Dear Ms Mason Re;_Master Bradley David Griffiths Thank for the Regulation 28 Report to Prevent Future Deaths (PFD) following the inquest into the death of Bradley David Griffiths, 18th November 2012_ We welcome the Coroner's interest and concern in this case and in ensuring that future deaths are prevented and that any risks to patients including those who transfer out of area are managed safely. Your PFD report raised the following 'Coroner's Concerns' "Evidence was heard from Vho was Bradley s Health Visitor. lexplained that she only saw Bradley once, which was for the birth visit on 30"h April
2012. Although two appointments were made with Bradley's mum for the 6 week routine check to take place, his mum did not them. After the second failed appointment Ms Mackie telephoned Bradley'$ mum on keer June 2012 and was informed by her that she had separated from Bradley's father and she and Bradley were in the Northampton area with friends and that she had registered with a new GP_ However, she wouldnot tell Ihere she was living or the details of her new GP As a resul sent Bradley s records to the "No Trace" storage at (he Child Health Department wilh expectation that would be sent to the next assigned Health Visitor: Your action to be taken delails: "In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

Jagtar Singh - Chair Simon Gilby = Chief Execulive Coventry & Warwickshire Partnership NHS Trust Wayside House Wilsons Lane Coventry; CV6 6NY Tel; 024 7636 2100 Fax: 024 7636 8949 WWW covwarkptnhsuk (Exflofur partnership with: Jcarw Cobts Colaa[ you living ~the they

The Trust would Iike to confirm the following: At Ihe time of Bradley's death, our processes for the Transfer Out of notes and information, did not robustly account for instances where families did not provide forwarding GP address, or where they provided incorrect details. Following the incident of Bradley's death in 2012, the Trust had recognised the concerns that you have raised following the inquest in your PFD report; We can confirm that we had taken steps to develop and then implement robust arrangements for ensuring children's 'Transferred Out of Area' records and arrangements for ensuring appropriate levels of contact with receiving areas, are carefully considered; in circumstances where staff are unable to locate childlfamily. The arrangements that we had already proactively put into place were: Completing a 'No Trace' processlchecklist, and a follow up review after 3 months; Supervision of each case by Pre-School Manager; to ensure all avenues have been considered , prior to 'No status being applied. The arrangements described above were laler incorporated into lhe Health Visiting Standards document (August 2014) . We have kept these arrangements under review; as of normal process, to ascertain whether any additional improvements can be made t0 strengthen the process in place am sorry that there was not the opportunily to confirm the changes in practice that we had made following Bradley' s death: 'hope this provides you with the assurance that you require that the Trust did recognise that Ihere was a in its service provision and had taken steps to rectify this al the earliest opportunily, shortly after Bradley's death, thereby preventing a recurrence with other patients urder our care.