Amanda Wood

NH.

Tameside and Glossop
Integrated Care
NHS FoundationTrus

Chief Executive Officer
Tameside and Glossop Integrated Care NHS Foundation Trust
Silver Springs Building
Ashton-under-Lyne
OL6  9RW

6 March 2026

Private and confidential
To be opened by the addressee only
FAO Mr Morris
Manchester South Coroner’s Court
1 Mount Tabor Street
Stockport
Cheshire
SK1 3AG

Dear Mr Morris,

Firstly, on behalf of the Trust, I would like to express my sincere condolences to Mrs. Wood’s
family fortheir loss.

Following  the  inquest  on  7th October  2025,  I  note  that  you  raised  concerns  around
documentation, specifically no  documentation around  sepsis screening prior to  Mrs  Wood’s
discharge from the Emergency Department (ED) on 28 th December 2024.

Firstly, it is  important to  note  that when  patients present to the  Emergency Department they
are  triaged  in  line  the  Manchester Triage  System, which  is  a  clinical risk  management tool
used by clinicians worldwide to enable them to safely manage patient flow when clinical need
far  exceeds  capacity.  The  triage  system  categorises  patients  in  order  of  priority  and  all
patients attending the ED  should be triaged, or initially assessed, within 15  minutes. As part
of this triage, observations are taken using the  National Early Earning Score (NEWS) which
is  a  tool  developed  by  the  Royal  College of  Physicians  which  improves the  detection  and
response to  clinical deterioration in adult patients and  is a  key element of patient safety and
improving  patient  outcomes.  Mrs.  Wood  scored  a  NEWS  of  1  and  was  categorised  as  a
category 3 at the point of triage which therefore did not trigger the sepsis pathway and was in
line  with  the  sepsis  policy.  A  sepsis  screen  would  not  be  repeated  prior  to  discharge,  the
treating consultant will review the patient based on their observations and NEWS2.

As mentioned in the evidence of the ED Consultant during the inquest, it was noted that there
were  no  other  documented  notes  regarding  this  attendance on  28 th December  2024.  The
documentation is not to the standard I would expect. I have spoken to the individual concerned
about their documentation and  they  have  reassured me  that  this  has  improved and  detailed
records are  now  being completed in line with their usual practice. It has also  been escalated
through their appraisal process.

 Tameside and Glossop
Integrated Care
NHS Foundation Trus

All  staff  in  the  Trust  are  aware  of  the  importance of  documentation, which  you  will  know  is
governed by both the Nursing and Midwifery Council Code (2018) and by the General Medical
Council. This  is  instilled in  staff  from  the  point  of  induction and  throughout regular teaching
sessions  at  divisional  meetings  held  throughout  the  year  like  the  junior  doctor  induction,
Patient  and  Staff,  Quality  &  Safety  Forum  (PASQASF),  specialty meetings  as  well  as  the
Legal  Conference in  September 2025.  Additionally, there have  been  seven-minute briefings
disseminated Trust wide dealing with the importance of documentation, in July and November
2025.

The  learning  around  this  inquest  and  your  concerns specifically on  documentation was  an
agenda  item  for  both  Patient  and  Staff,  Quality  &  Safety  Forum  and  the  Urgent  and
Emergency Care  Quality and Safety Meeting both on  17 th December 2025. These meetings
were  attended by  Divisional Management, clinicians and  nursing staff. In  addition, the  Trust
conducts  weekly  training  sessions for  middle  grade  doctors in  the  Emergency Department
every  Thursday  and  documentation  was  a  January  2026  agenda  item.  Training  is  also
delivered to junior doctors at their induction.

However, the  Trust  has  observed that  improvements are  required to  documentation, which
will  be  overseen  through  the  bi-monthly  Clinical  Effectiveness  Group  which  is  chaired  by
myself and is attended by the Chief Nurse, Deputy Chief Nurse, Associate Medical Directors,
Divisional  Nursing  Directors,  Clinical  Directors,  Divisional  Director’s  and  the  Deputy  Chief
Operating Officer. Through this  group,  I  am  commissioning a  doctors’ documentation audit
that  will  cover all  aspects of  documentation including ward  rounds, post-take and  discharge
documentation which will be undertaken in summer 2026. As the Trust is currently compiling
its annual audit programme, documenting the National and local audits that will be undertaken
in  2026/27, the  doctors’  documentation audit  will  form  part  of  that  audit  programme.  This
audit programme will be reviewed at the Trust’s non-executive led Quality Committee in April
2026.

In  the  meantime,  the  Emergency  Department  nursing  Team  Leader  completes  daily
documentation  audits  which  have  Matron  oversight,  and  any  poor  compliance  is  actioned
immediately  at  the  time  of  the  audit  Formalised  handover  documentation  has  also  been
implemented to ensure consistency in the handover of patient care and management plans.
The  Standard Operating Procedure has  been  updated to  guide the  assessment of  patients
being cared for in non-patient escalation areas (NPEA), to include an individual documented
risk  assessment and  a  team  leader checklist. Furthermore, practice-based educators have
redesigned the intentional rounding checklist.

In November/December 2025, an audit of 35 patients nursed in non-patient escalation areas
(NPEA)  of  the  Emergency Department was  conducted. This  included  reviewing notes  and
nursing  documentation  for  35  patients,  focusing  on:  A-E  assessment,  patient  safety
checklists,  nutrition  and  hydration,  body  map  and  skin  integrity,  NEWS2  policy  followed,
documentation of wristbands and personal hygiene needs. Whilst the electronic patient safety
checklists are finalised by clinical informatics, the Clinical Practice Educator has developed a
new  patient safety  checklist  document to  ensure  all  disciplines can  record  essential  safety
checks consistently, while maintaining registered nurse oversight and  accountability.

 NH

Tameside and Glossop
Integrated Care
NHS Foundation Trus

This audit has identified several challenges with documentation, particularly as patients are
moved from high-pressure areas such as Rapid Assessment and Ambulatory Majors, where
the high volume and rapid turnover of patients often result in minimal initial documentation.
To address these challenges, several measures have been implemented including the new
patient  safety checklist in  the  NPEA. Matrons' walk-arounds  have been revised  to  provide
focused oversight on documentation quality and adherence to standards. The documentation
audit process has also been redesigned, with responsibility assigned to the Band 7 nurse on
both day and night shifts to maintain accountability and drive improvement In addition, clear
documentation  reminders  have  been  placed  on  every  nursing  computer  to  reinforce
expectations and support staff.

I do hope that this letter provides you with further  reassurance, however, should you have
any queries arising from the content of this letter or require further information or clarification,
please do not hesitate to contact Legal Services on

Yours sincerely

Chief Medical Officer and Caldicott Guardian
On behalf of 
Tameside and Glossop Integrated Care NHS Foundation Trust

 (Chief Executive Officer)