Neil Clarke

Parliamentary Under-Secretary of State for  
Health Innovation and Safety  

39 Victoria Street  
London  
SW1H 0EU  

Mr Christopher Murray  
HM Assistant Coroner   
Manchester South Coronial Area   
1 Mount Tabor Street  
Stockport SK1 3AG  

 Dear Mr Murray,   

22 October 2025  

Thank you for the Regulation 28 report of 2 July 2025 sent to the Secretary of State for Health 
and Social Care about the death of Neil John Clarke. I am replying as the recently appointed 
new Minister with responsibility for Patient Safety.       

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Clarke’s 
death, and I offer my sincere condolences to their family and loved ones. I am grateful to you 
for bringing these matters to my attention. Please accept the department’s apologies for the 
delay in responding to this matter.  

I understand NHS England have responded to you separately. I also understand, Stockport 
NHS Foundation Trust have also responded to you.    

The  first  concern  you  raised  in  your  report  relates  to  considerations  given  to  the 
appropriateness, from a safety and well-being perspective, of surgical procedures involving 
elderly patients.   

You will be aware; from the response you received from NHS England that there is clear 
national guidance on perioperative care for both adults and specifically older people from 
the  National  Institute  for  Health  and  Care  Excellence  (NICE)  and  the  British  Geriatrics 
Society (BGS). NHS England has also undertaken considerable work to develop guidance 
on  Early  screening,  triaging,  risk  assessment  and  health  optimisation  in  perioperative 
pathways. This includes information on risk assessment and shared decision making. In 
response to  your  first concern,  I  am  assured  that  Stockport  NHS  Foundation Trust have 
taken  steps  to  improve  information  and  training  relating  to  shared  decision  making  and 
consent.  In  July  this  year  the  Trust  rolled  out  a  mandatory  training  programme  that  all 
clinical  staff  delivering  patient  care  are  required  to  be  enrolled  on.  Compliance  to  this 
training requirement is being reported through a governance process.   

Your second concern relates to the accuracy of handover communications between clinical 
staff in respect of patients returning to the main ward from the High Dependency Unit. You 
will be aware that prior to the inquest into the death of Mr Clarke, that the Trust’s Divisional 

  
  
  
  
  
  
 
  
   
  
  
  
   
  
  
 Nursing Director, together with senior nursing staff have implemented and continue to embed 
changes to  the discharge  process throughout  the  Division  of  Surgery and  the  wider Trust. 
These included updating the process to the discharge checklist completed by ICU/HDU staff 
for a patient transferred to a main ward and a joint handover process. The Trust has audited 
this updated approach to ensure it is fit for purpose and will continue to monitor it.  

The Government is prioritising patient safety and a learning culture in the NHS, to minimise 
harmful events but we also acknowledge that it is not realistic to eliminate all complications 
in patients undergoing life saving high risk surgery even when all reasonable mitigations are 
in place.   

The changes being made as part of the 10-year Health Plan and 
 report on 
the patient safety landscape will improve quality and thereby system safety by making it clear 
where responsibility and accountability sits at all levels of the system.   

To drive improvements in patient safety, we will usher in a new era of transparency, a rigorous 
focus on high-quality care and a renewed focus on patient and staff voice.   

Over recent years, the NHS has made significant strides to improve patient safety, including 
implementing key programmes under the NHS Patient Safety Strategy (2019). The Strategy 
is now achieving its aim of saving around 1000 lives per year and £100m in care costs per 
year.  

Measures we have taken over the last year include:  

•  Roll out of Martha’s Rule, which is now being expanded to all acute inpatient sites. 
From  September  2024  to  July  2025  more  than  260  Martha’s  Rule  escalation  calls 
required transfers of care to high dependency or intensive care units, enhanced levels 
of care or to tertiary centres.   
implementing medical examiners on a statutory basis to scrutinise all deaths that are 
not investigated by a coroner, in order to facilitate learning and improvement locally.  

• 

The  Care  Quality  Commission  is also  rebuilding  its  regulatory approach  via a  data-driven, 
intelligence-led model to enable the regulator to have a more rounded understanding of the 
service quality and safety Trusts are delivering.  

These  changes  will  ensure  the  safety  and  learning  cultures  across  the  NHS  are  more 
consistent.   

Thank you for bringing your concerns to my attention.    

Yours sincerely,  

Parliamentary Under-Secretary of State  
for Health Innovation and Safety

Mr Christopher Murray  
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 

20 August 2025 

Dear Mr Murray, 

Re: Regulation 28 Report to Prevent Future Deaths – Neil John Clarke who 
died on 26 February 2024.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 July 
2025 concerning the death of Neil John Clarke on 26 February 2024. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Neil’s family and loved ones. NHS England is keen to assure the 
family and yourself that the concerns raised about Neil’s care have been listened to 
and reflected upon.   

The  first  concern  raised  in  your  Report  was  over  the  considerations  given  to  the 
appropriateness,  from  a  safety  and  wellbeing  perspective,  of  surgical  procedures 
involving elderly patients who may benefit from conservative measures, together with 
the associated documentation and guidance advising patients of different treatment 
choices.  

Clinicians’  decisions  regarding  appropriate  care  require  weighing  up  the  risks  and 
benefits of a procedure, combined with the patient’s own views, to achieve effective 
shared decision making.  

Neil is described as a  ‘fit  81  year  old’.  The  Office of  National  Statistics (ONS)  data 
demonstrates that an 81 year old man has, on average, a life expectancy of 8 years 
ahead of them, until aged 89, and so it would seem appropriate that a fit 81 year old 
man  would  have  been  considered  for  both  surgical  interventions  and  conservative 
measures. However, life expectancy is also influenced by frailty and medical history. 
The  most  widely  used  tool  for  quantification  of  frailty  in  the  NHS  is  the  Rockwood 
Clinical Frailty Scale (CFS): 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
  
 An 81 year old man with a CFS of 7 entering a nursing home has a life expectancy, 
on average, of little over a year. Reciprocally, a ‘fit’ 81 year man (CFS 1-2) will have, 
on average, a life expectancy of 9 years or more. 

To  be  able  to  achieve  effective  shared  decision  making  on  treatment  choices  also 
requires information on the potential risk/benefits of the different surgical options. NHS 
England notes from your Report that different options were provided and discussed 
with  Neil,  to  include  conservative  management,  further  polypectomy  or  a  right 
hemicolectomy, the latter being advised as the most appropriate option by clinicians.  

There is clear national guidance on perioperative care for both adults and specifically 
older people from the National Institute for Health and Care Excellence (NICE) and 
the British Geriatrics Society (BGS) respectively. 

•  NICE Guidance NG180: Perioperative care in adults (published 19 

August 2020) 

Recommendations | Perioperative care in adults | Guidance | NICE 

•  BGS Good Practice Guide: Peri-operative Care for Older Patients 

Undergoing Surgery (published 23 January 2015) 

 
 
 
 
 Peri-operative Care for Older Patients Undergoing Surgery | British Geriatrics 
Society 

NHS  England  has  also  undertaken  considerable  work  to  develop  the  following 
guidance  on  Early  screening,  triaging,  risk  assessment  and  health  optimisation  in 
perioperative pathways: guide for providers and integrated care boards (published in 
May 2023 prior to Neil’s death and updated in May 2025), which includes information 
on  risk  assessment  and  shared  decision  making.  Point  5  under  the  ‘Five  core 
requirements for providers’ states: 

“Patients must be involved in shared decision-making conversations to discuss the 
benefits,  risks,  alternatives  and  likely  outcomes  of  the  surgery,  as  well  as  the 
postoperative  recovery  period.  This  allows  patients  to  confirm  their  decision  to 
proceed  with  the  surgery,  seek  further  specialist  advice  if  required  or  make  the 
informed choice to pursue alternative options”. 

Our Personalised Care Team have also produced supporting information on shared 
decision  making  including  ‘Decision  support  tools’  resources,  also  called  patient 
decision  aids,  to  support  shared  decision  making  by  making  treatment,  care  and 
support options explicit.  

It is outside of NHS England’s remit to provide comment on the appropriateness of the 
clinical decision to proceed with a right hemicolectomy in Neil’s case. The clinical team 
at  Stepping  Hill  Hospital  would  be  best  placed  to  comment  upon  the  specific 
circumstances of this case.  

Your second concern focused on the accuracy of handover communications between 
clinical staff regarding patients returning to the main ward from the High Dependency 
Unit (HDU) at Stepping Hill Hospital.  

Safe  and  appropriate handover  of  patients  is a  basic  and core  aspect  of  all clinical 
care.  We  refer  the  Coroner  to  Stockport  NHS  Foundation  Trust’s  response  to  your 
Report, on behalf of Stepping Hill Hospital, regarding this concern. NHS England has 
also asked to be sighted on their response and will consider this carefully.  

I  would  also  like  to  provide  further  assurances  on  national  the  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 Neil, 
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  
NHS England

Chief Executive 
Stockport NHS Trust 
Poplar Grove 
Stockport 
Cheshire 
SK2 7JE 

Our Ref:
Your Ref: 

12 August 2025 

Private and Confidential 
Mr C Murray  
Area Coroner 
1 Mount Tabor Street 
Stockport 
Greater Manchester 
SK1 3AG 

Dear Mr Murray 

Re: Death of Neil John Clarke 
NHS number: 
Inquest date: 1 May 2025  

I  am  writing  to  you  further  regarding  the  Inquest  into  the  death  of  Mr  Neil  Clarke  which 
concluded on 1 May 2025 and the request for assurance in respect of the following: 

•  Consideration to be given to the appropriateness, from a safety and well-being 
perspective, of surgical procedures involving elderly patients who may benefit 
from  more  conservative  measures  and  the  associated  documentation  and 
guidance advising patients of different treatment choices. 

Medical  professionals,  particularly  those  working  with  older  adults,  receive  training  and 
guidance  on  ensuring  informed  consent  and  discussing  all  treatment  options  with  their 
patients.    This  training  is  integrated  throughout  a  doctor’s  career,  from  medical  school 
through ongoing professional development. Training is guided by principles and regulations 
from  bodies  such  as  the  General  Medical  Council  and  the  Quality  Care  Commission. 
Training has an emphasis on shared decision making, where the doctor acts as an expert in 
medical  options,  and  the  patient  is  the  expert  in  their  own  values  and  preferences,  which 
encourages a collaborative approach. 

Training  also  highlights  the  importance  of  providing  patients  with  all  relevant  information 
about  their  condition,  prognosis,  and  available  treatment  options,  including  the  option  to 
take no action.  This  information must  also  cover  potential  benefits,  risks,  side effects, and 
complications  associated  with  each  option.  Additionally,  it  is  also  best  practice  for  the 
suitability of an elderly patient to undergo surgery to be discussed within a multidisciplinary 
team meeting, especially for those patients deemed at are at a higher risk. This allows for a 
more  balanced  assessment  of  the  benefits  and  risks  of  surgery  versus  alternative 
treatments or no treatment, leading to a more individualized and patient-centered care plan. 
This was the case for Mr Clarke following MDT review in September 2023. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I can confirm that the Trust undertook a review of the Trust’s Consent Policy in 2024 which 
stipulated  a  healthcare  professional  responsible  for  seeking  consent  must  have  received 
appropriate consent training.   

Consent training was not originally a requirement of the Core Skills Training Framework for 
mandatory or role specific training, however, it is a key component of CQC assessments to 
ensure  that  we  are  delivering  safe,  effective  and  person  centered  care.  Consent  training 
provides healthcare professionals with the knowledge and skills to communicate effectively 
with patients; assess their capacity to give consent; understand and decide when and how 
to  involve  family  members  or  legal  representatives  and  how  to  document  appropriately  to 
meet legal and ethical compliance. 

A  proposal  was  made  for  the  provision  of  consent  training  and  to  align  this  as  essential 
training for clinical staff with patient facing roles to be delivered by an appropriately sourced  
e-learning module and adapted to align with Trust needs.  The proposal was approved and 
Mandatory  Consent  Competency  requirement  was  rolled  out  on  22  July  2025.  All  clinical 
staff  involved  in  delivering  patient  care  have  the  requirement  attached  to  their  position  in 
ESR  (Electronic  Staff  Record)  and  will  be  auto-enrolled  in  the  relevant  e-Learning 
packages.  A  timeframe  of  October  2025  has  been  set  for  completion  by  all  relevant  staff 
with a three year rolling programme. 

Compliance  for  this  training  requirement  would  then  be  reported  through  governance 
processes  including  the  Educational  Governance  Group,  Patient  Safety  Group  and  at 
Divisional meetings. 

• 

Accuracy  of  hand  over  communications  between  clinical  staff  in  respect  of 
patients returning to the main ward from HDU. 

, Divisional Nursing Director, together with 

 would like to assure you that changes to process had been implemented 
prior  to  Mr  Clarkes’  inquest  and  these  changes  continue  to  be  embedded  throughout  the 
Division of Surgery and the wider Trust. Examples of the changes implemented are outlined 
below: 

1.  The  discharge  checklist  completed  by  ICU/HDU  staff  for  a  patient  transferred  to  a 
main  ward  has  been  updated  and  now  includes  a  dual  signature  feature,  meaning 
that  the  document  must  be  signed  by  both  the  ICU/HDU  nurse  and  the  receiving 
ward nurse. 

2. 

,  Matron  for  ICU,  has  been  auditing  the  implementation  of  the  updated 
checklist since February 2025. The audit has confirmed that ICU are 84% compliant 
with observations completed an hour before transfer (Trust target is 80%). In respect 
of completion of the transfer document, the audit shows that this was completed for 
82% of patients, with 96% being signed and dated by ICU and 88% signed and dated 
by the receiving ward. 

The Division of surgery will continue to monitor this for the next six months to ensure 
that this improved process is fully embedded within teams. 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  In addition, as part of the joint handover, when the ICU nurse arrives with a patient 
who is being transferred to a ward both nurses will be in attendance for the first set of 
observations,  which  are  recorded  on  Patientrack.  Observations done  at  the  point of 
transfer are  being audited  for  our  internal data  capture and  this  remains part of  the 
Trust’s  Quality  Safety  Improvement  Strategy  and  will  remain  an  ongoing  audit  and 
key performance indicator. 

4.  The Division of Surgery, are focused on supporting transfers within core hours, and 
before 17:00 hours, to ensure that we avoid any handover period on the main wards. 
A  daily  meeting  has  been  established  (Monday  to  Friday)  at  14:00  hours  where 
General Surgical Elective wards including ICU, HDU and theatres, together with site 
coordinators  and  manager  of  the  day  for  surgery,  meet  to  identify  appropriate 
patients who can be stepped down from ICU care to ward level care. The expectation 
is  that  once  the  patient  has  been  identified  for  transfer,  the  main  ward  will  actively 
communicate  once  that  bed  has  become  available.  The  aim  to  is  improve 
communication and ensure the timely transfer of patients.  

5.  Whilst  this  new  process  is  in  its  infancy,  we  will  continue  to  monitor  and  audit  this 
after  three months  in  respect  of  improved  transfer times  within  core  hours.  This  will 
be undertaken by December 2025. 

We  hope  that  the  information  provided  above,  including  the  implementation  of  consent 
training  and  its  alignment  to  essential  training  for  clinical  staff  with  patient  facing  roles, 
together  with  the  process  changes  in  respect  of  handover  information  and  documentation 
and our efforts to promote safer transfer of patients, assures you and Mr Clarke’s family that 
we  have  taken  the  learning  identified  as  part  of  our  review  of  Mr  Clarke’s  care  extremely 
seriously. We aim to use all learning positively in order to improve services and ultimately, 
patient care. 

I  would  like  to  assure  you  that  communication,  handover,  documentation  and  consent 
processes remain a focus and a priority for the organisation, and we will continue to strive 
for quality and the highest standards of patient care. 

Please do not hesitate to contact me if you require any additional information. 

Yours sincerely 

Chief Executive 

Enc.  

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