Derek Crowther

Corporate Legal Services
Trust Headquarters
225 Old Street
Ashton Under Lyne
Lancashire
OL6 7SF

3 December 2025 

Private & Confidential 
Christopher Morris  
HM Area Coroner 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG 

Dear Mr Morris, 

RE: Inquest touching on the death of Derek Crowther  

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation 
Trust  (PCFT)  and  the  issuing  of  a  Prevention  of  Future  Deaths  Notice  (Regulation 
28), arising from the inquest into the death of Derek Crowther.  

May  I  take  this  opportunity  to  extend  my  own  condolences  to  the  family  of  Mr 
Crowther  and  apologise  that  you  had  to  raise  concerns  relating  to  the  services  he 
accessed prior to his sad death.  

The  Trust  sets  out  its  response  to  the  points  below  raised  by  HMC’s  as  areas  of 
concern: 

1.  The Court heard evidence that a registered nurse working on the Unit at 
the  time  of  Mr  Crowther’s  death  was  not  up to  date  with  Immediate  Life 
Support  (‘ILS’)  training,  despite  this  being  termed  ‘mandatory’.  Having 
heard  evidence  from  the  Trust’s  Clinical  Excellence  Lead  for  Older 
Peoples’  Services,  I  am  concerned  that  instances  continue  to  arise 
across the Trust whereby clinical staff are undertaking shifts despite not 
being up to date with the required level of Life Support training. 

At  Mr  Crowther’s  inquest  you  heard  evidence  from  the  Trust’s  Clinical  Excellence 
Lead  for Older People  that  staff  member  trained  in  Immediate  Life  Support (ILS)  is 
present  on  all  shifts.  As  you  have  noted,  this  forms  part  of  the  mandatory  training 
requirements  for  staff  working  within  all  Healthcare  settings.  Ideally,  staff  would 
receive  refresher  training  before  the  expiry  of  their  existing  competency,  meaning 
that  their  compliance  was  continuous.  It  is  recognised  that  this  may  not  always  be 
possible and so NHS organisations are able to agree a tolerance or target threshold.  

The  Trust  recognises  the  critical  importance  of  ensuring  staff  are  appropriately 
trained  to  respond to medical emergencies and  has  taken  further action  to mitigate 
risk and improve compliance rates. It also acknowledges the risk associated with non  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 compliance  and  availability  of  training,  which  is  overseen  within  our  Resuscitation 
Committee but also reported as part of our management structures and governance 
meetings.  

The  Trust  has  increased  its  Trust  wide  compliance  target  to  85%.  This  figure  has 
been benchmarked against other NHS Trusts and is understood to be at the higher 
end  of  expectation  for  Mental  Health  organisations.  To  support  reaching  this 
increased  compliance  rate,  training  uptake  is  monitored  via  the  mandatory  training 
dashboard and reported through divisional governance to the Care Quality Oversight 
Group.  The ILS training  compliance  for inpatient  ward  staff  is currently  between  73 
and  74%.  While  we  acknowledge  this  is  below  our  revised  target,  we  continue  to 
work hard to improve this, with the oversight of our Trust Board.  

Increased  training  capacity  has  been  created  by  ensuring  additional  ILS  training 
sessions  have  been  made  available.  This  has  increased  capacity  and  reduced 
waiting  times  for  staff  who  need  to  book  onto  available  training.  Timetabling  of 
training has been adjusted to improve access for ward-based staff. The Trust is also 
addressing  non-attendance  on  ILS  training,  which  is  recognised  to  impact  on 
compliance  rates.  Non-attendance  on  a  booked  courses  is  escalated  to  Ward 
Managers and Network Quality Leads to support awareness but also understanding 
of the underlying causes or reasons why staff could not attend as planned.  

ILS  compliance  is  being  incorporated  into  ward  rota  planning  to  ensure  wards  are 
appropriately  staffed  whilst  simultaneously  releasing  those  staff  who  require 
refresher training, which will in turn lead to an increase in compliance.  The Trust is 
extending  ILS  training  to  additional  clinical  staff  groups  such  as  Bank  staff  and 
trainee doctors to increase resilience and the number of ILS trained staff present on 
the ward on a shift. 

Each  ward  is  required  to  have  at  least  one  ILS  trained  member  of  nursing  staff  on 
every  shift,  including  nights  and  weekends.  Compliance  with  this  requirement  is 
monitored daily through Safer Staffing meetings, with escalation where gaps arise to 
ensure an ILS trained staff member is available for all shits on every inpatient ward 
across the Trust.  

The  Trust  acknowledges  your  concerns  and  is  committed  to  ensuring  safe  staffing 
and prompt emergency response capability across all inpatient settings. The actions 
set  out  above  provide  immediate  mitigation  whilst  longer-term  improvements 
continue to strengthen the ILS cover on the wards.  

2.  Whilst  the  Court  heard  evidence  as  to  relevant  changes  made  to  the 
Trust’s  Observations  Policy  since  Mr  Crowther’s  death,  I  am  concerned 
that  despite  having  an  Electronic  Patient  Records  system,  there  is 
currently  no  mechanism  in  use  on  the  wards  for  contemporaneous 
digital recording of observations. I am concerned that an ongoing risk of 
future  deaths  arises  from  this  position,  in  the  view  of  the  potential  for 
such systems to accurately record timings of observations, facilitate  

 
 
 
  
 
 
 
 
 
 trend analysis (particularly in the context of a deteriorating patient), and 
reduce  the  potential  for  errors,  either  arising  from  incorrect  /  unclear 
manual recording of observations 

The  Trust  has  undertaken  some  focused  improvement  work  on  therapeutic 
observations of care, from December 2024 into the spring of 2025. This was led by 
our  Deputy  Director  of  Nursing,  Quality  and  AHP’s  and  informed  by  nationally 
indicated  best  practice  and  published  guidance.  This  included  the  creation  of  a 
policy, and the development of a targeted training course which was supported by an 
implementation  plan  for  staff  to  deliver  this  at  scale  and  pace,  within  the  individual 
care areas.  

This  method  of  delivery  was  intended  to  maximise  staff  attendance  and  was 
coordinated as part of a ‘focus week’, in which there was increased communications 
about the policy, requirements and methodology. This approach also allowed for our 
temporary workforce to be included in this.   

The Trust also established an Enhanced Therapeutic Observations of Care (ETOC) 
Task and Finish Group in March 2025. One of the workstreams within that group is 
the  development  of  an  electronic  observations  (eObs)  app.  This  response  will 
provide  additional  information  pertaining  to  that  workstream  in  addition  to  the 
information  provided  previously  regarding  the  broader  work  of  the  group  around, 
policy,  training,  culture  and  improvement.  The  development  of  an  eobs  app  is  just 
one  element  of  that  workplan.  The  build  and  configuration  work  has  began  on  the 
app. This will be ready for testing by March 2026 and pilot of the app commenced in 
April  2026.  At  this  stage  we  are  unable  to  give  a  full  implementation  go  live  date 
Trust  wide  but  can  update  you  in  our  progress  as  the  pilot  progresses  and 
concludes.  

I was sorry to learn that the Clinical Excellence Lead attending Mr Crowther’s inquest 
was  not  aware  of  these  developments  whilst  he  gave  evidence,  as  this  may  have 
provided you with the assurance of action that you were seeking. I understand that 
steps  have  been  taken  to  ensure  this  is  communicated  effectively  to  them  directly, 
but  also  reviewing  the  ways  in  which  this  progress  can  be  shared  with  staff  more 
broadly as we approach the testing phase of this process. We are working with our 
digital  team  we  have  set  April  ’26  as  a  realistic  date  that  we  can  deliver  a  pilot  on 
eObs.  

We understand a question was asked in relation to the eObs app in place at Greater 
Manchester  Mental  Health  NHS  Foundation  Trust  (GMMH)  and  the  ability  for  the 
Trust  to  adopt  this.  Whilst  GMMH  has  been  able  to  implement  therapeutic 
observations  on  some  of  their  wards,  which  had  Wi-Fi  upgrades,  there  are 
challenges  still  with  their  coverage.  GMMH are  currently  not  utilising  'offline' 
capability, which has been identified as key requirement for our e-Obs solution, given 
feedback  to  date  and  the  lessons  that  have  been  learnt  at  GMMH.  Without  'offline' 
capability we cannot guarantee that should there be a drop in Wi-Fi connection; data 

 
 
 
 
 
 
 
 
 
 integrity  would  be  maintained.  We  are  working  closely  with  colleagues  at  GMMH, 
sharing  learning  and  progress  to  inform  our  project  and  ensure  we  are  able  to 
implement an effective system at PCFT.  

I hope that the information within this response has provided you with the assurance 
that you were seeking in relation to learning from these events. Should you require 
any  further information  or clarification  on  the  details  within  this letter, please do  not 
hesitate to get in touch with me again.