Winnie Harrop

From 

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

1 May 2025 

Our ref: 

Jyoti Gill,  
HM Assistant Coroner for Manchester South 
Coroner’s Court, 
1 Mount Tabor Street, 
Stockport, 
SK1 3AG 

By email: 

Dear Ms Gill,  

Thank you for the Regulation 28 report of 19th March 2025 sent to the Secretary of State 
about the death of Winnie Harrop. I am replying as the Minister with responsibility for hospital 
and community discharge.  

First, I would like to say how saddened I was to read of the circumstances of Ms Harrop’s 
death, and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. 

Your report raises concerns over a lack of clear health and social care guidance on hospital 
discharge, specifically under what circumstances it is appropriate to send a patient back to 
a care home.   

There is in fact clear guidance on this issue, which can be found under section four of the 
published  ‘Hospital  discharge  and  community  support  guidance’.  This  statutory  guidance 
dictates that support should extend beyond discharge itself, and that local areas should have 
agreed protocols for collaborating with onward care providers about an individual’s hospital 
discharge through the care transfer hub. This should include agreed pathways for raising 
any concerns post-discharge and how to resolve these, including where care providers are 
required to make changes to care plans. 

Evidently, in Ms Harrop’s case, there was a new requirement for oxygen, and a need for a 
reassessment of her discharge plan. It is the responsibility of NHS England to engage with 
trusts to ensure that the statutory discharge guidance is followed. As such, in preparing this 
response, my officials have made enquiries with NHS England to ensure that we adequately 
and fully address your concerns. I have been made aware that they are preparing their own 
response  to  this  PFD  report,  which  will  incorporate  regional  input  to  provide  additional 
context and explanation for this very sad case. 

  
  
 
 
 
 
 
 
  
 
 
 
  
  
  
 
 
 Once again, I would like to offer my sincere condolences to Ms Harrop’s family. This situation 
is  an  unacceptable  one,  and  I  am  truly  sorry  for  the  devastating  and  irreversible 
consequences this has had. I can assure you that my officials are working with colleagues 
in NHS England, to ensure this situation is avoided at all costs in the future, and that  local 
systems follow and embed the existing guidance. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

MINISTER OF STATE FOR CARE

Ms Jyoti Gill 
HM Assistant Coroner  
Manchester South Coroner’s Court  
1 Mount Tabor Street 
Stockport 
SK1 3AG 

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

14 May 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Winnie Harrop who died 
on 16 August 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
March 2025 concerning the death of Winnie Harrop on 16 August 2024. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Winnie’s family and loved ones. NHS England are keen to assure 
the family and the Coroner that the concerns raised about Winnie’s care have been 
listened to and reflected upon.   

Your Report raised a concern around there being no clear guidance between health 
and social care as to the circumstances in which it is appropriate to send a patient 
back  to  a  care  home  following  a  hospital  admission.  You  also  raised  that  Winnie’s 
discharge letter failed to refer to the level of sedation provided or that there was a new 
oxygen requirement. This particular concern falls outside of NHS England’s remit and 
should be raised locally with Tameside and Glossop Integrated Care NHS Foundation 
Trust, should the Coroner require any further information beyond what is set out in this 
response.   

My  response  to  the  Coroner  has  been  aided  by  engagement  with  NHS  England’s 
National Clinical Director for Older People and our North West Regional Teams.   

The safe discharge of older people with frailty should always be a bespoke process, 
depending on the specific context of both the patient and the place of residence. NHS 
England  would  discourage  blanket  discharge  policies  which  address 
the 
responsibilities of care homes. There is substantial variability within the sector as to 
the competencies and equipment staff hold. However, when handing over care to any 
other care setting, including care homes, the correct policy should be that diagnosis, 
prognosis and future management are communicated by the discharging organisation. 
In the case of care homes, where competencies are not always straightforward and 
cannot be taken for granted, future management should not just be communicated but 
agreed  with  the  duty  manager  for  the  home.  If  the  home  cannot  meet  the  patient’s 
needs, as would seem to be the case in this instance, then it is incumbent for the NHS 
to continue to provide care.  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 The  Department  of  Health  and  Social  Care  (DHSC),  to  whom  your  Report  is  also 
addressed  to,  has  published  statutory  guidance  on  how  health  and  care  systems 
should support the safe and timely discharge of patients from hospital, which includes 
guidance  on  care  homes.  The  guidance  was  last  updated  in  January  2024.  The 
guidance and supporting documentation can be found here: Hospital discharge and 
community support guidance - GOV.UK. 

My colleagues from the North West region have been in contact with Tameside and 
Glossop Integrated Care NHS Foundation Trust, who have advised us that there is 
currently  no  Standing  Operating  Procedure  (SOP)  in  place  for  discharges  from  the 
Emergency Department (ED). However, where any patients are being returned to a 
care home, the home are contacted and updated on all events that have occurred in 
the ED and staff ensure completion of a ‘Return to 24 hour care’ form’, which includes 
sections  for  interventions,  results,  treatments  given  and  a  plan.  This  form  does  not 
currently  have  any  dates  or  version  control, however  the  Trust have  confirmed  it  is 
being  updated  and  will  include  version  control  and  review  dates.  Changes  are 
expected to be approved by the Trust’s Quality and Safety Meeting later in May 2025.  

The Trust advise that all patients have a discharge summary completed which outlines 
all key points of their hospital attendance and the management of their care during 
their admission within the ED. In addition, the Trust is currently reviewing and updating 
the safe sedation policy to include input from the ED. As per the Trust’s Patient Safety 
Incident Investigation (PSII) action plan, the immediate deployment in the ED of the 
Royal College of Emergency Medicine (RCEM) Guideline for Procedural Sedation in 
the Emergency  Medicine  (2024) has been  completed.  The  Trust’s  policy  reflect  the 
RCEM guidance.  

As additional oversight, there are weekly discharge planning meetings that take place 
which include representation from social care in terms of appropriate management of 
discharges  back  to  24-hour  care/care  homes.  There  has  been  a  meeting  held  with 
informatics  to  review  discharge  letters  and  discharge  checklists  and  further  work  is 
ongoing, which will be presented to a Working Group to improve.  

We  understand  that the  Coroner  was  satisfied  with  the  Trust’s  action plan  from the 
PSII that took place. 

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 
Winnie, 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,  

 
 
 
 
 
  
  
 
 National Medical Director