Dear Sir Inquest into the death of Harry David Hall Regulation 28 Report to Prevent Future Deaths Response We write in response to your Regulation 28 Report dated 1 May 2024 following your investigation into the death of Harry David Hall. Cumbria Northumberland Tyne and Wear NHS Foundation Trust would like to express our deepest condolences to the family of Mr Harry David Hall. The Trust takes all patient deaths very seriously and investigates them very thoroughly to establish if lessons can be learned or services can be improved. Your concern was as follows: 'No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time.' The Trust has since carried out a thorough investigation of Mr Hall's electronic healthcare records and established that the appointment dated Wednesday 17 May 2023 was created in error by an administrator, who has since left the organisation. At the time that the appointment was created, the administrator also created an appointment letter however the appointment letter was not sent out. A note was added to the Client Diary section of Mr Hall's electronic healthcare record confirming this. The image below shows the client diary section of the electronic healthcare record and highlights the date and time the May 17th appointment was initially entered by the admin staff member, and then the time it was cancelled. In the details column it is clearly noted that the appointment was cancelled as it had been entered in error.

This image below shows that a document (appointment letter) was added on 31 March 2023 at 09:35. The Document Description states that the letter has not gone out – appointment cancelled. There was therefore no cancelled appointment and therefore no omission of rationale for the perceived cancellation. Furthermore, as was explained in the hearing, Mr Hall would have been seen within the 18 week timeframe that was the appropriate benchmark at the time. Unfortunately, the location of the note was not clear to the two staff witnesses who attended Mr Hall's inquest to provide evidence. The staff members wrongly assumed that the reason why the appointment was cancelled should have been documented in the progress notes therefore they did not explore the Client Diary feature on the record which expanded to show the patients appointment details and appointment history. The Trust is confident that there was never an appointment planned for 17 May 2023 and Mr Hall was only ever provided with and made aware of the appointment dated 26 June 2023. At the point of Mr Hall's referral in March 2023, the Trust benchmarked on having no patients waiting over 18 weeks for assessment (this was the Trust's quality priority at the time). At that time, West Northumberland Community Treatment Team faced significant challenges regarding staffing resources. The challenges have now been resolved and the wait to assessment times have significantly reduced to under the new 4-week performance indicator, as stated in evidence during the hearing. In circumstances when scheduled appointments are cancelled for a genuine reason the Trust expectation for documentation of that reason is as follows: Staff Member Cancellation: If a staff member cancels an appointment, the Admin Team contact the patient to inform them. Patients are contacted by phone if the cancellation is last minute, and patients are texted if they cannot be reached by phone. The appointment is then cancelled in the patient's electronic healthcare record diary and the reason for the cancellation is documented i.e. cancelled by clinician. A note is also added to the patient's progress notes section on the electronic healthcare record. If the appointment is

rescheduled, an appointment letter is generated, sent to the patient and uploaded into the documents section of the electronic healthcare record. Patient Cancellation: If a patient contacts the service to cancel their appointment, the appointment is cancelled in the patient's electronic healthcare record diary and the reason for cancellation is documented i.e. cancelled by patient. A note is also added to the patient's progress notes section on the electronic healthcare record. If the appointment is rescheduled, an appointment letter is generated, sent to the patient and uploaded into the documents section of the electronic healthcare record. Appointment Created in Error: If an appointment is created in error by a staff member, the appointment is cancelled in the patient's electronic healthcare record diary and the reason for cancellation is documented i.e. created in error. We hope that the above demonstrates that the Trust has invested time, effort and resource into investigating the issue you highlighted with a view to improving patient care and safety and reducing the risk of any adverse incidents or outcome in the future. We often find it helpful to engage with Coroners in the local area to discuss any issues or concerns and would welcome a further conversation with you regarding this matter, should you find it useful to do so.