Barry Davies

NCA Headquarters 
3rd Floor 
Mayo Building 
Stott Lane 
Salford  
M6 8HD 

7 August 2026 

Ms Joanne Kearsley  
HM Senior Coroner for Manchester North  
Rochdale Coroner’s Court  
Floors 2 and 3 
Newgate House 
Rochdale  
OL16 1AT 

Dear Ms Kearsley, 

Inquest into the death of Mr Barry Peter Joseph Davies 

I am writing in response to your Regulation 28 report dated 12 June 2026 following the inquest into 
the death of Mr Barry Peter Joseph Davies. 

I would like to express how deeply saddened I was to read of the circumstances surrounding Mr 
Davies’ death. On behalf of the Trust, I would like to offer my sincere and heartfelt condolences to Mr 
Davies’ family and loved ones. I recognise how difficult this time continues to be for them, and I want 
to assure them that their concerns have been heard and are being taken very seriously. 

I am grateful to you for bringing these matters to my attention. The issues raised in your report are 
both important and concerning, and we are fully committed to learning from what has happened to 
help prevent similar occurrences in the future. 

You raised two specific areas of concern: 

1.  That neurological observations were not carried out as frequently as they should have been prior 

to Mr Davies’ deterioration being identified. 

2.  That neurological observations were discontinued on the evening of 22 October while Mr Davies 

was still awaiting a second CT scan. 

Trust Response and Actions Taken 

Evidence presented at the inquest by Dr 

, along with a subsequent statement from 

, Matron in the Emergency Department and Urgent Care Observation Unit, outlined the Trust’s 
initial learning. Since that time, we have continued to reflect carefully and have taken further steps to 
strengthen patient safety and care. 

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 We would like to provide assurance that a number of improvements have already been implemented, 
with further work ongoing: 

1.  A Neurological Observation Care Plan for head injuries has been developed to ensure early 
recognition of deterioration, with clear guidance on increasing observation frequency and 
escalation. This is currently undergoing final review and approval. This will be linked to the Head 
Injury Policy on the Trust Policy Hub and will be disseminated across the Trust by 30th August 
2026, this will be supported by a communication plan and followed by an audit programme 
(described in more detail at point 13).   

2.  The Head Injury Policy and Neurological Observations Care Plan has been further updated to 

reflect that the decision to cease neurological observations must be an MDT approach and clearly 
documented in the clinical notes. The amended policy will be submitted for approval and 
distribution across the Trust by 30th August 2026.  

3.  A Head Injury Admission Proforma has been developed which supports an initial admission 
assessment of the patient’s physiological observations and Glasgow Coma Scale, the 
neurosurgical plan including CT head findings and advice received from the neurosurgical team 
and a medication review including the use of anticoagulants and Haemostatics.  

4.  Local Standard Operating Procedure (SOP) - Urgent Care Observation Ward (“UCOU”) Head 
Injury Admission has been drafted which will provide local guidance for the Oldham Hospital 
Emergency Department and UCOU, for adult patients (age >16) who have a head injury that 
requires admission from the emergency department to the UCOU. This will be approved via the 
Clinical Service Unit Assurance Meeting and then circulated to staff by 30th August 2026. 

5.  A single NCA NEWS policy (NCAUECCC002 – “Observation policy for Patients 16 years and over” 
was launched on 10th June 2026 replacing the previous separate versions applicable to Salford 
Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust. The new policy includes 
additional guidance added to Neurological Observations – section 5.3 and will be included in the 
standard neurological observation training for nursing staff. 

6.  All registered nursing staff in the Emergency Departments across the NCA and Urgent Care 

Observation Unit at The Royal Oldham Hospital (the other sites do not have an observation unit) 
complete mandatory training in head injury and trauma care, including neurological observation 
requirements in line with NICE guidance. Current compliance is 100% for head injury training and 
94% for Trauma Immediate Life Support training. 

7.  A poster has been developed to highlight the requirement for frequent neurological observations in 
patients with a head injury. It also emphasises that any decision to cease these observations must 
be clearly documented in accordance with Trust policy. The poster is now displayed across all 
clinical areas.   

8.  A programme of monthly audits has been introduced to monitor compliance with neurological 

observations and care plans, enabling early identification of any gaps and further training needs. 
There were 11 admissions from 1st June 2026 to 8th July 2026 for post head injury care. 3 sets of 
notes have been sent for scanning so could not be reviewed. Of the remaining 8 patients all had a 
head injury proforma and neurological care plan completed and 98% of neurological observations 
were completed on time. None of the 11 patients required escalation. Audit results and identified 
learning is being shared with the team at time of audit, for real time feedback and support.  

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 9.  In relation to the incident, reflective learning has been undertaken with the medical and nursing 
staff involved. Learning from the incident has been shared more widely through team safety 
huddles, including neurological observations, timely escalations and referral to haematology for 
patients presenting with head injury.  

10. Regular “Learning from Datix” sessions are held within the department, where serious incidents 
are discussed openly to support continuous improvement. This case has shared within those 
sessions from June 2026 onwards.  

11. Martha’s Rule was introduced in March 2026, supported by bespoke staff training and clear 

escalation policies. This ensures that patients and their families can raise concerns and request a 
further clinical review if they feel their condition is deteriorating or not being recognised. Patients 
on the ward are now routinely asked about changes in how they feel, with structured processes 
such the new NEWS policy in place to respond promptly to deterioration.  

12. We are working closely with the radiology service to improve prioritisation of urgent CT scans, 

supported by the new head injury proforma that includes key safety prompts such as 
anticoagulation status.  

13. Discussions are ongoing regarding the future development of Patientrack, the electronic patient 
observation and monitoring system used across Bury, Rochdale and Oldham hospitals. This 
includes exploring potential solutions for the digital recording of neurological observations. Further 
review and stakeholder engagement will take place as this work progresses. 

We hope this provides assurance that we have carefully considered the findings from the inquest and 
have taken meaningful action. We remain committed to ensuring that the care we provide is safe, 
responsive, and centred on the needs of our patients and their families. 

Once again, I would like to extend my deepest condolences to Mr Davies’ family. We are very sorry 
for their loss, and we will continue to learn from this tragic event to improve the care we provide to 
others. 

Yours sincerely, 

Chief Finance Officer and Deputy Chief Executive 

Copy: Family of Mr Davies 

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