Joan Talbot

Assistant Coroner Liliane Field,   
London Inner South Coroner’s Court 
1 Tennis Street,  
London  
SE1 1YD 

SENT BY EMAIL ONLY 

23rd December 2025 

Denmark Hill 
SE5 9RS 

Dear Assistant Coroner Field,  

Response to Regulation 28 Report to Prevent Future Deaths: Mrs Joan Talbot 

We  are  grateful  to  you,  for  bringing  matters  of  concern  to  the  attention  of  King’s  College  Hospital  NHS 
Foundation  Trust  (the  Trust),  through  your  Regulation  28  Prevention  of  Future  Deaths  report  dated  11th 
November 2025 (PFD).  This was a very sad case, and the Trust wishes to express its sincere condolences to 
the family of Mrs Talbot.  The Trust has given careful and thorough consideration to the concerns you have 
raised, and its formal response is set out below. 

Your summary and recommendations were as follows:  

“ In many respects, the Trust has moved on in a positive way from the systems in place at the time when Mrs 
Talbot was under its care. The functions of EPIC outlined by 
 clearly have the potential to improve 
continuity of care. However, setting aside the training in EPIC necessitated by its introduction, it is not clear 
that training has evolved at the same pace or reached all those who need it. As 
 has pointed out, 
the standards 
 referred to in her statement should have been in place at the time. 3 17. I do not feel 
it would be proportionate to defer my decision on this issue in order to ask the Trust to provide the further 
 for the simple reason that I have been left with the overall impression that, 
evidence suggested by 
despite having the tools with potential to help improve continuity of care between different admitting teams 
in patients with multiple admissions, the Trust has not taken the additional necessary step to ask itself how 
these tools can be used most effectively in this specific scenario, whether further refinements to the existing 
systems  and  processes  may  be required  and  therefore  what  further  targeted training  may  be  necessary  to 
support healthcare professionals, as well as how to evaluate the effectiveness of these tools. Their effectiveness 
appears to be assumed.” 

Patient safety and quality are central priorities for the Trust.  Accordingly, the issues highlighted in the PFD 
have been subject to thorough review by both the Patient Safety Team and the Executive Team. 

The  Trust  has  further  considered  the  PFD  in  collaboration  with  colleagues  at  Guy’s  and  St  Thomas’  NHS 
Foundation Trust (GSTT), recognising that all EPIC-related development and configuration is undertaken on a 
cross-Trust basis following the joint procurement of the EPIC electronic patient record system.  Since EPIC Go-

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Live in October 2023, a number of quality improvement pieces of work  have been undertaken to improve 
patient safety & quality, through an initial ‘stabilisation phase’ of urgent work, followed by an ‘optimisation 
phase’ of improving functionality across a number of domains. We are conscious that further improvements 
are required and we are not complacent with regard to pace and scope of this work. Improvements in medical 
notes documentation commenced over the last few months, in particular a ‘Problem List Etiquette Guide’ has 
been produced, which outlines expectations for the use of problem lists and associated documentation fields.  
Although the referenced problem list functionality was not yet deployed at the time of the incident (as the 
previous electronic patient record system was still in operation), the Trust  acknowledges there is scope to 
enhance  both  EPIC’s  documentation  capabilities  and  the  guidance  provided  to  clinicians  regarding  its  use. 
Therefore,  in  response  to  the  concerns  raised,  the  Trust  has  committed  to  establishing  a  cross-Trust  EPIC 
Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and 
monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality 
improvement initiatives.  The drafting of the DQG’s terms of reference has specifically addressed the matters 
raised  within  the  PFD,  ensuring  that  the  DQG’s  work  programme  is  both  data-driven  and  aligned  with 
identified risks. Subject to final approval, it is anticipated that the DQG will be operational from early 2026 and 
will report through existing EPIC governance and oversight structures.  The draft terms of reference can be 
found in Appendix 1 (attached). It is planned to signed off the scope and membership of the meeting across 
both Trusts in January. In the meantime, the Problem List Etiquette Guide will be tabled and discussed at the 
Clinical Directors Meeting and the Governance Lead Forum in early 2026 so that learning in relation to the PFD 
can be facilitated.   

We  trust  that  this  response  provides  assurance  that  the  matters  raised  in  the  PFD  have  been  carefully 
considered and that appropriate actions are being taken to reduce the risk of similar incidents occurring in the 
future.    The  Trust  will  continue  to  monitor  the  effectiveness  of  these  actions  through  its  established 
governance and reporting arrangements. 

Should you require any further information or clarification in relation to this response, the Trust would be 
pleased to provide this. 

Yours sincerely, 

Chief Executive  

 
 
 
 
 
 
 
 
 
 Appendix 1 

Medical Documentation Quality Taskforce 

Problem: 
Poor quality medical documentation has several important consequences: 

1.  Patient safety 

A recent Prevention of Future Deaths notice issued to KCH has highlighted the utilisation of problem lists 
as a mechanism to deliver continuity of care across multiple admissions. While the incident in question 
took place before the implementation of Epic, there is a requirement that the trust now examines whether 
the relevant tools available in Epic are being used optimally. 

2.  Suboptimal coding 

While improvements in coding should not be the only goal of driving change in clinician behaviour, there 
is no doubt that improved documentation quality will also lead to benefits in coding depth and accuracy; 
this has been demonstrated in other Epic organisations. Additionally, future AI tools will depend on the 
accuracy and completeness of the medical record in generating useful and safe outputs. 

3.  Poor clinician experience 

The  problem  of  information  overload  in  Electronic  Health  Records  is  recognised  to  be  an  important 
contributor to EHR-related clinician burnout. Across GSTT and KCH clinicians are spending more time in 
notes and making less use of charting efficiency tools than in most other UK Epic sites. 

Most clinicians can describe ways in which documentation falls short, but there has been no systematic 
effort to define best practise and target quality improvement. Problem areas include: 
1.  Excessive use of copy/paste leading to ‘note bloat’ and difficulty identifying key new content. The use 

of copy/paste is greater at GSTT and KCH than most other UK Epic organisations 

2.  Care plans are often out of date if copied forward from previous entries 
3.  Poor use of tools summarising active problems during inpatient episodes, and patchy use of problem 

lists which span across episodes of care 

4.  Key discussions and assessments are often not recorded, and relayed verbally or using handover tools 

instead 

Aims and objectives: 
1.  Agree  in-Epic  metrics  and  audit 
standards to baseline quality and 
track impact 

2.  Engage with residents and senior 
clinicians  to  identify  barriers  to 
best practise 

Potential  in-Epic  metrics  include  use  of  copy/paste,  note 
length,  %  problem  lists  reviewed  within  first  72h  of 
admission, number of problems created 

3.  Oversee build changes within Epic 
facilitate  quality 
to 

which  will 
improvement 
navigators, note templates etc) 

(changes 

Recent  changes  in  the  Critical  Care  ward  round  template 
promise  to  drive  improvements  in  problem  list  accuracy: 
this  will  be  monitored  and  implemented  elsewhere  if 
successful.  
inpatient 
UCLH  has 
documentation  workflow  which  have  brought  about  in 
increase in the proportion of problem lists updated daily. 

introduced 

changes 

the 

to 

 
 
 
 
 
 
 
 
 
 
 4.  Design  and  oversee  broader 
quality improvement projects 

5.  Review  current  EPIC  teaching  & 

training  

Engage with QI Fellows in both trusts. Targeted areas such 
as  Medicine,  Maternity,  Critical  Care  before  widespread 
roll-out 

Ensure that the audit end-points are adequately covered in 
current  induction  /  other  training.  Update  materials  to 
cover the completed build changes 

Proposed membership (cross-Trust): 

Interested Clinical Directors 

•  Medical Information Officers/representatives 
• 
•  Chief Specialist Registrars  
•  Analyst support (Orders) 
•  Patient Safety / Quality and Assurance / Governance representative(s)