Dear Mr Osborne

Regulation 28 Report following an Inquest into the death of Mr Ronald Kelly

I am writing following receipt of a Regulation 28 Report dated 15 November, following on from the Inquest you held on 10 November. I was saddened to hear of the death of Mr Kelly and the very sad circumstances around it which you describe as follows:

The deceased was found hanging … He had recently been discharged from hospital and was struggling to cope.

I was surprised to receive a Regulation 28 report given that the Hospital was not represented at the Inquest, nor were we asked to provide statements in relation to the issues that caused you concern. The concern which you specifically raise for the hospital is as follows:

That a 91-year-old man was discharged from hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping.

Since receipt of your Regulation 28 Report, we have reviewed records in respect of Mr Kelly and his recent admission.

Mr Kelly attended the Emergency Department (ED) via his General Practitioner on 31 August. He was admitted with an incarcerated hernia and surgery was planned.

Mr Kelly went to theatre on 01 September and had an open right inguinal hernia repair. A urinary catheter was placed. His post-operative recovery was uneventful. On 02 September, the Consultant reviewed him in the morning and stated that he might be suitable for discharge if he managed following a trial without his urinary catheter. At noon, one of the hospital’s Discharge Officers discussed Mr Kelly’s home and social

history with him. Mr Kelly advised that he had no package of care, he had a partner who supported him, and he felt they could manage. He consented to the Discharge Officer contacting his partner to confirm that no further support was needed.

The Discharge Officer contacted Mr Kelly’s partner who advised that she was happy for him to come home and could support him provided he was able to walk up the stairs. She also advised that there was no equipment at home, and she did sometimes have difficulty in showering / bathing Mr Kelly. The Discharge Officer advised that the therapy team would be asked to review Mr Kelly, and they would update her when there was further information.

The Discharge Officer asked a Registered Nurse to complete a referral for Physiotherapy. In the mid-afternoon, the physiotherapist assessed Mr Kelly: he managed a ‘stairs assessment’, was independent with bed mobility, transfers (from bed to chair, chair to standing etc…) and was walking independently without any mobility aids. Mr Kelly was given a ‘useful numbers contact list’ if he felt he needed any support following discharge. He was not felt to have any equipment needs. Mr Kelly was not judged to require a support / care package and nor did he seek such.

Shortly after 5pm, Mr Kelly’s nurse documented a successful trial without urinary catheter. Bloods had been requested for the following morning (to review inflammatory markers, CRP) and the potential for discharge the next day was noted (depending on blood results). Of note, this was a day later than the Consultant’s earlier suggestion.

On Saturday 03 September, a consultant reviewed Mr Kelly, noted a satisfactory CRP, and a plan was made for discharge that day assuming no specific home / social issues. A Discharge Officer contacted the Mr Kelly’s partner once again, updated her on the outcome of the therapy assessment and advised that he could go home that day. She agreed to collect him when he was ready and did so shortly after 4pm.

The nursing records note that Mr Kelly was alert and orientated, independent and self- caring. He was given the useful numbers list if he felt he needed support post discharge.

While it is impossible not to be affected by the circumstances of Mr Kelly’s death over two weeks later, we have not identified anything that we would seek to do differently in similar circumstances. An elderly gentleman received prompt surgical treatment and his discharge needs were subsequently explored with him and his family by

appropriate members of staff. Mr Kelly’s functional ability was, with his agreement, assessed by a qualified therapist. The professional opinion was that no formal support was required. Signposting information as provided to Mr Kelly such that he would know where to go for support should his situation change.

Mr Kelly was judged to have mental capacity throughout his admission (from providing informed consent for surgical intervention, through to discharge planning). His self- autonomy was respected in line with his mental capacity. Importantly, Mr Kelly did not ‘refuse to wait over the weekend for a care package’: he was not judged to require a care package, nor did he or his partner seek one.

From the information that we have subsequently received, it seems that Mr Kelly’s partner having a fall four days after his discharge may have been a key event: this could not have been predicted or averted by the hospital. The medical information that we hold at the hospital, in the round, did not point to significant psychiatric illness: the only pertinent entry was made in the Emergency Department some months prior where there is passing reference to Mr Kelly having started and quickly stopped an anti-depressant in the community.

I am conscious that discharge from hospital can be a challenging area, with widespread concern nationally around the availability of domiciliary support and funding of the same. On this occasion, I consider that hospital procedures functioned well and could not reasonably have foreseen subsequent events. It is unfortunate that a Regulation 28 Report was felt to be the appropriate route for us to share this information.

Dear Mr Osborne, Re: Regulation 28: Report to prevent future deaths Thank you for your Regulation 28 report dated 15 November 2022 following the inquest into the death of Mr Ronald Kelly. I am writing to provide Central and North West London NHS Foundation Trust (CNWL)’s response to the concerns that you raised in that report. Firstly, we would very much like to extend our condolences to Mr Kelly’s family and friends. We note that Trust witnesses were not required to provide written evidence or to attend the inquest to give oral evidence. However, in response to your officer’s request, the Trust did provide Mr Kelly’s medical records before the inquest. You raised three matters of concern:
1. That a 91-year-old man was discharged from the hospital following surgery, having refused to wait over the weekend for a care package to be put in place and there was no follow-up arranged to either assist him with his care or to ensure that he was coping.
2. That when the GP practice made a subsequent referral for a visit and assessment by the district nurse, it was rejected on the basis that the appropriate referral was to “home first“. The GP forwarded the referral but nothing was actioned.
3. There does not appear to be any system to ensure that a patient discharged home possibly needing support and care are automatically followed up. Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700

In response to your first point, we did not receive a referral for Mr Kelly either before or at the point of discharge and were not involved in his care whilst he was an inpatient at MKUH. We note that MKUH have provided a full response in relation to the discharge process, which they kindly shared with us. We continue to work closely with MKUH to discuss the inpatient-to-community interface to improve the patient journey, avoid prolonged admissions and enhance the care provided in the community. On your second point, on 7 September 2022, a referral was received by the CNWL District Nursing Single Point of Access (SPA) service from Mr Kelly’s GP. The referral was screened and responded to on the same day, advising that Home First (the reablement service provided by MK Council) would have been more appropriate. The team also requested further information about whether Mr Kelly had any nursing needs or was housebound and did not hear back from the GP. Since Mr Kelly’s death, the service has undertaken a review session with staff to identify learning about our referral process. We will amend the Standard Operating Procedure to ensure that we instigate tighter follow up when we request additional information on referrals. Thank you for bringing your concerns to our attention. I hope that this response provides some reassurance to both you and Mr Kelly’s family that the Trust takes the concerns raised seriously. Should you have any further questions, please do not hesitate to contact me.