Patricia Walker

Dear Assistant Coroner Robinson 

Our Ref: LS/KD/240326/L1 

24 March 2026 

Strictly Private and Confidential 
Miss Sally Robinson 
East Riding and Hull Coroners 
The Guildhall 
Alfred Gelder Street 
Hull 
HU1 2AA 

Hull Royal Infirmary 
Anlaby Road 
Hull 
HU3 2JZ 

Email:

Regulation 28 Report to Prevent Future Deaths – Mrs Patricia Irene Walker 

Thank you for your Regulation 28 Report to Prevent Future Deaths dated 27 January 2026, 
issued following the inquest into the death of Mrs Patricia Irene Walker.  

We again express our sincere condolences to Mrs Walker’s family. 

We recognise the Coroner’s concern that staffing on Ward 90 was sub-optimal due to 
recruitment difficulty, meaning that “TAG nursing care is not always possible” and that patients 
are therefore at increased risk of falls.  

While the concern is identified in relation to Ward 90, the Trust agrees that safe nurse staffing 
and the ability to deliver consistently high standards of fundamental care is a Trust-wide patient 
safety priority, particularly across inpatient wards where acuity, dependency and operational 
pressures have increased. 

1)  Summary of the Trust-wide actions taken 

The Trust has established daily operational controls to mitigate staffing pressures in real time. 
Daily staffing meetings take place across all sites, where ward-level escalations relating to 
actual versus planned staffing, changes in acuity, and red flag indicators are reviewed by 
dedicated staffing representatives. These representatives cover all Trust sites, providing a 
consistent view of risk and enabling rapid redistribution of workforce to the highest priority 
areas.  

Information from these meetings feeds directly into twice-daily Trust-wide safe staffing meetings 
chaired by a Nurse Director, providing senior clinical oversight of staffing gaps, mitigations and 
risk management. Subject matter specialists in enhanced care attend to advise on patients 
requiring enhanced observation, specialling or alternative care models, and site matrons attend 
to ensure alignment between staffing decisions, patient flow and operational pressures.  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Out of hours, staffing escalations are directed to site matrons who provide senior clinical 
leadership 24 hours a day, 7 days a week, and who review and authorise redeployment, 
temporary staffing requests and enhanced care arrangements during evenings, nights and 
weekends, ensuring continuous oversight and rapid response to any deterioration in staffing 
levels or patient acuity outside core hours. 

In addition to the above, as part of a wider programme to strengthen safe staffing and reduce 
reliance on temporary mitigation, the Trust (as part of Humber Health Partnership) has 
undertaken a comprehensive safer staffing establishment review using recognised safer staffing 
tools (including the Safer Nursing Care Tool census approach) and triangulation with patient 
outcomes.  

This work identified: 
•  There is a gap between baseline establishments and assessed requirements across 

inpatient areas (predominantly on the Hull Royal site), emergency departments, and some 
community nursing services when assessed against the available safer staffing tools; and 
that the Trust is in the bottom quartile nationally for CHPPD.  
a structured RAG prioritisation of areas for investment, using professional judgement and 
outcome triangulation. 
that funding the “red” areas would require investment, equating to 123.82 WTE, and that 
this is intended to support safer care delivery and reduce premium “bad cost” spend by 
moving to substantive recruitment where possible. 

• 

• 

The review findings and recommendations were considered by the Trust Boards-in-Common, 
and the Boards approved the nursing establishment investment, including funding for red-rated 
areas as a priority for patient safety. 

The Boards further agreed that, where the investment enables substantive recruitment into 
specific areas, bank and agency usage should reduce accordingly and will be monitored, with 
clear accountability where usage increases again. 

2) Trust-wide approach to reducing falls risk and strengthening fundamental care 

delivery 

The Trust recognises that low staffing levels and skill mix gaps can directly affect the ability to 
provide consistent fundamental care (including observation, rounding, toileting support, and 
timely response), which in turn can increase falls risk for frail patients. 

Accordingly, the Trust-wide programme includes: 
•  Targeted investment in inpatient wards (prioritised via RAG) to strengthen day and night 
staffing, particularly non-registered workforce where gaps drive reliance on short-term 
mitigations. 

•  Reducing inappropriate 1:1 mitigations: the paper notes use of security bed watch staff for 
patients requiring one-to-one supervision, acknowledging this can be inappropriate and 
linked to reduced non-registered nursing capacity; the intention of investing in the non-
registered workforce is to reduce reliance on this mitigation and improve patient experience.  

•  Standardised oversight of enhanced observation: all patients requiring security bed watch 

are assessed every 24 hours by a specialist registered nurse (7 days/week), with support to 
clinical areas to ensure patients are cared for in the most appropriate way.  

 
 
 
 
 
 
 
 •  Strengthened staffing governance and assurance: the review work included an assurance 

site visit by the Regional NHS England team at Hull Royal Infirmary in November 2025, who 
were assured by the safe staffing processes undertaken to identify staffing requirements 
and recommendations.  

3)  How this addresses the Ward 90 concern 

While the Trust’s actions are Trust-wide and intended to improve safety across multiple 
wards/services, the approved investment recommendations do include Ward H90, which is 
identified as SNCT Red with a recommended uplift the number of Health Care Assistant 12 
hours per day.).  

We hope this provides assurance that the Trust is not only addressing safe staffing at system 
level but is also implementing targeted improvements in the frailty ward setting relevant to the 
concerns. 

4)  Timetable for implementation (Trust-wide programme) 

The Trust-wide programme will be implemented on a phased basis, prioritising areas assessed 
as “red” through the safer staffing review, and aligning investment to recruitment and 
affordability planning.  

5)  Monitoring and assurance 

The Trust will monitor the impact of these actions through staffing and quality measures, 
triangulated with patient outcomes and incident learning, including temporary staffing usage, 
staffing fill rates, and patient safety indicators such as falls (including falls with harm), 
particularly across frailty wards. 

The Boards have also agreed strengthened governance and reporting arrangements, including 
receipt of a safer staffing paper every six months, with the next report scheduled for April 2026. 
Future reports will include benchmarking against peers and KPIs to evidence the outcomes and 
benefits of the approved investment, including a baseline position and expected improvements 
following implementation. 

The Executive Team will report to the Workforce, Education & Culture Committees-in-Common 
on how the staffing investment will be managed, including expectations around redeployment 
and the planned reduction and ongoing monitoring of bank and agency usage. 

In closing, the Trust recognises the importance of the matters raised and is committed to 
providing assurance that safe staffing is being addressed both at ward level and across the 
wider organisation. The Board-approved Safer Nurse Staffing Establishment Review and 
associated governance actions provide a Trust-wide framework to identify risk, prioritise 
investment and strengthen establishments, supported by ongoing triangulation of staffing 
information with patient outcomes and incident learning. 

Yours sincerely 

 
 
 
 
 
 
 
 
 
 
 
 
 Interim Group Chief Executive

Sally Robinson  
Assistant Coroner  
East Riding of Yorkshire and  
City of Kingston Upon Hull 
Coroner’s Service 
The Guildhall 
Alfred Gelder Street 
Hull  
HU1 2AA 

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

3rd March 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Patricia Irene Walker  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28th 
January  2026  concerning  the  death  of  Patricia  Irene  Walker  (date  of  death  not 
specified in the Report but in or around February 2025). In advance of responding to 
the  specific  concerns  raised  in  your  Report,  I  would  like  to  express  my  deep 
condolences to Patricia’s family and loved ones. NHS England is keen to assure the 
family and yourself that the concerns raised about Patricia’s care have been listened 
to and reflected upon.   

Your Report raised concerns that staffing was sub optimal, and remains so, on Ward 
90 at Hull Royal Infirmary as recruitment is difficult. This means that TAG nursing care 
is not always possible and patients are at an increased risk of falls. 

We note that your Report has also been sent to Hull University Teaching Hospitals 
NHS  Trust,  who  would  be  best  placed  to  respond  to  your  concerns  from  a  local 
perspective. NHS England has endeavoured to address your concerns as far as we 
are able to, but consider the issues in this case do fall outside of our usual role and 
remit.  

Staffing / recruitment concerns and TAG nursing care 

It  is  important  to  acknowledge  that  this  incident  occurred  within  a  busy  frailty  ward 
where nurses and doctors must manage multiple acutely unwell patients.  

Although the term “TAG nursing care” was used in your Report, it is unclear exactly 
what this refers to as this has not been stated within your Report and NHS England 
was not a party to the inquest, and so has not heard any evidence on this particular 
issue.  There  are,  as  far  as  we  are  aware  no  nationally  standardised  or  formally 
recognised definitions of TAG nursing care within NHS England, National Institute for 
Health  and  Care  Excellence  (NICE)  guidance,  or  wider  UK  professional  nursing 
literature.  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 For this response, ‘TAG’ has been understood as a locally defined model related to 
the  abbreviation  for  a  Triage  Assessment  and  Goal  setting  approach  that  helps  to 
identify and prioritise patients based on the severity of their illness, acute episode, or 
condition.  

NHS provider organisations have a statutory duty to ensure that services are staffed 
safely  and  appropriately  to  meet  the  clinical  needs  of  patients.  Each  Trust  or  NHS 
organisation is responsible for its own recruitment and therefore any further queries in 
this regard will be better addressed by Hull University Teaching Hospitals NHS Trust. 

Across  all  national  guidance  (see  “Supporting  Guidance”  below),  evidence 
demonstrates  that  inadequate  staffing  increases  fall  rates,  delays  detection  of 
deterioration, and reduces the ability to deliver safe, preventative care.  

National  frameworks  highlight  that  safe  staffing  must  be  aligned  to  patient  acuity 
(severity  and  urgency  of  a  patient’s  condition),  dependency,  and  clinical  risk, 
especially in high risk populations such as older adults with frailty.  

Frail older adults are at high risk of falls and prevention is a key nursing responsibility. 
Nurses should perform falls risk assessments on admission, and regularly thereafter, 
and implement the required nursing interventions to prevent and mitigate the risk of 
falls.   

For frail, high risk patients, adequate registered nurse presence is essential to deliver 
enhanced care observations and provide cognitive and psychological care, assist with 
mobility  support,  and  regularly  assess  and  implement  the  required  interventions  to 
support patient safety and care quality.  

Safe  staffing  tools  should  be  used  alongside  professional  judgement  to  ensure 
responsive  allocation.  Areas  caring  for  frail  older  adults  require  enhanced  staffing 
models due to higher dependency.  

Supporting guidance  

National Quality Board guidance (2016) on safe staffing sets out the expectations for 
providers in ensuring safe, sustainable, and productive workforce planning and sets 
expectations for Board-level assurance on safe staffing. 

NICE Guideline NG249 (2025), relevant to falls assessment and prevention, outlines 
best practice including identification of people at high risk of falls; comprehensive falls 
assessments covering gait, balance, cognition, continence, medications, vision, and 
environmental factors; tailored interventions to reduce risk and continued engagement 
in falls-prevention strategies. 

To ensure high standards of care, the Nursing and Midwifery Council’s safe staffing 
guidelines state that staffing must reflect skill mix, patient need, and safe ratios, and 
that  organisations,  not  individuals,  are  responsible  for  ensuring  safe,  appropriate 
staffing levels. 

Regional response 

 The  NHS  England  North  East  and  Yorkshire  Regional  Team  have  liaised  with  Hull 
University Teaching Hospitals NHS Trust regarding your Report. Whilst the Trust will 
be responding directly to the Coroner in separate correspondence, they have advised 
the Regional Team of steps they have already taken regarding staffing. At the Trust’s 
February Board meeting, a business case was presented to propose an increase to 
nursing staff following a safer nurse staffing review.  

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 
Patricia, 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