussions with staff. 

•  Patients with a learning disability, cognitive impairment or those living with dementia have the 

appropriate alert symbol displayed on their PSAG (patient safety at a glance)/bedside board and 
are wearing a blue wrist band. This is evidenced by review of appropriate patients and PSAG 
boards, and discussions with staff. 

•  Where a patient has a learning disability or is subject to the EPO policy the appropriate alert 

symbol is in use. This is evidenced by observing the PSAG board. 

•  Patients with a cognitive impairment, dementia, learning disability or autism have had the 

appropriate care plan implemented, on an individualised basis, and the elements within this are 
being followed. This is evidenced by reviewing documentation and observing practice. 

Share Learning Take 5 

As I have referenced above (§1) the Share Learning Take 5 presentation includes education as to the 
Hospital Passport and its importance in assisting treating teams to identify problems quickly. 

A6 
 
 
 
 
 
 
 
 
 The Share Learning Take 5 presentation was presented at the Oldham Care Organisation Nursing 
and Midwifery Professional Forum on 23 April 2025. The forum, chaired by the Oldham Care 
Organisation Director of Nursing, includes senior nursing staff, ward managers, lead nurses and 
midwives, assistant directors of nursing and midwives from both community and acute hospital 
settings. Expectations and the standards for checking of Hospital Passports and communicating with 
relatives/carers was discussed, as well as access to the Learning Disability team for support and 
advice. 

Senior Nurse Walkabout 

The ‘Senior Nurse Walkabout’ took place on 25 April 2025 and focussed on patients with a learning 
disability, review of safety huddle ‘red flags’ and Hospital Passports. A spot check audit was 
completed focusing on the following four points: 

•  How many patients with a learning disability were on the ward? 
•  Were all the patients with a learning disability identified on the safety huddle? 
•  Did patients with a learning disability have a Hospital Passport? 
•  Was the Hospital Passport up to date? 

Any shortfalls / non-compliance with the utilisation of Hospital Passports were addressed in real time 
and sharing of good practice will be discussed in the post-walkabout briefing. Going forward there will 
be a quarterly focus on patients with a learning disability on the Senior Nurse Walkabout.  

The Enhanced Patient Observation (“EPO”) policy review and audit tool 

The EPO Policy outlines the approaches to the provision of holistic person-centred care. The current 
policy is under multi-disciplinary review to ensure it reflects the changes in Through 2024/25, a 
collaborative approach aimed at improving the effectiveness of therapeutic observations of care, 
using the least restrictive approaches.  An EPO audit tool was developed September 2023 to support 
role modelling by senior staff and to improve assurance across the Trust. The tool was further 
developed to support the oversight of the quality of the EPO process. In addition, the improvements to 
the Safecare system has supported monitoring of the numbers of patients on EPO. The tool has been 
further modified to support improvements in quality for identified, current learning points particularly 
identified with the EPO process from recent IPAAS assessments. 

This work is underpinned by promotion of This is Me/Hospital Passports to better understand the 
needs of our most vulnerable patients. A series of targeted and bespoke bitesize training sessions 
have been provided by the Enhanced Care team (bringing together falls prevention, dementia 
specialists and the AD for Healthcare behaviours) to frontline staff and managers, promoting a 
strength-based approach to EPO. This approach has been shared with interest with an NHSE 
Enhanced Therapeutic Observation of Care (ETOC) advisory group and recognised as a programme 
of good practice. 

3.  A best interest decision was made without taking into account the views of the long-term 

carers and social services and their knowledge of him as an individual 

The best interests decision making process in April 2024 

 as to the composition of the best interest 
The Trust acknowledges the evidence provided by 
meeting held on 12 April 2024. It also acknowledges that this meeting/decision making process ought 
to have included Mr Fernandez’s carers (and any other professional with an interest in his welfare). It 

A7 
 
 
 
 
   
 
 
 
 
 
 is acknowledged that this would have enabled the best interest decision to be better informed as to 
his wishes and feelings on that matter.  

The Trust’s conclusions as to the utilisation of the Hospital Passport contributed to this omission but it 
also accepts that further education as to its adherence to proper best interest decision making under 
the Mental Capacity Act 2005 (“MCA”) is necessary.  

MCA training 

The Trust commissioned 4 education sessions on incapacitated consent in early 2025 which outlined 
the requirements of section 4 of the MCA and importantly why the views of care staff for an individual 
in Mr Fernandez’s circumstances would be essential to a holistic appraisal of his best interests. At the 
time of writing over 650 staff are currently registered to attend these sessions.  

The Trust Level 3 safeguarding adult mandatory training programme has a significant focus on the 
MCA and its application in practice. Current organisational compliance with Level 3 Safeguarding 
adult training is at 95%. MCA and Deprivation of Liberty Safeguards (DoLS) training have been better 
defined to support the application of MCA beyond the requirement for application of a DoLS 
authorisation to ensure the MCA is more effectively considered for a wider group of patients, including 
those with learning disabilities. The application of the MCA is essential to the EPO procedures to 
ensure the least restrictive option of observation and support is provided. 

MCA audits 

Mental capacity ward audits have been reviewed and updated with the roll out of a new audit tool 
commenced from April 2025. The Trust safeguarding adults team have worked with the clinical audit 
team on the audit programme, and safeguarding practitioners are delivering MCA audit training to 
lead nurses across the Trust. The audit is in development, working alongside frontline staff to improve 
compliance and auditable sample sizes.  

Audit findings for quarter one will be reported via local care organisation steering groups, the Trust 
Safeguarding Committee and Experience Group in Quarter 2 of 2025/26. 

Summary of Actions and Impact on Patient Care 

In response to the concerns raised, the Trust has initiated a series of targeted actions, including a 
review and strengthening of the Learning Disability and EPO policies, enhanced staff training on the 
Mental Capacity Act, increased visibility and utilisation of Hospital Passports, and improved 
communication with care providers. These changes are supported by audit mechanisms and safety 
huddles to ensure consistent practice. Collectively, these measures will improve the identification and 
support of patients with learning disabilities, ensure timely and informed decision-making, and 
enhance the delivery of safe, personalised care. All actions will be completed and embedded within 3 
months to ensure lasting improvements in patient outcomes. 

Further Review  

The Coroner advised in her summing up that the matter needs to go in for a LeDeR review urgently.  
I can confirm that Mr Fernandez’s death was referred to LeDeR by the Trust the following day, on 19 
April 2024. We have since contacted LeDeR again for an update and are told that the review was on 
hold pending the inquest process and will now resume. 

A8 
 
 
 
 
 
 
 
 
 
 
 
 
 I hope the above offers you reassurance of the Trust’s ongoing commitment to managing patient 
safety risks and to continually improve the care and services we provide. 

Please do not hesitate to contact me if you require any further information in relation to our response 
or if you would like me to share the PCA or other documentation referred to above.  

Yours sincerely 

Chief Executive Officer 

A9

Oldham Council ASC learning from working with MF

Item

Learning

Key Actions

Proposed
commencement
date

Responsible Officer

Outcomes

1.

Participation in
medical best interests’
decisions under MCA

Where Adult Social
Care have a long-term
role in a person’s life,
they will be considered
interested persons to
be consulted in
medical best interest’s
decisions.

Where the medical
best interest decision
constitutes:





a life changing
decision
or
relates to
article 1 and 2
human rights

Adult social care
should prioritise
attendance at any
medical best interest

MCA Strategy

7 Minute briefing to be created and
disseminated across ASC re:
Learning from the case of MF.

 Risk rating framework to support
practitioners to make safe and informed
decisions regarding attendance at
medical best interest’s meetings led by
other organisations to be created and
disseminated across ASC.

Documents to be added to ASC
SharePoint site as ongoing practitioner
learning and guidance.

Learning to be added to MCA theory to
practice training,

     June 25.

Head of Service for
Safeguarding and
Principle Social
Worker

Supported by:

MCA and
Safeguarding Lead

Quality improvement
Officer

Adult Social Care will consistently and
effectively fulfil their role as interested
persons in medical best interests’
decisions.

Adult Social Care will support partner
organisations to make high quality best
interests’ decisions/

Adult Social care will support the best
possible outcomes for individuals subject
to medical best interests’ decisions.

.

Progress and Evidence

RAG

.

 decision meeting it has
been invited to attend.

Information sharing
regarding other
interested persons

2.

Where Adult Social
Care have
commissioned a care
provider for an
individual subject to a
medical best interest
decision, the carers
may also be considered
interested persons to
be consulted in
medical best interest’s
decisions.

When Adult Social Care
are invited to attend
medical best interests’
decision meeting, they
should share
information with the
organisation leading
the best interest’s
decision process about
the care provider, to
ensure that they too
can be invited to the
best interest meeting.

MCA Strategy

7 Minute briefing to be created and
disseminated across ASC re:
Learning from the case of MF.

Risk rating framework to support
practitioners to make safe and informed
decisions regarding attendance at
medical best interest’s meetings led by
other organisations to be created and
disseminated across ASC.

Risk rating system to include the need to
consider if any information about other
interested persons including care
providers should be shared with the
decision-making organisation.

Document to be added to ASC
SharePoint site as ongoing practitioner
learning and guidance.

June 25.

Head of Service for
Safeguarding and
Principle Social
Worker

Supported by:

MCA and
Safeguarding Lead

Quality improvement
Officer

Information held by Adult Social Care on
other interested persons will consistently
be shared with partner agencies to
support partner to effectively carry out
best interests’ meetings.

 3.

Tracking hospital
admissions for people
open to the specialist
teams within Adult
Social Care

Where people are
known to specialist
teams within Adult
Social Care, the
specialist team need to
proactively case track
the hospital admissions
for these individuals.

Case tracking will
support the
responsible team to
participate in effective
multiagency working
around the adult.

This proactive
approach will support:





attendance at
and
participation
in any
upcoming
best interests’
meetings
effective
hospital
discharge
planning.

Learning Disabilities and Autism Team to
assign responsibility for hospital
discharge work to a named worker
within the service.

Named Learning Disabilities and Autism
hospital discharge worker to proactively
track people open to the team who are
admitted to acute hospital and fully
engage in multiagency working.

Learning Disabilities and Autism Team to
train duty workers to cover this role
when the named worker is not available.

ASC Mental Helath teams to review how
acute hospital admissions and
discharges are managed by their area of
service.

ASC Mental Health Teams  to ensure
individuals open to their teams are
appropriately tracked and full
engagement in  multi-agency working is
in place from ASC re the hospital
admission and discharge planning.

      June 25

Head of Service for
Learning Disabilities
and Autism and Head
of Service for Mental
Helath

Specialist teams within Adult Social Care
will have robust processes in place re
hospital admissions and discharges.

 Specialist teams within Adult Social Care
will be aware of any upcoming multi
agency meeting for the individuals they
support and be able to plan for
appropriate attendances.

Date: 20 May 2025
Your ref 

Ms Joanne Kearsley
HM Coroners Court
 Floors 2&3 Newgate House, Newgate 
Rochdale
OL16 1AT

Legal Services
Council Offices, Spindles Shopping Centre
George Street
Oldham, OL1 1LF

Dear Ms Kearsley

Re: RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

This is Oldham Council, Adult Social Care’s response to your report made under paragraph 7, 
Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013, dated 4th March 2025 following the sad death of Mr Mark 
Anthony Fernandez on the 30th October 2024

The Council apologises for the delay in responding to you, no disrespect was intended in 
responding to the Regulation 28 Report. 

Thank you for your identification of a number of matters of concern, which are set out in the 
report.  The report specifically requests action taken or proposed action to be taken that will 
seek to address the concerns identified in the report. Attached to this letter is an action plan 
that provides specific actions that the Council is seeking to implement to alleviate the Concerns 
raised and the target time frame for these actions being June this year.

The Council can also confirm that the commissioned IMCA service is able to cover medical 
best interest decisions. adult social care will work with them to ensure that where they feel 
interested persons have not been invited to medical best interest decision meetings, they 
ensure appropriate information is shared with the organisation leading the decision. 

Should you have any queries about this letter, please don’t hesitate to contact

Yours sincerely

Interim Borough Solicitor

A10