Myles Scriven

Executive Medical Directors Office 
Huddersfield Royal Infirmary 
Acre Street 
Huddersfield 
HD3 3EA 

9 September 2025 

VIA EMAIL 

Mr Crispin Oliver 
HM Assistant Coroner 
The West Yorkshire (Western) Division 
Cater Building 
1 Cater Street 
Bradford 
BD1 5AS 

Dear Mr Oliver,  

Re: Prevention of Future Deaths Report – Mr Myles Scriven 

I am writing on behalf of Calderdale and Huddersfield NHS Foundation Trust in 
response to the Prevention of Future Deaths Report relating to the tragic death of Mr 
Myles Scriven. We wish to express our deepest condolences to Myles’ family and 
acknowledge the profound loss they have experienced. We welcome the opportunity 
this review has provided to reflect, learn, and strengthen our systems to support 
patients with learning disabilities and autism. 

As outlined in the Trusts evidence provided during this case, we already have a 
robust framework of governance and oversight in relation to this important agenda. 
The Learning Disabilities group, which is responsible for the operational delivery of 
our learning disabilities strategy, reports into the Quality Committee which is a 
subgroup of our Trust Board, as well as the Health Inequalities Group.  

We recognise that in this case despite excellent compliance with training and our 
efforts in relation to describing the expected pathway of care for all patients with 
learning disabilities, we did not see the outcome or impact that was expected for 
Myles and his family. 

We have taken this opportunity to scrutinise existing processes to agree a response 
that we anticipate will be able to demonstrate our ongoing compliance with expected 
standards of care as well as the impact that this has on experience and outcomes for 
patients and their families.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Governance and oversight  

We have a well-established Learning Disabilities group that has developed our 
existing strategy and drives operational delivery of this. This group has previously 
been led by our Nurse Consultant for learning disabilities, supported by 
representatives from each clinical division. The group includes members who have 
learning disabilities which provides an expert lens on all activities to ensure that 
actions meet the needs of this patient group.  

The approach to quality improvement has been revised to ensure that each division 
describes priorities with measurable actions that can be monitored in relation to 
impact and effectiveness. Representatives will be held to account for delivery of 
priorities through this group. 

We have strengthened the medical leadership into this group and have welcomed 
 is taking a 

 as the medical lead for learning disabilities. 

key role in reinforcing messages with medical colleagues across the organisation 
and is supporting our renewed audit program. We have also appointed 

 who is our Deputy Chief Nurse to work with the 

 as the co-chair 

of this group to support senior nursing leadership and oversight.  

This triumvirate will be responsible for ensuring that any issues identified through the 
revised audit program are addressed at a service and individual level. 

 also attends the Patient Experience and Involvement Group to report on 

activities against our strategy. We have recently welcomed a colleague with Learning 
Disabilities into our patient experience team. This individual supports colleagues to 
understand the lived experience of people with Learning Disabilities and takes a lead 
role on many of our strategic ambitions, particularly in relation to learning and the 
delivery of bespoke training as well as Part 2 of the Oliver McGowan training. We are 
building a library of digital stories that will further support understanding in relation to 
patient experience and outcomes.   

As part of our response to the implementation of the Patient Safety Incident 
Response Framework we have developed a Lessons Learnt Forum. This group is 
becoming established with a focus on how we can evidence shared learning across 
the wider organisation.   

The Chief Nurse will be chairing a new Quality Assurance Group from September 25 
that will report directly into a sub committee of the board. This group will be 
responsible for oversight of compliance against expected standards of care for all 
patients including effective record keeping. Findings from the revised audit program 
will be fed into this group for action.   

An important action from this case has been the changes we have made to our 
learning from deaths  process specifically for people with Learning Disabilities, this 
will have oversight from the Medical Director through the clinical outcomes group, 

 
 
 
 
 
 
 
 
 
 which reports to the trust Quality Committee which is a sub-committee of the Trust 
Board. 

Clinical Oversight 

To support clinical oversight of patients with learning disabilities we are further 
developing the learning disability dashboard within KP+ (Qlik Sense) digital system. 
This is a data analytics/reporting tool which has the LD flag built into reporting fields 
which allows the Trust to identify patients with a learning disability so that clinical 
teams can use this data to allow prioritisation of care needs and oversight of care 
delivery. 

A flag is added to the electronic record of a patient with a learning disability and any 
reasonable adjustments identified are recorded within the flagging system. 
The VIP hospital passport is used to capture relevant information regarding a 
patient’s care needs and any additional support or communication needs the 
individual patient has. The revised dashboard will also include compliance in relation 
to the data collated through the revised audit program, for information and action and 
to inform divisional priorities. 

The clinical operational site team ensure that the Situational Report (SIT REP), 
which has a learning disability section, is updated daily. This ensures patients with 
additional needs are in the right environment, the right transfers happen, monitoring 
any delays and escalating as needed. The data is shared through site meetings, 
happening on multiple occasions throughout the day. 

Each clinical team has access to expert advice from our Learning Disabilities 
Consultant Nurse. We recognise that with a growing caseload it is not always 
possible for her to oversee every patients care which is why we are developing our 
expertise within the wider senior nursing team. We are undertaking a scoping 
exercise to understand whether our existing resource meets current needs and will 
be in a position to update on this review in the next 6 months. 

All colleagues have access to our Multi Professional MDT meeting which meets on a 
weekly basis. The purpose of this meeting is to request expert support and advice in 
the management of any patient with complex needs. Further work will be undertaken 
to evaluate the impact of the MDTs inputs and ensure that all colleagues are aware 
of the referral criteria for this meeting. 

Standards of Practice and Quality Improvement   

The organisation has a network of Learning Disabilities champions who receive 
enhanced training, education and supervision in relation to this agenda. Whilst we 
will continue to support existing individuals with an interest in this role, we will be 
developing all our senior ward, department and community leads to become 
champions as the accountable leaders in those areas. We are reviewing the training 
provided to this group to ensure that it addresses the key issues identified through 
this case as well as audit findings.  

 
 
 
 
 
 
 
 
 
 
 We have a Patient Centred Care Group that is a sub - group of the Patient 
Experience and Involvement Group. This group is led by an Associate Director of 
Nursing and is responsible for the development of evidence based practice in 
relation to the delivery of person centred care. We are currently piloting ‘behind the 
bed boards ‘to replace existing boards. These boards describe what is important to 
patients and provide an opportunity for patients and families to capture key 
information, questions or concerns for their clinical team. The boards also act as a 
prompt for patients, relatives and our teams to capture important information in 
relation to reasonable adjustments or care needs. The boards will be rolled out 
across all areas by December 2025 with an associated plan to evaluate their impact.  

The Trust has been running a structured quality improvement project, called the Well 
Organised Ward programme for 12 months. This programme is an improvement 
initiative designed to enhance the efficiency, safety, quality and effective 
coordination of inpatient care. It centres around four key principles: daily board 
rounds to ensure shared understanding of patient needs; a clear plan for every 
patient, led by a designated coordinator or nurse in charge; strong multidisciplinary 
team (MDT) leadership involving a diverse range of professionals; and a planned 
date for discharge to support timely transitions of care. By embedding these 
practices, the programme promotes consistency, improves communication, and 
enables staff to spend more time delivering direct, person-centred care. The program 
reports into our executive board and is supported by a set of metrics that 
demonstrates each areas compliance against the standards. 

The Trust operates a 24/7 clinical site model with experienced senior nurses on site 
at all times. This model supports oversight of patients with learning disabilities 
supporting clinical teams to deliver care with specific responsibility for auditing 
practice in line with expected standards The clinical site matron team have oversight 
during the out of hours and weekend periods with ward and department Matrons 
assuming this responsibility in hours. 

As an early adopter of Martha’s Rule we are progressing this across adult and 
children’s services to ensure that patients families and carers are able to escalate 
safety concerns for an immediate review and response from a clinical team. The 
Trust is undertaking continuous evaluation and is part of the national and regional 
programme of work and research for this important initiative. 

We have already identified through our enhanced audit program that changes are 
needed to the current learning disability care plan. 
Chief Nursing Information Officer and stakeholders across Bradford and Airedale, 
who share our clinical record system, to revise the content and approach to 
completion of this care plan. This will be supported through a training program that 
clearly describes expectations for completion. Once the care plan is live in our 
electronic patient record the results will be added to our quality assurance dashboard 
for oversight and action. 

is working with our 

 
 
 
 
 
 
 Although we have a robust Mental Capacity Act policy that is aligned to national 
standards, we recognise that this needs strengthening in relation to the application of 
principles 1 and 2. This will be reinforced through training and monitored through the 
revised audit program which will focus on the 3 key principles in relation to this.  

Assurance and audit  

We have an extensive audit program that audits standards of care for patients with a 
learning disability aligned to national standards and toolkits. These audits are 
reported into board through various sub committees of the board.  

In September 2024, the Chief Nurse commissioned an external audit by Audit 
Yorkshire to evaluate systems and processes for managing adult patients with a 
learning disability, with a particular focus on A&E waiting times and readmission 
rates. The audit returned an overall opinion of significant assurance, recognising the 
Trust’s strong monitoring of health inequalities data for people with learning 
disabilities. 

An internal audit followed in April 2025, specifically examining themes and trends 
related to learning disabilities. This provided further assurance of good practice, 
while also identifying areas for improvement. Additionally, a Thematic Review of all 
incidents involving patients with learning disabilities between March 2023 and 
September 2024 revealed that 1% of all reported incidents related to this patient 
group. Further learning was identified through deep dives into falls, nutrition, and 
pressure ulcer cases, which are now informing targeted improvement work. 

The Trust has also undertaken deep dive audits into emergency and acute care, 
mortality rates, and DNA (Did Not Attend) appointments for patients with learning 
disabilities. These findings have led to further improvement initiatives and 
collaborative work with West Yorkshire Association of Acute Trusts (WYAAT), 
particularly around reviewing neurology services to ensure the needs of people with 
learning disabilities are appropriately addressed. 

We recognise through this process that audits in real time are required to address 
issues and provide ongoing assurance that the care is delivered in line with local and 
national standards. As highlighted in Ms McKie’s evidence, senior nursing leadership 
reviews now take place every weekend across both Huddersfield and Calderdale 
hospital sites. These reviews provide assurance that sustained improvements are 
being made.  

Through a standardised audit process (incorporating the national 15 steps challenge 
of seeing care through patient and relative eyes) and direct ward engagement, 
nursing leaders verify compliance with legal and regulatory standards, ensure 
consistent use of care plans and hospital passports, and promote timely 
administration of critical medications for patients with a learning disability. This 
provides the opportunity to resolve any issues identified at the point of care with 
feedback given in real time to the team involved.   

 
 
 
 
 
 
 
 
 
 
 A more detailed audit is undertaken for patients with a learning disability on a weekly 
basis that provides an in-depth review of the care being delivered, focusing on 
patient, family and carer involvement and evidence of a senior review and 
implementation of any specialist recommendations. The findings from these audits 
will be discussed at the monthly Quality Assurance Group as well as the Learning 
Disabilities Group. 

We are developing a monthly audit that will focus on application of the mental 
capacity act for patients with a learning disability that will be undertaken by our 
medical lead for learning disabilities and nurse consultant. This audit will be 
managed through existing governance structures but importantly will be used as an 
opportunity to recognise themes and trends and address practice at an individual 
level.  

Training 

The Trust has implemented the national Oliver McGowan mandatory training 
programme which is over a three year cycle.  

To date, 91.83% of staff have completed Part 1 training via the e-Learning for Health 
platform. 

Part 2 (Tier 1) webinar and (Tier 2) face-to-face training is underway, with structured 
evaluation captured at the point of delivery. A mid-programme audit is planned to 
ensure staff understanding and confidence, with any persistent gaps escalated to the 
national oversight body. 
 is supporting the identification of key individuals 
with responsibility for leadership and oversight of care deliver for priority places on 
this training. 

We are enhancing the Learning Disabilities and Mental Capacity Act training into 
Trust induction and preceptorship training for all staff groups and reviewing the 
existing training offer in Safeguarding and other training sessions that can should 
reference learning disability awareness. We recognise that this area requires 
ongoing focus and attention and are developing an approach to learning that will be 
delivered in the clinical setting such as bite sized learning and 7-minute briefings.  

Scenario based approaches will also be adopted for our learning disabilities 
champions supported through robust clinical supervision. 

Since the conclusion of the inquest, the Trust has undertaken a further self-
evaluation through a Quality Summit. We are committed to ensuring that there is a 
continued focus on the additional learning identified through Myles case. We will be 
flexible and adaptive in our approach to ensure an appropriate response to 
continuous improvement.     

As part of that commitment, we will provide you and the Senior Coroner with a 
further update in six months to share progress and developments. 

 
 
  
 
 
 
 
 
 
 
 Should you require any further clarification or additional information, please do not 
hesitate to contact me. 

Yours sincerely, 

Executive Medical Director