Jacqueline Aarons

Parliamentary Under-Secretary of State 

39 Victoria Street  
London  
SW1H 0EU  

12 January 2026 

HM Coroner Andrew Walker 
Northern London 
Barnet Coroner’s Court 
29 Wood Street 
Barnet, EN5 4BE 

Dear Andrew Walker 

Thank you for the Regulation 28 report of 13 November 2025 sent to the Department of 
Health and Social Care about the death of Jacqueline Aarons. I am replying as the 
Minister with responsibility for disabilities.        

Firstly, I would like to say how saddened I was to read of the circumstances of Miss 
Aarons’ death, and I offer my sincere condolences to her family and loved ones. The 
circumstances your report describes are concerning and I am grateful to you for bringing 
these matters to my attention.  

The report raises concerns about the threshold at which patients with learning disability 
are admitted to hospital; the requirement for in-person consultations with a doctor; and the 
provision of safety netting advice for those with caring responsibilities who are not 
medically trained.    

In considering your report, officials within the Department of Health and Social Care have 
made enquiries with NHS England and concluded that these concerns are more 
appropriately addressed by NHS England directly. I am advised that NHS England will 
therefore provide you with a full and comprehensive response on the concerns you have 
raised.  

I hope this response is helpful.   

Yours sincerely  

PARLIAMENTARY UNDER-SECRETARY OF STATE 
FOR HEALTH INNOVATION AND SAFETY

Mr Andrew Walker  
Senior Coroner for North London 
Barnet Coroner’s Court 
29 Wood Street 
Barnet  
EN5 4BE  

Co-National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

8 April 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Jacqueline Aarons who 
died on 19 November 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  13 
November 2025 concerning the death of Jacqueline Aarons on 19 November 2024. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Jacqueline’s family and loved ones. NHS England 
are keen to assure the family and yourself that the concerns raised about Jacqueline 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Jacqueline’s family or friends. I realise that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them.  

Your report raised concerns around the following:  

1.  The  need  for  recognised  lower thresholds  for hospital admission for patients 

with learning disability  

2.  The need for face-to-face consultations by a doctor  
3.  Following any consultation, there should be written instructions including safety 
netting advice, set out in such a way that they may be understood and acted 
upon by staff who may not be medically trained.  

Recognised lower thresholds for hospital admission for patients with a learning 
disability 

It  is  recognised  that  people  with  a  learning  disability  experience  significant  health 
inequality, including diagnostic overshadowing and reduced life expectancy. They do 
not  always  express  symptoms  of  pain  or  disease  in  ways  similar  to  other  people 
because of challenges in communication or understanding of physical signs affecting 
their body. They may not act upon discomfort, pain, or distress. This is more likely in 
autistic people with or without a learning disability. Family and paid carers may not be 
aware of the subtle signs of distress in the person with a learning disability.  

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 The use of the Modified Early Warning Score (MEWS) can support earlier identification 
of  clinical  deterioration  by  providing  an  objective  measure  of  physiological  change. 
While  MEWS  is  not  a  substitute  for  clinical  judgement,  it  can  act  as  an  important 
adjunct  in  decision  making  for  people  with  a  learning  disability,  particularly  where 
communication difficulties or atypical presentations may mask severity of illness. 

This approach is consistent with   Learning from Lives and Deaths  – People with a 
Learning Disability and Autistic People (LeDeR), which highlights the need for earlier 
recognition, timely escalation, and proactive responses to physical health concerns to 
reduce avoidable deaths and health inequalities. 

For these reasons, a lower threshold for clinical assessment in hospital is warranted. 
In  addition,  expert  clinical  in-put  from  a  Learning  Disability  Physician  would  assist 
front-line clinicians in formulating care plans for the people with learning disability and 
Autistic people.  

Face to face consultation by a doctor 

The importance of face-to-face clinical assessment by a doctor is acknowledged for 
people  with  a  learning  disability  where  there  are  concerns  about  deterioration, 
uncertainty in presentation, or escalation of risk. 

Given  the  known  challenges  of  diagnostic  overshadowing  and  atypical  symptom 
presentation,  in  person  consultation  allows  for  a  more  comprehensive  assessment, 
including  physical  examination,  observation,  and  holistic  consideration  of  the 
individual’s  baseline  functioning.  This  is  particularly  important  where  remote 
consultation may limit accurate assessment or where nonverbal indicators of distress 
or illness may be present. 

This  approach  supports  safer  clinical  decision  making  and  reflects  best  practice  in 
delivering reasonable adjustments to ensure equitable access to healthcare. 

 Written instructions and safety netting advice following consultation 

Following any consultation, clear written instructions and safety netting advice should 
be provided. These instructions must be set out in a way that can be understood and 
acted  upon  by  staff  who  may  not  be  medically  trained,  including  carers,  support 
workers, and residential staff. 

Written guidance should: 

• 
• 
• 
• 

• 

Clearly describe what symptoms or changes to look out for 
Specify when and how to seek urgent medical help 
Use plain language and avoid unnecessary medical terminology 
Be  tailored  to  the  individual’s  communication  needs  and  level  of 
understanding 
Be copied to the person’s GP 

 
 This is essential to ensure continuity of care, reduced reliance on verbal recall, and to 
support timely escalation if the person’s condition worsens. 

Workforce  capability  in  this  area  is  supported  through  initiatives  such  as  the  Oliver 
McGowan  Mandatory  Training,  which  aims  to  improve  staff  knowledge,  skills,  and 
confidence  in  providing  safe,  compassionate,  and  appropriately  adjusted  care  for 
people  with  a  learning  disability  and  autistic  people.  The  functions  of  the  Learning 
Disability Physician and Liaison Nurse in Learning Disability support enhanced clinical 
practice of front-line clinical staff in hospital services and in primary care services. 

I  would  also  like  to  provide  further  assurances  on  the  national  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 
Jacqueline 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