Kenneth Foster

Trust Headquarters  
Executive Offices 

Ground Floor                                 

Pathology and Pharmacy Building 

The Royal London Hospital                     

 80 Newark Street 
London 
E1 2ES 

Our ref:   ID508817 
Your ref:  30061170 

Date: 11th July 2025 

Private & Confidential 

East London Coroners Court 
Queens Road 
Walthamstow 
London 
E17 8QP 

Dear HM Coroner, 

Thank you for your letter dated 12 May 2025 following the inquest of Mr Kenneth Martin Robert 
Foster detailing concerns arising from the evidence presented and inviting the Trust to consider 
the implementation of changes to reduce the risk of future harm or death.  

The  Prevention  of  Future  Death  report  has  been  reviewed  at  Whipps  Cross  Hospital  (WCH) 
Divisional and Hospital Boards to agree actions that will have an impact across the Barts Health 
group. The PFD and response has been shared at Trust Safety Committee, with National Health 
Service  England  (NHSE),  the  Care  Quality  Commission  (CQC)  and  the  North  East  London 
Integrated Care Board (NELICB).  

Your concerns  

A failure in governance at the Trust meant this case was not identified as an incident worthy of 
investigation through the Patient Safety Incident Response Framework (PSIRF). This omission 
gives rise to concern that future deaths may follow due to an inability on the part of the Trust to 
identify, reflect upon and remediate sub-optimal practice.  

In  this  case  the  Trust’s  incident  reporting  system,  morbidity,  and  mortality  (M&M)  meeting 
process and Patient Safety Incident Response Meeting (PSIRM) procedure were inadequate. 

Our response 

The Trust deeply regret the concerns as described by HM Coroner and are sorry for the impact 
these will have had on Mr Foster’s family.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust acknowledge that Mr Foster’s family raised serious concerns in their family statement 
about the care provided to Mr Foster during his final admission to Whipps Cross Hospital. The 
family  concerns  were  investigated  and  responded  to  via  the  complaints  process.  The  Trust 
recognise that provision of the complaint response 2 days before the inquest was unacceptable. 
The  Trust  accept  that  this  will  have  contributed  to  the  lack  of  assurance  the  family  and  HM 
Coroner were provided in relation learning and improvement that must be derived from the care 
and treatment provided to Mr Foster. 

Since December 2024, at Whipps Cross Hospital, each new inquest opened is reported via the 
incident  reporting  system  (Datix).  The  cases  are  presented  at  the  Patient  Safety  Incident 
Response Meeting (PSIRM) and where a Mortality and Morbidity Meeting (M&M) has not yet 
been held, arrangements are made to expedite this process to inform decision making around 
the type of learning response required in accordance with the Patient Safety Incident Response 
Plan. 

The M&M for Mr Foster was undertaken on 30 December 2024, the documentation indicates 
that  his  care  was  graded  (according  to  the  National  Confidential  Enquiry  into  Perioperative 
Deaths)  as  an  outcome  ‘A’,  indicating  a  good  standard  of  care.    It  should  be  noted  that  this 
meeting  took  place  before  the  family  concerns were  submitted.    The  Patient  Safety  Incident 
Response Meeting took place on 14 February 2025 (following confirmation that an inquest had 
been  opened.  The  meeting  attendees  relied  on  the  M&M  and  Structured  Judgment  Review 
(SJR) findings and determined that the case did not meet the criteria (according to the hospital 
Patient Safety Incident Response Plan) for a learning response to be commissioned. 

Whipps Cross Hospital, having reviewed the case again as part of the response to this PFD 
now  consider  that  the  case  could  have  been  brought  back  to  the  Patient  Safety  Incident 
Response Meeting when the family’s complaint was submitted.  Taking into consideration the 

family  complaint,  which  detailed  a  number  of  concerns  around,  basic  care,  communication, 
nutritional  support,  and  medication  the  NCEPOD  grading  could  be  revised  to  outcome  ‘C’ 
indicating a need for improvement.  Whilst a Patient Safety Incident Investigation (PSII) may not 
have  been  indicated,  it  is  clear,  in  retrospect  that  further  investigation  should  have  been 
considered  e.g.  After  Action  Review  (AAR)  or  Multi-Disciplinary  Team  (MDT)  review.  The 
complaint  investigation  should  have  been  provided  sooner  and  could  have  contained  more 
assurance around learning and improvement in response to the findings from the complaints 
investigatory process. 

As part of the learning from this PFD, the Whipps Cross Hospital Senior Leadership Team will 
ensure  that  families  are  contacted  as  part  of  the  Patient  Safety  Incident  Review  Meeting 
(PSIRM) process to ensure that a more robust review is undertaken. Taking account of family 
concerns should be a key aspect to  inform decision making around the level of investigation 
required.  This action will also ensure reviews include the views of the patient’s family, in line 
with  Patient  Safety  Incident  Response  Framework  (PSIRF)  compassionate  engagement 
principles. 

In order to gain additional assurance, the Trust has commissioned a review to be undertaken 
by a specialist within the North London Integrated Care Board and supported by NHSE to review 

 
 
 
 the governance processes relating to this case.  The review will be completed by the end of 
August 2025 and the outcome will be shared with HM Coroner.  An integral part of this review 
will  be  engaging  with  the  Foster  family  to  understand  their  experience  of  the  governance 
process.    The  learning  from  this  review  will  have  implications,  not  only  from  Whipps  Cross 
Hospital but for the Barts Health group. 

Whipps Cross Hospital teams are committed to preventing avoidable harm to patients and would 
like to thank the Foster family and HM Coroner for highlighting a gap in governance processes. 
We are committed to learning from this and making improvements. We hope that this response 
provides  assurance  around  the  actions  that  will  be  completed  and  monitored  to  effect 
improvement in response to this PFD. 

If you have any queries, please do not hesitate to contact me. 

Yours sincerely 

Group Chief Medical Officer 
Barts Health NHS Trust

From 

Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London  SW1H 0EU   

21st August 2025  

Our ref: PFD – 25-05-12 - FOSTER  

HM Coroner Mr Graeme Irvine  
124 Queens Road, 
Walthamstow, 
E17 8QP 

By email: coroner@walthamforest.gov.uk   

Dear Mr Irvine,   

Thank you for the Regulation 28 report of 12 May 2025 sent to the Secretary of State for 
Health and Social Care about the death of Kenneth Foster. I am replying as the Minister with 
responsibility for patient safety.  

Firstly, I would like to say how saddened I was to read about the circumstances of Mr Foster’s 
death and I offer my sincere condolences to his family and loved ones.  I am grateful to you 
for bringing your issues of concern to my attention.   

Your report raises a concern that Mr Foster’s death was not identified as an incident that 
warranted an investigation by Barts Health NHS Foundation Trust under the Patient Safety 
Incident Response Framework (PSIRF).  

In preparing this response, my officials made enquiries with NHS England’s National Patient 
Safety Team to ensure that I can adequately address your concerns.  

The PSIRF, introduced in August 2022, promotes four core principles to inform learning from 
safety  events:  compassionate  engagement,  systems-based 
learning,  proportionate 
responses and supportive oversight.   

While  PSIRF  represents  a  significant  improvement  to  the  way  that  the  NHS  responds  to 
patient  safety  incidents,  PSIRF  does  not  alter  the  requirements  set  out  in  the  National 
Learning from Deaths policy framework. These require a patient safety incident investigation 
to be undertaken into any event where problems in care are thought more likely than not to 
have led to the death of a patient.  

Judging whether a death has more likely than not been caused by a patient safety incident 
is not always straightforward. In many cases it can be reasonable to believe that even when 
a  patient  safety  incident  has  occurred  in a  patient’s  care,  that  incident  did  not  lead to  the 
patient’s death. Due to the complexities of healthcare, there can be situations where different 
people can hold reasonable but opposite views about the same case.  

There will also be many cases where death occurs, and no significant patient safety incidents 
have occurred at all.  

As such, under PSIRF, not all deaths will be investigated. This will include some which go to 
inquest. Decision-making regarding patient safety incident response should be documented 
by Trusts as part of a robust governance process. Where a specific learning response is not 
undertaken in relation to an incident discussed at inquest, the organisation should be able to 
explain why this was the case.  

  
    
  
  
  
 
 Nonetheless, I note that you have also sought a response from the Chief Executive Officer 
of  the  Trust, 

  and  have  now  received  a  response  from 

, Group Chief Medical Officer at the Trust.   

The Trust has stated, in light of the concerns your report has raised, North London Integrated 
Care Board, supported by NHS England will review the governance processes relating to Mr 
Foster’s case to see where improvements can be made and where the Trust can learn from 
the gaps in its governance, identified by your coroner’s report.   

The Trust have stated that the review will be completed by August 2025 and shared with you.  

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

All good wishes,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH