Edith Jones

Chief Executive Officer 
Tameside Hospital 
Ashton-under-Lyne 
OL6 9RW 

06 August 2026 

Private and confidential 
To be opened by the addressee only  
HM Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
Cheshire 
SK1 3AG 

Dear HM Coroner     

Name: Edith Jones 
Date of birth: 22 May 1932 
Date of death: 17 October 2025 

Firstly, on behalf of the Trust, I would like to express my sincere condolences to the family of Mrs 
Edith Jones, for their loss.  

We have carefully reviewed the concerns raised in your Regulation 28 Report, specifically in relation 
to  the  quality  of  documentation,  senior  oversight  of  the  District  Nursing  Service  (DNS)  and  how 
complex cases are managed and escalated and the triage process, to which we provide the following 
response. 

Documentation 

It was identified that there were lapses in documentation during the DNS involvement in the care 
and treatment provided to Mrs Jones for which we apologise.  

As  a  District  Nursing  Service,  where  care  is  delivered  to  patients  in  either  their  own  home  or  a 
community  setting  as  part  of  a  multi-disciplinary  team,  we  understand  the  importance  of 
documentation and the accuracy of records. Accurate records ensure continuity of care by way of a 

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 review of previous assessments and interventions and to plan for on-going treatment. We regret that 
we were unable to deliver this level of scrutiny to Mrs Jones’ visits.  

In September/October 2025, the District Nursing Service focused significantly on ways to improve 
documentation including, but not limited to, documentation quality, missing consultations, missing 
outcomes and audit reliability concerns. These areas of concern were further emphasised following 
the inquest of Mrs Jones. It was apparent that attempts to review and improve the service were not 
to the standard we strive to achieve and as such, since April 2026, the service had demonstrated 
organisational  learning  through  a  service  wide  documentation  review,  EMIS  template  review, 
enhanced  documentation  audits,  review  of  clinical  decision-making  standards,  Team  Leader 
involvement in governance workstreams and a focus on escalation processes and triage quality.  

Over the past 6 months, there have been significant improvements to strengthening documentations 
standards, audit processes and clinical record assurance across the whole of the District Nursing 
Service. In September/October 2025, the services identified challenges relating to documentation 
audits, inconsistent recording, missing consultations, and missing outcomes within EMIS. As such, 
documentation quality was recognised as a priority area requiring focused improvement. 

Since then, the service has implemented a comprehensive documentation improvement programme 
which has been further strengthened following this inquest. This work has included: 

•  Establishment of the District Nursing Documentation Group, led by 
Leaders, to review standards and drive continuous improvement 

 and Team 

•  Review and  refinement  of  EMIS  templates  to  ensure documentation  supports professional 

• 

decision-making, risk assessment and clinical oversight.  
Increased  focus  on  documenting  clinical  reasoning,  escalation  decisions  and  patient-
centered care plans.  

•  Team Leaders taking an active lead role in reviewing records, supporting staff development 

and providing assurance regarding documentation quality.  

•  Use of audit findings to inform training priorities, learning activities and quality improvement 

programme 

•  Alignment  of  documentation  audits  with  Quality  Assurance  Rounds,  accreditation  and 

governance processes to strengthen overall assurance frameworks 

As a result of the above, and through reviewing the audit data via our accreditation processes, we 
have  seen  a  substantial improvement across  all  District  Nursing  Teams  in  the  Tameside  locality. 
Hyde and Dukinfield, Mossley and Stalybridge (DMS) were previously amber, are now green. This 
demonstrates  the  District  Nursing  Service  determination  to  enhance  patient  safety  and  provide 
improved governance oversight and accountability. It reflects a focused commitment to patient safety 
and  demonstrates  that  the  service  is  now  operating  with  greater  reliability  and  resilience  across 
these localities. The District Nursing Service currently have no red scoring accreditation areas. 

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 Quality Assurance Rounds are undertaken routinely at team level to provide strengthened oversight 
of  day-to-day  practice  and  an  additional  layer  of  assurance  between  formal  accreditation  cycles. 
Their purpose is to confirm that care remains safe, effective and consistently aligned with expected 
professional  standards,  while  enabling  early  identification  of  emerging  risks  and  reinforcing 
accountability for clinical quality. These rounds receive both divisional and organisational oversight, 
ensuring that findings, actions and improvements are visible across senior leadership structures and 
that  any  concerns  are  addressed  promptly  and  monitored  through  established  governance 
pathways. Through this process, the Division gains reliable assurance that high standards of care 
are being sustained and that improvements are embedded in a consistent and measurable way. 

The Division have carried out a documentation audit which demonstrates a significant improvement 
between January and April, with compliance increased from 53.3% to 81.7%. This improvement was 
sustained in July, reaching 83.3%, indicating that improvements implemented within the first quarter 
have been maintained. 

Senior oversight 

A significant achievement over the last six months has been the service's increased focus on the 
identification,  escalation  and  management  of  deteriorating  patients.  During  September/October 
2025,  the  service  recognised  deteriorating  patient  training  and  compliance  as  a  challenge,  with 
concerns  around  implementation  of  new  training  requirements  and  a  need  to  strengthen  staff 
knowledge,  competencies  and  assurance  processes.  At  that  time,  Matrons  were  attending  the 
Divisional  Deteriorating  Patient  Group  and  seeking  greater  Team  Leader  involvement  to  support 
rollout and embed learning within practice. 

Since  then,  several  developments  have  strengthened  the  service's  response  to  deteriorating 
patients: 

• 

• 

Introduction of enhanced operational oversight through the  “Team Leader of the Day” and 
“Coordinator of the Day” roles, providing clear escalation routes and senior clinical support 
for teams managing complex or deteriorating patients. 
Improved daily management of capacity, demand and acuity through the SITREP process 
and  Out  of  Hours  (OOH)  handover  meetings,  enabling  earlier  identification  of  patients 
requiring urgent intervention and escalation. Each day is RAG rated as Red, Amber or Green 
dependent on the allocation of visits and the level of deferred activity. All Red rated days are 
escalated to the Divisional Nurse and AHP Director for support and action. Red days are also 
incident reported as a red flag staffing for organisational oversight.  

•  Focused  review  of  documentation,  clinical  decision-making  and  escalation  processes 
following  the  Prevention  of  Future  Death  (PFD)  report,  ensuring  greater  emphasis  on 
professional judgement, recognition of clinical deterioration and timely escalation of concerns. 

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 • 

Increased  use  of  caseload  reviews  and  triage  processes  to  ensure  patients  with  complex 
needs, frailty, end-of-life care requirements and changing clinical conditions are appropriately 
prioritised. 

The  District  Nursing  Service  continues  to  embed  daily  safety  huddles,  now  strengthened  by 
enhanced  senior  oversight,  providing  a  more  reliable  structure  for  identifying  risk  and  supporting 
clinical  teams.  Leadership  resilience  has  increased,  with  clearer  operational  control  and  a  more 
coordinated  approach to managing  capacity,  demand and  patient  flow  across  the  service.  These 
developments collectively reinforce the Trust’s responsibility to ensure that all healthcare services 
remain safe, effective and accountable, with appropriate governance mechanisms in place to identify 
concerns early and act promptly. 

The  Division  has  implemented  a  formal  requirement  that  any  deferred  work  or  unmet  need  is 
escalated to a Band 7 Team Leader for review, discussion, and approval. This process ensures that 
decisions to move a visit or intervention to another time or day are subject to senior clinical oversight, 
reducing  the  risk  of  inappropriate  delay  and  strengthening  accountability  for  safe  caseload 
management. Once approved, all deferred activity is re-prioritised and scheduled for completion the 
following  day,  ensuring  patients  receive  timely  care  and  that  emerging  risks  are  identified  and 
mitigated.  This  structured  escalation  process  provides  clear  governance,  enhances  visibility  of 
workload pressures, and supports consistent clinical decision-making across teams. 

The Division has also approved the introduction of a senior District Nursing Caseload Facilitator role, 
designed to provide strengthened oversight of caseload demand, patient flow and the consistency 
of  care  planning.  This  role  will  support  teams  to  organise,  review  and  prioritise  caseloads  more 
effectively,  ensuring  that  all  patients  have  clear  plans,  defined  outcomes  and  timely  progression 
through the service. At the time of writing, recruitment to this post is underway and interviews are 
taking  place,  reflecting  the  Division’s  commitment  to  further  enhancing  safe  practice,  operational 
grip and accountable caseload management. 

The Division has established a weekly pressure ulcer and complex wounds meeting, chaired on a 
rotational basis by either the Matron for Tissue Viability or the Divisional Nurse and AHP Director, to 
provide senior clinical oversight of patients whose wounds are non-healing, deteriorating or complex 
in nature. This meeting is attended by all District Nurse Team Leaders across the localities, ensuring 
consistent  review,  shared  learning  and  coordinated  action  planning.  Through  this forum,  patients 
with  higher-risk  wound  presentations  are  discussed  at  senior  level,  with  clear  actions  agreed, 
monitored and implemented to support safe practice, timely intervention and improvement in wound 
outcomes. This structure strengthens governance around wound care, promotes early identification 
of  concerns,  and  ensures  clinical  teams  receive  the  guidance  and escalation  support  required  to 
maintain patient safety and drive continuous improvement. 

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 The Division also carry out a Deteriorating Patient Audit. The result of that audit demonstrate that 
clinical  monitoring  standards  for  deteriorating  patients  remain  consistently  high,  with  April 
compliance  at  93.3%  and  July  at  92.3%.  Physiological  observation  recording  has  strengthened 
further, improving from 93.8% in April to 98.5% in July, demonstrating enhanced reliability in core 
assessment processes. NEWS2 recording compliance has remained at 100% across both months, 
evidencing  sustained  adherence  to  national  early-warning  requirements.  These  metrics  confirm 
robust  clinical  oversight,  reliable  recognition  of  deterioration,  and  continued  improvement  in  the 
quality and consistency of patient observations. 

The Divisional Deteriorating Patient Group continues to prioritise this metric through strengthened 
audit, clearer expectations, and systematic monitoring of pathway use across all teams. This focused 
oversight provides assurance that pathway utilisation is being actively addressed and that further 
improvement  is  anticipated  as  compliance  becomes  more  consistently  embedded  in  everyday 
practice. 

The Division is delivering a structured improvement programme to strengthen the assessment and 
management of lower-limb wounds, with a clear focus on early recognition of non-healing wounds, 
timely escalation, and consistent use of the limb of concern pathway. This work aims to ensure that 
patients with compromised limb status are identified at the earliest opportunity and that appropriate 
interventions, including consideration of compression therapy where clinically indicated, are initiated 
without delay. To support this, the Division has established dedicated training clinics offering both 
theoretical teaching and supervised hands-on practice. The programme commenced in July, with 
five  staff  completing  the  training,  and  further  cohorts  planned  over  the  next  six  months  to  build 
capability and improve healing outcomes for patients with lower-limb wounds. 

Triage process 

The Service has also reinforced its approach to referral management and triage. Since 2025, triage 
processes  have  evolved  from  development  of  standard  operating  procedures  into  embedded 
operational  practice.  Enhanced  referral  prioritisation,  allocation  processes  and  daily  clinical 
oversight have improved patient flow, reduced delays and ensured patients receive care in the most 
appropriate  setting.  These  developments  have  supported  safer  management  of  demand  and 
increasing patient complexity.  

In 2025, the service managed referrals via a separate Triage team, however, on review it was noted 
that this team lacked the awareness of capacity and demand in teams and this may have contributed 
to  the  increase  in  deferred  activity.  Therefore,  the  decision  was  made  to  disband  this  team  and 
redistribute the resource back into clinical roles to strengthen the triage and decision within each 
District Nursing Team. This enabled prompt and timely decision making by the providing team and 
removed any delay or unnecessary additional triage burdens.  

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 Significant  improvements  have  been  made  in  the  recognition  and  management  of  deteriorating 
patients. Greater operational leadership, improved triage arrangements, daily acuity monitoring and 
strengthened  escalation  processes  have  provided  clearer  pathways  for  clinical  review  and 
intervention.  Learning  from  the  PFD  findings  has  reinforced  the  importance  of  documentation, 
clinical oversight and timely escalation, resulting in improved assurance surrounding care for frail 
patients, end-of-life patients and those with complex healthcare needs 

Workforce improvements 

It is known that there is a National shortage of district nurses and Tameside is not different. it is not 
unknown that in recent years that there have been several reported vacancies across the Service of 
varying  levels  of  qualification  and  skill  set.  Recruitment  gaps  were  contributing  to  workforce 
pressures,  sickness  management  challenges,  capacity  concerns,  and  reliance  on  NHS 
Professionals staffing. There has been a concerted effort over the last 6 months to recruit to the 
vacant posts, and we are pleased to share: 

•  There were 3 new starters joined in April 2026.  
•  Four new starters joined in May 2026.  
•  Workforce  numbers  increased  during  May  2026,  with  an 

improvement 

in  overall 

establishment.  

•  The  service  moved  from  experiencing  frequent  operational  escalation  and  23  red  days  in 
March to reporting no red days in April and May, reflecting improved workforce capacity and 
operational resilience.  

•  No staffing-related patient safety incidents were reported in April and May compared with 13 

recorded staffing incidents in March.  

The service has further improved wound care practice through increased investment in workforce 
development, competency assessment and clinical governance. Learning from incidents, inquests 
and PFD findings has informed  expansions in wound assessment, documentation standards and 
escalation processes. The development of Leg Ulcer Assessment Clinics and enhanced training in 
leg  ulcer  management  and  Critical  Lower  Limb  Pathways  has  improved  staff  knowledge, 
strengthened  multidisciplinary  working  and  supported  earlier  identification  of  patients  at  risk  of 
deterioration.  

The  Divisional  Nurse  and  AHP  Director  for  Integrated  Care  recently  set  up  the  District  Nursing 
Improvement  Group  providing  strategic  leadership  and  governance  oversight  for  strengthening 
safety, quality and operational reliability across District Nursing. The groups programme of work is 
centred on improving the triage process to ensure consistent prioritisation and risk-based decision 
making, enhancing caseload management so workload is balanced, transparent and responsive and 
raising  documentation  standards  to  support  accurate  clinical  records,  defensible  practice  and 
effective  information  sharing.  A  further  priority  is  embedding  clearer  expectations  for  recognising 

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 and escalating concerns in a timely and appropriate manner, ensuring staff have the confidence and 
competence  to  act  early  when  patient  risk  increases.  Assurance  will  be  generated  at  team  level 
through a monthly highlight report underpinned by robust audit process, demonstrating measurable, 
sustained  improvements  and  providing  a  clear  governance  line  of  sight  from  frontline  practice  to 
senior leadership.  

The  Divisional  Nurse  and  AHP  Director  is  engaged  at  both  a  regional  and  national  level  with 
improving  District  Nursing  services  including  being  actively  involved  with  the  development  of  a 
national  framework  for  deferred  work  which  will  be  released  by  autumn.  This  will  provide  clear 
guidance  and  accountability  for  providers  and  commissioners  in  managing  the  patient  risk 
associated with unmet need.  

Significant  changes  have  recently  been  made  to  the  leadership  structure  within  the  community 
services,  strengthening  both  operational  oversight  and  clinical  governance.  The  introduction  of 
dedicated Leads for Nursing and AHP’s, each reporting to the Divisional Nurse and AHP Director. 
This has created clearer lines of accountability and enhanced professional leadership across District 
Nursing.  This  structure  ensures  that  clinical  decision-making,  workforce  support  and  quality 
improvement are guided by senior leaders with the appropriate expertise, enabling more consistent 
standards of care and more responsible management of emerging risks. Alongside this, a revised 
meeting  structure  has  been  implemented  to  ensure  assurance  and  governance  frameworks  are 
robust,  transparent  and  aligned  with  organisational  expectations.  Regular  forums  now  provide  a 
systematic  route  for  sharing  risk,  reviewing  performance  and  escalating  concerns,  ensuring  that 
information flows effectively from frontline services to senior leadership and that clinical safety and 
quality concerns are both known and acted upon.  

Workforce stability within the District Nursing Service has strengthened over recent months. Three 
new  starters  commenced  in  April  2026,  followed  by  a  further  four  in  May  2026,  resulting  in  a 
measurable improvement in overall establishment and operational capacity. This increased staffing 
resilience  is  reflected  in  the  service’s  escalation  profile:  the  23  red-rated  days  reported  in  March 
reduced to  zero  in  both  April and  May,  demonstrating  significantly  improved  operational grip  and 
reduced  workforce-related  pressure.  Correspondingly,  no  staffing-related  patient  safety  incidents 
were recorded in April or May, compared with 13 such incidents reported in March. Together, these 
indicators provide assurance that recent recruitment activity and strengthened workforce oversight 
have contributed to a safer, more stable and more reliable service. 

Overall, the District Nursing Service has demonstrated a clear trajectory of improvement, delivering 
safer  care,  stronger  governance,  improved  operational  performance  and  enhanced  workforce 
resilience.  Through  learning  from  incidents,  inquests  and  external  reviews,  the  Service  has 
embedded a culture of continuous improvement which has resulted in measurable improvements in 
patient  care,  staff  support,  service  delivery  and  organisational  assurance.  Whilst  workforce 
sustainability, sickness absence and capacity and demand continue to require ongoing focus, the 

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 service is in a significantly stronger position and is well placed to continue its improvement journey. 
The Trust remains committed to continuous improvement in patient safety and ensuring that learning 
from this case is embedded in practice. 

Finally,  is  important  to  us  that  concerns  are  reviewed,  and  learning  identified  and  shared  across 
clinical teams as this helps us to strive to prevent harm and improve outcomes for our patients.   

I do hope that this letter provides you with further reassurance, however, should you have 
any queries arising from the content of this letter or require further information or clarification, 
please do not hesitate to contact Legal Services on 

Yours sincerely 

Deputy Chief Nurse 
On behalf of 
Tameside and Glossop Integrated Care NHS Foundation Trust 

(Chief Executive Officer) 

B10

HM Coroner South Manchester
Coroner’s Court 
1 Mount Tabor Street 
Stockport, SK1 3AG 

09/07/2026

Dear HM Senior Coroner Alison Mutch

Re: Edith May Jones Date of Birth :22/05/1932; Date of Death: 17/10/2025
Address: 4 Windermere Road, Hyde, Tameside, SK14 4PU
Place of death: Stamford Unit, Darnton Road, Ashton Under Lyne.
Date of Inquest:17/04/2026

Response to Report to Prevent Future Deaths

Thank you for your Report to Prevent Future Deaths dated 15 May 2026 concerning 
the death of Edith May Jones, who sadly died on 17 October 2025.

First, I would like to offer my sincere condolences to the family and friends of Ms 
Jones.

I understand that one concern has been directed to The Brooke Surgery ('the 
Practice'), namely: '5. The GP practice did not have an effective system to promptly 
triage referrals from the 111 service or information provided by a patient’s family.'

On 28 August 2025, the Practice was notified that NHS 111 had been contacted 
regarding Ms Jones. A member of the Practice’s administrative team spoke with Ms 
Jones’ daughter to obtain further information, correctly recognised that clinical 
assessment was required and sought to contact the duty GP for advice through 
multiple channels. The duty GP was not immediately available as they were 
managing other clinically urgent matters, however, contact was promptly made with 
Ms Jones’ carers and further information was obtained from them within two hours. 
The following morning, a Nurse Practitioner from the Practice spoke with the carers 
and it was agreed that Ms Jones required escalation to hospital.

The Practice has carefully reflected on this incident and has implemented a number 
of changes to strengthen its systems and ensure that potentially urgent information is 
consistently identified, prioritised and actioned by an appropriate clinician.

In September 2025, the Practice introduced a revised on-call structure whereby each 
clinical session is supported by both a duty clinician and a second on-call clinician. 
This change, introduced as part of wider service development, has strengthened 
resilience within the clinical triage system, provided additional support for the 
escalation of urgent concerns and reduced reliance on a single clinician during 
periods of high demand.

B1 On 9 June 2026, a Significant Event Analysis was completed, and the learning from 
this was shared with Practice staff at a clinical meeting on 18 June 2026.

Following this, the Practice implemented a new External Clinical Communication and 
Triage Protocol ('the Protocol'), which sets out the Practice’s approach to the receipt, 
prioritisation, escalation and documentation of external clinical communications. The 
Protocol and its particulars were presented to staff at the clinical meeting on 18 June 
2026. It has also been made available on the Practice’s internal knowledge platform, 
TeamNet, for staff review and future reference.

The Practice intends to review the effectiveness of the Protocol in September 2026, 
and the management of NHS 111 referrals will form part of the Practice’s periodic 
governance and audit processes.

If the Practice can be of any further assistance, please do not hesitate to contact me.

Yours sincerely

GP Partner
The Brooke Surgery

Operations Manager: 

. Business Manager: 

20 Market Street, Hyde, SK14 1AT

B2