Delwyn Preece

Chief Executive’s Office 
Woodfield House 
Tickhill Road Site, Tickhill Road, Balby 
Doncaster, DN4 8QN 

12th May 2026 

Mrs S L Slater 
Area Coroner 
South Yorkshire (East District) 
Coroner’s Court and Office 
Crown Court 
College Road 
Doncaster  DN1 3HS 

Dear Ma’am, 

Regulation 28 report to prevent future deaths – Mr Delwyn Preece (

Thank you for your Regulation 28 Report to Prevent Future Deaths concerning the death of Delwyn 
Preece and for your offer to extend our deadline for reply.  As indicated, we wanted to respond to time 
recognising the harm suffered by his family, and diligent work here since.  

On behalf of the Trust, I again extend our sincere condolences to Mr Preece’s family. Please be assured 
that your report has been given the highest priority and serious consideration at executive level. My 
colleagues, our Chief Nurse, 
developed a response plan which I, among others have then tested for sufficiency, pace and impact. We 
have already implemented a series of changes in response to this case, even prior to the issuance of your 
report, and we will maintain oversight of these improvements through our quality and safety governance 
processes. Our approach is focused on strengthening systems, standards and oversight so that learning 
translates into tangible improvements, rather than attributing blame to individuals.  The Board, meeting in 
public, considers all PFD notices and response plans: and will visibly track the actions outlined here. 

 and Chief Medical Officer, 

 have 

Section 17 Leave – Strengthened Documentation and Patient Safety 

The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to 
informal patients) has been revised to clarify and strengthen documentation requirements around leave. 
Importantly, these changes were put into effect before your report was issued. We have mandated that: 

• 

Pre-leave assessment: Before any patient goes on leave, a thorough pre-leave mental state and 
risk assessment must be conducted and documented. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • 

• 

• 

Post-leave review: Upon the patient’s first return from leave, staff must record a timely review of the 
patient’s condition and any issues arising from the leave. 

Proportionate documentation for short, repeated leaves: For subsequent brief leave episodes 
(such as multiple short “fresh air” breaks on the same day), documentation can be proportionate, 
unless there is a material change in the patient’s presentation. This adjustment is to ensure that staff 
can comply with the policy in practice while still maintaining safety oversight. 

Recording key details: For every period of leave, the patient’s appearance and clothing, along with 
the expected return time, must be noted to support prompt escalation if the patient does not return 
as expected. 

These amendments ensure a safer and more auditable standard of practice, especially for informal 
patients who may take frequent short leaves. The revised approach retains the essential safety intent of 
our previous policy while making it realistically deliverable and enforceable in day-to-day care. The 
Section 17 leave policy document has been formally updated and version-controlled under the authority of 

, Chief Medical Officer. 

Inpatient Clinical Documentation – Contemporaneous Entries and Retrospective Recording 

The Trust has also reinforced strict standards for clinical record-keeping in our inpatient services. All 
entries in patient records must be contemporaneous – meaning written as soon as possible after care is 
delivered – rather than batch-written at a later time. Nursing staff have been explicitly instructed to avoid 
so-called “long day entries” at the end of a shift. Instead, there should be distinct documentation across 
morning, afternoon, evening and night shifts to reflect the patient’s ongoing status and care. These 
expectations have been clearly communicated and embedded into our documentation policy. 

Retrospective entries (notes added after the fact) are now expected to be rare and promptly handled. If, in 
an exceptional circumstance, a clinician must add a note retrospectively, the entry must be clearly marked 
as “retrospective”, must state the reason for the delay, and should be completed as soon as possible – 
within the same shift whenever feasible. This standard aligns with our existing policy guidance that 
records should be completed as soon as practicable after an event, and that any delayed entry be 
explicitly identified and justified. By tightening these practices (and discouraging any retrospective entries 
beyond 24 hours in 24-hour inpatient settings), we aim to preserve the integrity and reliability of the clinical 
record for patient safety and continuity of care. 

Systems and Oversight Enhancements – Real-Time Recording and Audit Processes 

We are bolstering our systems to better support these documentation standards. The Trust has increased 
the availability of point-of-care electronic devices on wards so that staff can document care in real time at 
the patient’s bedside. This practical step is intended to make timely record-keeping more achievable in 
busy clinical environments. 

In particular, we are implementing reports to flag any clinical notes entered more than 24 hours after the 
event, enabling targeted management review and additional support or training where needed. These 
system improvements will give us greater oversight and help ensure compliance with documentation 
standards across the organisation. 

We also recognise that in some community services, immediate electronic documentation is not always 
practical. Even so, any entries in community records must still be transparently identified as retrospective 
and include a justification for why real-time entry was not possible. The distinction between continuous 
inpatient care and intermittent community contact is acknowledged, but the principle of transparency in 
record timing remains consistent. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Investigation and Audit Trail Awareness 

It is essential that those reviewing incidents and conducting investigations are fully informed about 
interpreting record-keeping timestamps. We have reiterated to our investigation teams how our electronic 
patient record system (SystmOne) denotes retrospective entries. A clock symbol in the system clearly 
flags an entry that was made later than its event time, and on-screen hover text displays the actual date 
and time when the entry was added. We have emphasised that investigators must be trained to recognise 
and understand these audit trail indicators to ensure no retrospective entry goes unrecognised during a 
review. This measure is part of our commitment to robust internal learning: by improving investigator 
competence in using these system tools, we further safeguard the quality and accuracy of our 
investigations and, ultimately, patient safety. 

Effective Implementation and Ongoing Oversight 

We have widely publicised internally the need for us to act and change.  I issue a weekly video message 
to staff, which is typically watched by 1,000 of our 4,100 people, and which spoke to the issues you found 
and our response; our bi-monthly Learning Matters magazine has included material to the same effect.  I 
know that working instructions from our Chief Nurse to ward managers have been issued. 

But the three principal routes to oversight are as follows: 

• 

• 

• 

The introduction of our trust wide always measures (of which there are five) will give us visibility on 
key 100% compliance issues daily.  Always measure 5 will require teams to record any care or 
service that is not accessible or available, including untaken leave. 
Our audit of contemporaneous documentation has already begun, and a focused audit on S17 leave 
both for detained and informal patients will take place in Q2 (August) and again in Q4 (February – 
testing the revised policy framework we have already implemented. 
The Board’s Mental Health Act committee will alter its reporting and approach for this year to have a 
specific additional focus on informal patients, in addition to its primary scrutiny of lawful detention. 

Nothing above detracts from the sadness we feel at Mr Preece’s passing, but we do believe we have a 
meaningful and structured response intended to prevent others suffering.  Should you require any further 
information or clarification on the measures outlined above, please do not hesitate to contact me. 

Yours sincerely 

Chief Executive