Dear Mr Rheinberg Re: David Moran deceased Thank you for your letter dated 6 January 2017 with regard to your findings into the death of Mr David Moran and the directions given under Regulation 28 and 29 of the coroner's (investigation) Regulations 2013. would like to advise you of the actions the Trust has taken before the inquest and since receiving your letter. Taking the matters of concern raised in turn, would like to advise you of the following: (1) The Trust Guidance for categorising the urgency of referral appeared imprecise. Further, in that the referral system will often depend on telephone conversation there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity. At the time of the incident the Trust guidance set three levels of priority in dealing with referrals, emergency, urgent and routine. The deceased's referral priority was assessed to be routine: Unfortunately, information from Mr Moran's family relating to concerns of deterioration in Mr Moran's presentation were not properly communicated or documented within the Assessment Team: Consequently, the increasing need for urgent assessment was not identified: A Better View__. of mind & body Chief Executive: Mr. Simon J. Barber Chairman: Mr: Bernard Pilkington SMOKEFREE Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000 Your Rbou, tive 1 21sA8169

Since August 2016 a clinical project group has been developing a telephone system for the Assessment Team and this has been piloted in Warrington in December 2016. The project has been positively evaluated and Standard Operating Procedures developed to support the roll-out of this initiative_ The Standard Operating Procedures provide clear guidance relating to the area of concern highlighted in part (1) of the Regulation 28. This means that all referrals where there is any element of uncertainty or where person will not engage in the telephone triage, the default position will be to arrange an urgent face to face assessment within 72 hours of referral: Additionally, the Trust electronic patient recording system, RiO, is in use by all clinical and administrative staff which allows the tracking of progression of patient's referral. Additionally, the system enables staff to view information with regard to any changes in referral priorities. The Standard Operating Procedure went 'live' within Warrington Assessment Team as of 6 February 2017 and will be 'live' Trust-wide by April 2017 . (2) Communication between administrative staff and nursing / clinical staff did not appear to be effective_ The work of the Assessment Team can be unpredictable due to the unplanned nature of referrals. can confirm that at the time of the incident; the communication between administrative, nursing and clinical staff did not meet the standard we would expect_ As a result of this, the Team Manager and senior operational managers have taken the following actions The Team has been briefed that all information relating to patient and their referral must be documented within the electronic patient recording system RiO contemporaneously. Information on RiO is available to all staff 24 hours day: The Assessment Team now has a robust in place whereby a senior clinical member of staff reviews all referrals on daily basis and this information is relayed into the teams daily recorded morning meeting in which referrals are identified and actions and responsibilities for all staff are delegated. Training in the form of lessons learned took place with the team through January 2016 and included an update of guidance and systems currently in place_ If can be of any further assistance or you require further information about the steps we have taken, please do not hesitate to contact me