Ruairi Stewart

HM Coroner for Cheshire 
Cheshire Coroner’s Court  
Museum Street 
Warrington 
WA1 1JX 

Dear Madam 

1st May 2026 

Inquest touching upon the death of Ruairi Stewart – Regulation 28 response 

Thank you for providing a copy of your Regulation 28 report, dated 10 March 2026.   

Alternative Futures Group Limited (“AFG”) operates Weaver Lodge Independent Hospital. We have carefully 
considered the concerns identified, which have been reviewed at senior clinical and executive level, including 
oversight by AFG’s Board-level Quality and Safety Committee. We set out below the organisation’s response, 
including actions taken and further measures to be implemented to mitigate the risk of recurrence. 

AFG  recognises  the  seriousness  of  the  issues  identified  and  has  taken  steps  to  ensure  that  learning  is 
embedded and subject to ongoing organisational oversight. 

MDTs 

Concern 1 

The timing of the shifts of the named nurse for the patient meant that she was not able to attend any 
MDT for the patient over many months and her input was therefore only in writing.  

Actions taken: 

•  An  updated  standard  operating  procedure  has  been  implemented  requiring  MDT  scheduling  to  take 

account of named nurse availability. 

•  Where  attendance  of  an  individual’s  named  nurse  is  not  possible,  for  example  due  to  annual  leave 
commitments, an appropriate alternative clinician  is required to physically  attend in  their place. That 
individual  will  undertake  preparation  with  the  patient  prior  to  attendance,  to  ensure  all  relevant 
information is captured and considered.   

•  Attendance at MDTs by a patient’s named nurse, or an alternative in their place, is formally recorded, 

with ongoing compliance monitored through routine monthly audits by a senior practitioner.  

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 2 

The  named  nurse  written  reports  provided  inaccurate  information  to  the  MDT,  giving  a  reassuring 
picture of compliance which is not reflected by the written records. 

Actions taken: 

•  A  standardised  MDT  reporting  template  has  been  introduced  into  the  Digital  Support  Record  (DSR) 
system, AFG’s electronic patient record software.   The named nurse (or an alternative individual, as 
detailed in response to Concern 1) is sent the template attached to the MDT invite, and  is required to 
complete  this form seven  days prior to the MDT  meeting. The completion of this form triggers other 
processes within the DSR system, including monthly compliance checks and clinical supervision by a 
senior practitioner.  

•  That  supervision  is  then  itself  subject  to  separate  audit  by  management  at  service  level,  with  any 
findings  being  incorporated  into  organisational  quality  reporting  to  ensure  oversight  and  continuous 
improvement. 

• 

In light of the evidence heard during the inquest, a formal conversation with all registered professionals 
will  take  place  at  their  next  clinical  supervision  session,  to  reinforce  the  paramount  importance  of 
accurate record-keeping, document management and prioritisation of patient safety at all times.  

Concern 3 

The MDT made plans for a patient to have drug tests. These were not allocated to an individual to be 
accountable and were instead allocated to "staff". These tests were not carried out as planned. 

Actions taken: 

•  All clinical tasks are now clearly and unequivocally allocated to a named individual and recorded within 

the DSR system, to ensure clear accountability and ownership. 

•  Task completion by the assigned individual is monitored daily during shift handovers by oncoming staff, 
with  any  outstanding  action  either  being  completed  by  the  incoming  staff  or  escalated  to  senior 
management.  Ongoing  compliance  is  monitored  via  monthly  handover  form  audit  by  a  senior 
practitioner,  which  also  enables  early  identification  of  trends  and  implementation  of  remedial  action 
where appropriate.  

Leave 

Concern 4 

When  the  responsible  clinician  was  away  for  an  extended  period,  leave  was  managed  by  a  non  s12 
doctor. There is no contemporaneous documentary evidence of the decision-making process by that 
doctor to reinstate leave as decisions were made outside the formal s17MHA framework. 

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Actions taken: 

•  All  clinical  decision-making,  including  that  relating  to  MHA  matters,  is  now  documented  within  each 
patients’ file, both within the DSR system as well as additionally in any relevant minutes – for example 
within MDT meeting minutes, where a clinical decision has been taken during the course of that meeting.  

•  Specifically in respect of s.17 MHA decision-making, AFG has updated and reissued to staff guidance 
as to the process to be followed. In addition, AFG has moved to a system of two leave forms for each 
patient:  one  that  covers  all  escorted  and  emergency  arrangements;  and  a  second  which  covers 
unescorted leave, to minimise the impact to restriction and recovery.  

•  To  ensure  ongoing  compliance  AFG  has  introduced  regular  cross-peer  audits  of  the  s.17  leave 
checklists. The results of the most recent process in March 2026 showed that there were no risks or 
major issues in any of AFG’s other sites.  

•  This  audit  process  has  recently  been  reviewed  by  CQC  Mental  Health  Act  Inspectors  and 
representatives from Cheshire and Merseyside’s ICB at another of AFG’s sites, with a positive and fully 
compliant outcome. 

Substance misuse management 

Concern 5 

On at least one occasion leave was suspended due to suspected drug use but no drug test was taken 
and  no  search  carried  out,  and  there  was  no  documentation  indicating  that  consideration  had  been 
given to undertaking these acts. 

Concern 6 

On multiple occasions information about recent drug use was not part of the shift handover notes. 

Concern 7 

Decisions were made to grant unescorted leave to a patient with a known and recent history of cocaine 
use whilst on unescorted leave, without a full appreciation of their recent substance misuse history. 

Concern 8 

Information from the patient that he intended to carry on taking cocaine was not handed over to the 
staff who made the final decisions about leave and checked the patient on return. 

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.   

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Actions taken for Concerns 5 to 8: 

•  The search policy has been updated and where a search or drug test is required, this is documented 
within the DSR system.  Staff have received refresher training  in conducting searches as part of the 
compliance process, and reminded of the importance of documenting all such actions. 

•  Staff are required, and have been reminded to record in handover notes and MDT meetings, all material 
disclosures.  To  help  with  this  process,  the  handover  template  has  been  reviewed  and  updated,  to 
ensure it adheres to national standards and guidance. The adequacy of handover notes, and sufficiency 
of information provided, is reviewed monthly by a senior practitioner, and are also audited by a service’s 
registered manager to ensure appropriate completion and provision of information. 

•  MDT  documentation  has  been  revised  and  updated  to  require  inclusion  of  a  clear  and  current  risk 
summary,  and  staff  have  been  reminded  to  consider  all  the  patient’s  documentation  including 
interactions  with  the  patient.  The  patient’s  perspective  is  included  as  part  of  the  MDT  preparation 
documents.   

Documentation 

Concern 9 

Care plans that should have been in place were either not created at all or were not fully completed. 

Actions taken: 

•  Before a new service user is accepted into a service, an admission care plan is carried out, and this is 
uploaded  to  the  DSR  system.  Within  72  hours  of  admission,  the  registered  manager  reviews  the 
admission care plan to ensure that the correct care plan is in place and meets the individual’s needs. 
Following admission and initial review, the DSR system creates a prompt, assigned to a patient’s named 
nurse, to review and where necessary update the care plan on an at least monthly basis. Care plans 
will also be updated on a shorter timescale if there is a clinical need, for example an adverse event or 
change in a patient’s presentation/ risk profile. Care plan reviews and updates are audited on a monthly 
basis to ensure continuing compliance, so that any remedial actions can be taken swiftly if required. 

•  As part of the clinical review process, care plans are audited monthly by a senior practitioner to ensure 
that the care plan is an accurate representation of the patient’s care. If a senior practitioner concludes 
that the contents of the care plan require  improvement, then the senior practitioner will  address this 
directly with the named nurse. 

•  There is also a clinician-led quality and practice development forum in place to coach and mentor nurses 

on care plan best practice, which meets monthly.  

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 Concern 10 

The CQC were not notified of periods when the patient went absence without leave. 

Actions taken: 

•  From  a  regulatory  standpoint, AFG  is  not  required  to  report  unauthorised  absences  of  a  person 
liable to be detained under the MHA. Weaver Lodge is not an inpatient unit to which the categories 
of low, medium or high security applies, as required by Regulation 17(3)(ca) of the Care Quality 
Commission (Registration) Regulations 2009, and which mandate reporting requirements. 

•  Following the Inquest, a safeguarding submission was made by AFG to the CQC as regards the 
general concerns raised at the hearing, and AFG has in addition clarified and reminded all staff of 
their statutory reporting requirements, including in respect of safeguarding.  

Concern 11 

Over the course of the inquest there were multiple, serious, disclosure issues relating to non-disclosure 
of medical records. It appears that at the time medical records were kept across a variety of locations 
and programmes, electronic and in paper. Staff therefore would not have had a central place to go to 
find all relevant clinical information about a patient. I am informed that there are plans to implement an 
electronic record keeping system but I do not have information about the nature, scope or timeframes 
for this. 

Actions taken: 

• 

• 

In response to the Coroner’s concern, AFG has reviewed its approach to record collation and disclosure 
and has taken action to strengthen the consistency and auditability of this process. 

Information relevant to a person’s care may legitimately be held across a range of appropriate sources, 
including  DSR,  external  clinical  correspondence,  and  records  held  or  sent  by  third  parties.  Where 
records are required for an inquest, Subject Access Request, claim, complaint, investigation or other 
formal request, AFG recognises the value of having a clear process for identifying and bringing together 
relevant sources. 

•  AFG has developed a structured Disclosure Control Toolkit and supporting user guide. This provides a 
stepped governance process for record collation and  disclosure, with a nominated  lead and  defined 
input from operational, governance, information governance and legal colleagues as appropriate. 

•  The process is designed to map both work as expected and work as done. It identifies what records 
should ordinarily exist, where those records are expected to be held, and then records what searches 
were  completed,  who  completed  them,  what  was  found,  and  whether  any  limitations  require 
explanation. 

•  The process also  allows relevant custodians  to confirm whether, for any reason, potentially relevant 
information  may  sit  outside  the  expected  record  locations.  This  supports  a  more  complete  and 
transparent  search  process  without  relying  solely  on  informal  local  knowledge  or  a  single  system 
search. 

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  The process includes checkpoints before searches begin and before documents are disclosed. This 
supports source mapping, documented searches, appropriate oversight, quality assurance and proof 
of service before a response is issued. 

•  AFG is aligning this process with relevant governance routes, including the Death Review process, so 
that following a patient death, inquest notification or other formal request, there is a significantly clearer 
route for identifying, preserving, collating, reviewing and disclosing relevant documentation 

•  Staff  have  been  reminded  that  relevant  person/patient  information,  including  externally  generated 
clinical  documents  received  by  a  property,  must  be  recorded,  stored  and  uploaded  in  line  with  the 
expected DSR process. 

Quality of investigation 

Concern 12 

The post event reflective practice report from AFG does not identify any of these issues. The "summary 
of issues / concerns highlighted" are wholly positive. Post-incident reflection and investigation is an 
important tool to improve practices and prevent future deaths. Similar concerns  about the quality of 
investigations by AFG were raised in a Regulation 28 report issued by the Manchester City Coroner in 
2022 in relation to a death in 2019 (Shona Campbell). 

Actions taken: 

•  The  investigation  into  the  death  in  2019  was  not  completed  by  AFG  but  provided  by  a  specialist 
independent, third-party organisation. Whilst in this Regulation 28 report the Coroner suggested that 
the breadth of the independent investigation missed opportunities for additional learning and practice, 
the conclusions were wholly accurate. 

•  All future serious incidents will be reviewed in accordance with PSIRF framework.  

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Conclusion 

AFG  recognises  the  seriousness  of  the  matters  identified  and  the  importance  of  ensuring  that  learning  is 
translated into sustained and practical improvement. 

The actions outlined above are not limited to Weaver Lodge but are being applied, where appropriate, across 
all AFG services. Delivery and effectiveness of these actions are subject to ongoing audit, senior management 
oversight, and reviewed by the Board through AFG’s Quality & Safety Committee. This is intended to ensure 
that  improvements  are  embedded,  monitored,  and  sustained,  and  that  risks  are  appropriately  identified  and 
managed across the organisation. 

We trust that this response provides assurance that appropriate action has been taken to address the concerns 
raised but should further information be required please do not hesitate to contact the Company. 

Yours faithfully 

Chief Quality & Risk Officer 
Alternative Futures Group 

Alternative Futures Group Limited 
6th Floor, St Pauls Square, Liverpool L3 9SJ 
T: 0151 489 5501 W: afgroup.org.uk 
Registered in England 2679915 Registered Charity Number 1008587.