Dear Mr Walker

Re: Response to Regulation 28 Report to Prevent Future Deaths – Asher Blackman

Thank you for your Prevention of Future Deaths (PFD) report dated 06 March 2026, following the inquest into the death of Mr Asher Blackman, which concluded on 17 December 2025.

On behalf of Central London Community Healthcare NHS Trust (CLCH), I would like to express again our sincere condolences to Mr Blackman’s family. The Trust has carefully reviewed the matters raised in your report and, to ensure that we fully reflect on and learn from the events leading to the death of Mr Blackman, has undertaken a programme of Trust‑wide engagement events. These sessions have been designed to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’, ensuring that current approaches to managing situations where clinical staff are unable to gain access to a patient appropriately identify and assess all potential risks, and that proportionate mitigations are implemented to meet individual patient need.

We have undertaken engagement events which have been well received and attended by approximately 420 staff to date. The sessions have supported the reinforcement of the requirement to ensure clinical records are comprehensive in all situations and contain where possible verified next of kin and emergency contact details completed at the first point of contact.

Below is the detailed response from CLCH addressing the concerns you outlined. Matter of Concern 1 The initial District Nursing assessment did not record next of kin details or provide clear instructions regarding the actions to be taken should access to the patient not be obtained.

- 2 - Response: The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations to ensure that:
• Next of kin and emergency contact details are mandatory fields and are completed at triage where the information is available and if this not available, staff are expected to obtain this from the patient at the first visit.
• Electronic patient record systems display essential patient information prominently on the front page of the record to improve accessibility. In addition, the Trust has a long-term plan to improve visibility of this information on the system, and we are working with the Information Management Team to update the electronic patient record system to include prompts and alerts to support completion and verification of this information. Matter of Concern 2 The policy relating to non‑access did not sufficiently address the need for police involvement where a patient’s life may be at risk as a result of repeated failure to gain access. Response: The No Access: Not Seen: Disengagement Policy states that, while police involvement is not routine, it is both justified and expected where a failure to gain access gives rise to immediate or escalating concerns regarding patient safety or risk to life. The policy further provides for escalation to emergency services, including the police, where urgent visual confirmation of a patient’s wellbeing is required; where access is obstructed by others and there are genuine concerns regarding safety; or where non‑access indicates a risk of significant harm or death. In accordance with the Right Care, Right Person framework which is a National (England/Wales) Police policy, the Trust policy requires staff to frame any request for police assistance by explicitly articulating the specific risk posed by the patient to themselves and/or others, rather than requesting a general welfare check. Notwithstanding the existence of this Trust policy, the Trust is currently undertaking a comprehensive review informed by recent staff engagement activities. This review is intended to strengthen the policy by placing greater emphasis on the immediate escalation of a “no access” visit where a patient is assessed as being at significant clinical risk, including cases requiring critical interventions such as blood glucose monitoring and insulin administration. The Trust will also be providing patients with additional information about how it will support them in circumstances where there is no access. The Trust acknowledges the seriousness of the issues identified and remains fully committed to continuous improvement to prevent recurrence. The actions described above have been reviewed through the Trust’s clinical governance and patient safety frameworks. Compliance with revised processes will be monitored through established quality assurance mechanisms, including documentation audits, staff feedback, and incident review processes. The Trust remains firmly committed to learning from this case and to strengthening systems, processes, and clinical practice to reduce the risk of similar incidents occurring in the future.

- 3 - Conclusion Central London Community Healthcare NHS Trust has formally reviewed the incident in accordance with its Patient Safety Incident Response Framework (PSIRF) and has identified opportunities to enhance existing processes. The Trust is assured that the actions implemented to embed improvements within the No Access: Not Seen: Disengagement arrangements, together with the proportionate PSIRF response, directly address the concerns raised in your report and significantly strengthen safeguards for patients receiving community nursing services. In addition to the engagement events, the Trust has taken steps to refresh staff knowledge on how to respond safely and appropriately to instances of no access, aligned with the concerns you have raised.

We trust that this response provides assurance that appropriate and proportionate actions have been taken to mitigate the risk of future incidents of this nature. Please do not hesitate to contact us should you require any further information or clarification.