Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0303, written 17 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jun 2025 |
|---|---|
| Reference | 2025-0303 |
| Deceased | Hazel Gambles |
| Coroner | Simon Tait |
| Coroner area | South Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: Date: 17 June 2025 Case: CORONER’S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS Foundation Trust 1. CORONER , Chief Executive, Rotherham I am Simon Tait, Assistant Coroner for South Yorkshire East 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 6 February 2025 I commenced an investigation into the death of Hazel Gambles. The investigation concluded at the end of the inquest . The conclusion of the inquest was a narrative conclusion that: The deceased died as a result of naturally occurring frailty of old age. Her pre-existing Alzheimer's disease, coronary artery atherosclerosis and chronic obstructive pulmonary disease contributed to her death, as did a head injury sustained during an in-patient fall while in hospital. 1a Extreme frailty of age 1b 1c II Alzheimer's disease, chronic obstructive pulmonary disease, coronary artery atherosclerosis, recent head injury 4. CIRCUMSTANCES OF THE DEATH Hazel Gambles suffered a fall at home on 10 January 2025. She was admitted to Rotherham District General Hospital. She had not sustained any injuries in the fall at home but was felt to have community acquired pneumonia and was admitted for investigation. A falls risk assessment was done on admission identifying her as a falls risk, but the falls prevention measures section of the assessment was not completed, and no such measures were put in place. On 11 January at 00.18 Mrs Gambles was transferred to Ward B4. According to the Trust guidelines, a further falls assessment should have been done within six hours of admission to the ward but that did not take place. At 20.00 she had an unwitnessed fall and was noted to have injuries to her face. At 23.50 a falls risk assessment was done. The falls prevention measures section of the form was not completed. At 01.04 Mrs Gambles was reviewed by a doctor. The assessment should have taken place sooner given the injuries to her face and the fact that she was on anticoagulation. The request for medical review is recorded in the records but not timed as it should have been. Following medical review, a CT scan was undertaken and Mrs Gambles was found to have suffered a small bleed on her brain. This bleed had been sustained in the in-patient fall. Her family were told of the fall but were not told about the result of her CT scan, or that she had suffered the bleed. Contrary to Trust policy there was no Datix report submitted in respect of the fall, meaning that the fall was not reviewed or investigated at the time. On 23 January 2025 Mrs Gambles was discharged to a care home. The discharge letter did not mention the in-patient fall. She died on 27 January 2025. The head injury sustained in the in-patient fall more than minimally contributed to her death. 5. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – There are several areas of concern around failures in documentation and failures to follow Trust policy, namely: 1. Lying and standing Blood Pressure was not recorded on admission. 2. There was no documentation of any falls prevention measures at the time of the first falls assessment. 3. There is no evidence of falls prevention measures being put in place following the first falls assessment. 4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen. 5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed. 6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain. 7. No Datix report was done following the in-patient fall leading to a delay in investigation. 8. The in-patient fall is not mentioned on the Discharge letter. I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 12th August 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, . I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 17 June 2025 Signature for South Yorkshire East
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Care Group 1 (Medicine) Nurse in Charge Handover Checklist Expectations: The Nurse in Charge Handover Checklist must be completed at each Nurse in Charge handover Ward Manager to review daily, Matron to review weekly and share at the monthly Quality Meeting with HON/DHON. Form to be scanned and saved to the ward shared drive. Date: Lead From: Time: Lead To: Yes – provide details No – what action/escalation Have staff being allocated to patient areas? (Please give details of where staff are allocated and NIC) Is the health roster up to date? (State if any sickness has occurred, review 24 hours in advance and escalate) Has the emergency equipment being checked? Is there any Tendable Audits that need completing? (Include results below 80% that need to occur weekly) Has board round being completed following SHOP principles? (Identify lead and attendees, escalations to site rep and MOD) Is there any referrals that need to be made? (Therapy, speciality reviews, dietician, SALT, TVN, admiral nurse) Are there any deteriorating patients or patients you are concerned about? (discuss NEWS, RESPECT, escalation and plan) Are there any outstanding jobs on the nursing assessment board? Identify patients who are MFFD and Golden Patients for discharge. Has the Criteria to reside being reviewed? Has there been any incidents? Have these been reported via datix? Is there any family meetings/communication needing to be arranged or arranged? (including DOC) Is there any patient on a DOLS, patients who lack capacity or requiring enhanced care supervision and have the request forms being sent to MOD inbox? Ring the MOD on 8357 to inform them an enhanced care has been submitted or at weekend to ring staffing 8386 Are there any complex patients identified on the ward requiring input from other services? CG 1 NIC handover updated July 2025. GS HON, JB DHON, RS Matron. Care Group 1 (Medicine) Nurse in Charge Handover Checklist Expectations: The Nurse in Charge Handover Checklist must be completed at each Nurse in Charge handover Ward Manager to review daily, Matron to review weekly and share at the monthly Quality Meeting with HON/DHON. Form to be scanned and saved to the ward shared drive. Date: Lead From: Time: Lead To: Yes – provide details No – what action/escalation Have staff being allocated to patient areas? (Please give details of where staff are allocated and NIC) Is the health roster up to date? (State if any sickness has occurred, review 24 hours in advance and escalate) Has the emergency equipment being checked? Is there any Tendable Audits that need completing? (Include results below 80% that need to occur weekly) Has board round being completed following SHOP principles? (Identify lead and attendees, escalations to site rep and MOD) Is there any referrals that need to be made? (Therapy, speciality reviews, dietician, SALT, TVN, admiral nurse) Are there any deteriorating patients or patients you are concerned about? (discuss NEWS, RESPECT, escalation and plan) Are there any outstanding jobs on the nursing assessment board? Identify patients who are MFFD and Golden Patients for discharge. Has the Criteria to reside being reviewed? Has there been any incidents? Have these been reported via datix? Is there any family meetings/communication needing to be arranged or arranged? (including DOC) Is there any patient on a DOLS, patients who lack capacity or requiring 1-1 supervision and have the request forms being sent to MOD inbox? Are there any complex patients identified on the ward requiring input from other services? CG 1 NIC handover updated July 2025. GS HON, JB DHON, RS Matron.
Care Group 1 (Medicine) Safety Huddle Log Expectations: The Huddle is to be completed 3 times a day (AM, PM & Night) or following an incident. Ward Manager to review daily, Matron to review weekly and share at the monthly Quality Meeting with HON/DHON. Log scanned and saved to the ward shared drive. Date: Time: Lead: Present: Shift Allocation/Key messages Patient Safety/Experience Concerns Safeguarding issues Your Health and Wellbeing – breaks Escalations from NIC following review of Patient Overview Board and Nursing Assessment Board (on Meditech) and discuss outstanding actions - Any escalation? Escalations to NIC - Deteriorating patients - The NIC Must be informed and communication must be maintained - escalate to ART if required. Escalations to Matron/Matron of the Day Is there any family discussions that need to take place? including changes in patients condition, post incident, discharge planning. Has the process been identified and has this been arranged including MDT? Tissue Viability - Is the right equipment in place? Have the assessments been completed within the required timeframe? Any escalations? Falls - Is the right equipment in place and are falls prevention measures in place? Have the assessments been completed within the required timeframe? Has the L&SBP being completed? Any escalations? Enhanced Care - support options explored - LD, MHLT, admiral nurse, family support? This is me completed? Enhanced care submitted if appropriate? Mental Health - Any patients concerned about? Any Missing/risk of missing persons? Protocol followed? Any escalations? IPC - Any special precautions in place? Any escalations? Discharge planning to include discussions with family, golden patients, C2R, IDT position/to be completed, EDD, follow therapy plan/equipment Moving and Handling – referral to therapy, ongoing requirements CG 1 huddle updated July 2025. GS HON, JB DHON, RS Matron. Care Group 1 (Medicine) Safety Huddle Log Expectations: The Huddle is to be completed 3 times a day (AM, PM & Night) or following an incident. Ward Manager to review daily, Matron to review weekly and share at the monthly Quality Meeting with HON/DHON. Log scanned and saved to the ward shared drive. Date: Time: Lead: Present: Shift Allocation/Key messages Patient Safety/Experience Concerns Safeguarding issues Your Health and Wellbeing – breaks Escalations from NIC following review of Patient Overview Board and Nursing Assessment Board (on Meditech) and discuss outstanding actions - Any escalation? Escalations to NIC - Deteriorating patients - The NIC Must be informed and communication must be maintained - escalate to ART if required. Escalations to Matron/Matron of the Day Is there any family discussions that need to take place? including changes in patients condition, post incident, discharge planning. Has the process been identified and has this been arranged including MDT? Tissue Viability - Is the right equipment in place? Have the assessments been completed within the required timeframe? Any escalations? Falls - Is the right equipment in place and are falls prevention measures in place? Have the assessments been completed within the required timeframe? Has the L&SBP being completed? Any escalations? Enhanced Care - support options explored - LD, MHLT, admiral nurse, family support? This is me completed? 1-1 submitted if appropriate? Mental Health - Any patients concerned about? Any Missing/risk of missing persons? Protocol followed? Any escalations? IPC - Any special precautions in place? Any escalations? Discharge planning to include discussions with family, golden patients, C2R, IDT position/to be completed, EDD, follow therapy plan/equipment Moving and Handling – referral to therapy, ongoing requirements CG 1 huddle updated July 2025. GS HON, JB DHON, RS Matron. CG 1 huddle updated July 2025. GS HON, JB DHON, RS Matron.
Quality Insights - Inpatient Falls Cover Sheet Report Name: Quality Insights - Inpatient Falls Purpose: To provide data and insights on the number of inpatient falls within the trust and monitor this over time against national benchmarks Data source(s): Datix, Meditech Refresh frequency: Daily Report Last Refreshed: 07/07/2025 Background filters/exclusions: Only adult general and acute wards are included within this report. Falls are defined as 'Fall from height, 'Fall from trolley' and 'Trip on level ground'. Collapses and rejected Datix incidents are excluded. Last Modified Date: 09/07/2024 Sign Off Status: Approved Report Owner: , Deputy Chief Nurse Questions & Queries : Quality Intelligence Business Partner - rrr e would love to hear your feedback, please contact rrgh-tr .bi-analytics@nhs.net ggh-tr.bi-analytics@nhs.net bi-analytics@nhs.net y @ WWe would love to hear your feedback, please contact feedback/suggestions feedback/suggestions forfor Quality Insights - Inpatient Falls Falls Rate 07-Jul-2025 Report Refreshed Time Period 19/12/2022 30/06/2025 Show data Combined Individual Ward Select all A1 A2 A3 A4 A5 A7 Acute Medical Unit Acute Surgical Unit B05 B10 B11 Coronary Care Unit Fitzwilliam Orthopaedic Trauma Rockingham Orthopaedic IP Short Stay Unit Sitwell Stroke Unit Total Number of Falls 2253 Falls Per 1000 Bed Days 6.24 Total Number of Bed Days 360,962 Moderate and Above Falls Moderate and Above Per 1000 Bed Days 52 0.14 Falls Per 1000 Bed Days for G&A Inpatient Areas Dashed line is national benchmark 6.63 8 7 6 5 4 Jan 2023 Jul 2023 Jan 2024 Jul 2024 Jan 2025 Moderate and Above Falls Per 1000 Bed Days for G&A Inpatient Areas Dashed line is national benchmark 0.19 0.4 0.2 0.0 Jan 2023 Jul 2023 Jan 2024 Jul 2024 Jan 2025 Quality Insights - Inpatient Falls SPC Charts 07-Jul-2025 Report Refreshed Time Period 01/02/2025 28/02/2025 Total Number of Falls 69 Falls Per 1000 Bed Days 6.32 Falls Per 1000 Bed Days for G&A Inpatient Areas Total Number of Bed Days 10,926 Moderate and Above Falls Moderate and Above Per 1000 Bed Days 0 0.00 Ward Select all A1 A2 A3 A4 A5 A7 Acute Medical Unit Acute Surgical Unit B05 B10 B11 6.32 Moderate and Above Falls Per 1000 Bed Days for G&A Inpatient Areas Feb-25 Coronary Care Unit Fitzwilliam Orthopaedic Trauma Rockingham Orthopaedic IP 0.00 Short Stay Unit Sitwell Stroke Unit Feb-25
Our reference: INQ497 Your reference: NJM/cb/tji/28304436 Rotherham Hospital Moorgate Road Oakwood Rotherham S60 2UD Telephone 01709 820000 www.therotherhamft.nhs.uk 12 August 2025 Dear Mr Tait, Inquest touching the Death of Hazel Gambles – Regulation 28 Response I write further to your letter dated 17 June 2025, where you set out matters of sufficient concern to you to invoke your statutory duty under paragraph 7, schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I was very sorry to hear that you were in a position where you felt a report was necessary. As a Trust, we take any deaths very seriously and always strive to learn from any incidents. I am very sorry to the family and friends of Mrs Gambles that our care didn’t reach the expected standard and that they did not have the experience that we strive to achieve at The Rotherham NHS Foundation Trust. For ease of reference, I have addressed your concerns in the order presented. 1. Lying and standing Blood Pressure was not recorded on admission. In Mrs Gambles’ care records it was documented that she hadn’t had her lying and standing blood pressure taken. Lying and standing blood pressure is part of the falls risk assessment and should be completed each time the risk assessment is re-done. To mitigate the risk of this being missed, there is now a falls champion on each ward and part of their responsibility is to educate the team around the importance of risk assessments. The falls champions are also tasked with completing checks to ensure that lying and standing blood pressures have been completed for those who need it. There is also now a healthcare assistant assigned on every shift and part of their role is to ensure that those patients who require a lying and standing blood pressure, have had this undertaken. Since Mrs Gambles’ admission, the Trust has also implemented a nurse in charge checklist and a standardised nursing handover. The nurse in charge checklist provides a further level of senior oversight on the ward to ensure that risk assessments are being completed to the expected standard. Please find the nurse in charge checklist attached to this response as Exhibit 1. 2. There was no documentation of any falls prevention measures at the time of the first falls assessment. In the care of Mrs Gambles, unfortunately there was no documentation to confirm whether any falls equipment was in place, following her falls risk assessment. At the time of Mrs Gambles’ admission, the falls prevention measures part of the risk assessment was not a mandatory field and so there was a risk that this would be missed. Since Mrs Gambles’ death, this has now been changed to a mandatory field within the risk assessment. This means that nursing staff are unable to progress with documentation until they have completed the entry, and so it should be clear as to what falls prevention measures are required for each individual patient. Compliance with this is audited as part of the Tendable audit. The Tendable falls inspection overall outcome from February 2025 to August 2025 shows that overall compliance has risen from 78% in February 2025 to 98% in August 2025. In relation to falls, the Trust has also successfully recruited a falls lead practitioner. This practitioner is due to commence next month (September 2025). The falls lead will have a responsibility to drive improvements in the prevention and treatment of all falls within the Trust. Part of their role will be looking at clinical effectiveness and to look at anything which may fall outside of the falls audit. They will also be reviewing the national falls audit and considering where further improvements need to be made. The Trust has also now implemented a standardised safety huddle log. Please find this attached at Exhibit 2. Within this, there is a section in relation to falls and specific prompts to ask: Is the right equipment in place and are falls prevention measures in place? Have the assessments been completed within the required timeframe? The Trust will measure compliance and effectiveness of this throughout the implementation phase. 3. There is no evidence of falls prevention measures being put in place following the first falls assessment As mentioned in the previous section, we have now ensured that these fields are mandatory and so this should prompt the staff to ensure that falls prevention measures are put in place. The Tendable audit questions are monitored on a monthly basis and any actions arising from non-compliance with this are monitored. There is also a falls section Chief Executive, The Rotherham NHS Foundation Trust Executive Assistant: Email 2 within the Trust’s Exemplar Accreditation programme which is designed around the CQC key lines of enquiry to ensure the quality of care delivered to patients within a ward environment. Each area is measured continuously. It is also expected that once the falls lead practitioner starts in September 2025, part of their portfolio will be to ensure that appropriate audits take place and if there are any areas where further quality improvement work can be undertaken, they will be tasked with identifying this. There are also monthly external assurance audits undertaken by someone external to the ward. A senior member of staff will go and look at the entire environment to see whether the appropriate signage is up – i.e. gingerbread man. The senior member of staff will also check on other aspects of the patients care such as nutrition and hydration documentation to ensure that everything is being undertaken as expected. Each nurse also has a professional responsibility to make sure whatever they document is correct and implemented. 4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen. Since Mrs Gambles’ admission, we have now implemented an overview dashboard within the Meditech system (the Trust’s medical records system). This is an electronic dashboard and shows in real time which risks assessments have been completed and which are still outstanding for each patient. The use of this board throughout the nurse in charge shift means that they now direct staff when assessments haven't been completed and it is much clearer to identify when risk assessments are overdue or have not taken place. Risk assessments also now refresh on transfer to a new ward so that there is less risk of a staff member copying the previous ward assessments. On transfer to a new ward, the staff member will be presented will a completely blank risk assessment which will prompt them to fill in the assessment from scratch based on the patient’s current presentation. Ward B4 was initially set up as a winter pressures ward, but now has a substantive leadership team. As it is a new ward, it is in its baseline data gathering year and has not had an initial accreditation (using the Exemplar Accreditation Programme), however this will happen in October 2025 once there is a year’s worth of data. This will include handover and falls assessments and any non-compliance will lead to clear improvement actions. 5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed. Chief Executive, The Rotherham NHS Foundation Trust Executive Assistant: Email 3 The induction of resident doctors includes sessions on resuscitation and more details are now included on the response to a deteriorating patient. The clinical teams (resident doctors and the acute response team) will prioritize deteriorating patients who need to be reviewed overnight (elevated NEWS2 scores or abnormal neurological signs). The Trust is moving towards employing two medical registrars on call overnight. We have reviewed the national audit of inpatient falls (NAIF) data which demonstrates that the Trust is routinely completing accurate assessments for patients who fell in hospital and sustained an injury. The data confirm that the medical review for these patients is now taking place within 30 minutes. Mrs Gambles’ care will not be included in the NAIF figures as the inclusion criteria at that time only covered patients who had a fall that resulted in a fractured neck of femur. Since 1 January 2025, the audit now includes more injuries than just a fractured neck of femur. The audit now includes head injury, spinal injury, hip fracture, vertebral fracture, rib fracture, humeral fracture, distal forearm fracture, pelvic ring fracture or any other fracture. As part of this audit, any patients who have had an inpatient fall that sustain an injury included within the audit, will be reviewed and the data shared, including improvement actions. 6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain. Mrs Gambles’ family should have been updated on the findings of the CT scan and I am very sorry to see that this didn’t happen. To improve communication with family, we have implemented a number of changes. There are daily ward rounds on all medical wards and the Trust is working to ensure that “board rounds” take place prior to the ward round to ensure that all relevant information is captured and that all patients have a senior review on a daily basis. Some consultants already have time in their job plans for a consultant communication with families after the ward round, via telephone call. We are now changing job plans to ensure that all medical consultants have dedicated time to do this. The nurse in charge checklist includes a specific question to ask “is there any family meetings / communication needing to be arranged”. The nurse in charge checklist is completed at each nurse in charge handover. The safety huddle log also includes a prompt to as “is there any family discussions that need to take place? Including changes in patient’s condition, post incident, discharge planning.” The safety huddle is completed three times a day (morning, afternoon and night). As a Trust, we also now have a further safety net with the introduction of Martha’s Law, which was introduced in February 2025. This provides a direct number for patients and families that feel they are worried about the medical care they are Chief Executive, The Rotherham NHS Foundation Trust Executive Assistant: Email 4 receiving, their condition is deteriorating, and they don't feel listened to or if they want a second opinion. The contact number is displayed across the Trust and within each Ward and Bay area. As a Trust, we have seen positive outcomes from patient and family feedback who have felt the need to access this resource and support. 7. No Datix report was done following the in-patient fall leading to a delay in investigation. No Datix report was completed after the in-patient fall and this should have been done at the earliest opportunity, following the fall. The responsibility of completing a Datix report is the person who has identified a safety incident or significant concern. In the event that a Datix is not completed during the shift due to distraction, capacity or not having access to the system, this should be escalated to the nurse in charge who will complete on the persons behalf. The nurse in charge checklist now asks the question “has there been any incidents? Have these been recorded via Datix?”. This gives an opportunity for the senior team to consider whether there are any outstanding incident reports and if so, ensure that these are reported at the earliest opportunity. The induction for temporary staff form includes a specific section on Datix and when an incident should be reported and the process to follow post falls. Whilst the nurse involved in Mrs Gambles care wasn’t temporary, this ensures that any temporary staff on the ward are aware of the expected process to follow. 8. The in-patient fall is not mentioned on the Discharge letter. The Trust acknowledges that the discharge letter was not to the standard that would have been expected and that crucial information, including the inpatient fall was not included within this. As a Trust, we have now added a mandatory question to the inpatient discharge summary to ask whether the patient has had a fall, VTE (Venous Thromboembolism), pressure ulcer or any other incident. This will prompt clinicians to consider whether any of these have occurred and if so, it will be clear on the discharge summary. This will be monitored throughout the implementation stage, to ensure effectiveness. We also review where we stand nationally in relation to falls and use a PowerBi dashboard to monitor this. I have enclosed the most updated version with my response at Exhibit 3. This demonstrates that although there has been a couple of months falls have slightly increased, we have predominantly been sitting under the national average for all falls and for moderate and above harms falls for quite some time. I hope the above provides you and Mrs Gambles’ family with assurance that the Trust has taken this report very seriously, and has established stronger procedures to ensure that we improve the quality of care we provide to our patients. Chief Executive, The Rotherham NHS Foundation Trust Executive Assistant: Email 5 If I can be of further assistance, please do not hesitate to contact me. Yours sincerely Chief Executive Dr Richard Jenkins Chief Executive, The Rotherham NHS Foundation Trust Executive Assistant: Sharree JohnstoneDirect Line 01709 424001 Email sharree.johnstone@nhs.net 6
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