Dear Assistant Coroner Field,

Response to Regulation 28 Report to Prevent Future Deaths: Mrs Joan Talbot

We are grateful to you, for bringing matters of concern to the attention of King’s College Hospital NHS Foundation Trust (the Trust), through your Regulation 28 Prevention of Future Deaths report dated 11th November 2025 (PFD). This was a very sad case, and the Trust wishes to express its sincere condolences to the family of Mrs Talbot. The Trust has given careful and thorough consideration to the concerns you have raised, and its formal response is set out below.

Your summary and recommendations were as follows:

“ In many respects, the Trust has moved on in a positive way from the systems in place at the time when Mrs Talbot was under its care. The functions of EPIC outlined by clearly have the potential to improve continuity of care. However, setting aside the training in EPIC necessitated by its introduction, it is not clear that training has evolved at the same pace or reached all those who need it. As has pointed out, the standards referred to in her statement should have been in place at the time. 3 17. I do not feel it would be proportionate to defer my decision on this issue in order to ask the Trust to provide the further evidence suggested by for the simple reason that I have been left with the overall impression that, despite having the tools with potential to help improve continuity of care between different admitting teams in patients with multiple admissions, the Trust has not taken the additional necessary step to ask itself how these tools can be used most effectively in this specific scenario, whether further refinements to the existing systems and processes may be required and therefore what further targeted training may be necessary to support healthcare professionals, as well as how to evaluate the effectiveness of these tools. Their effectiveness appears to be assumed.”

Patient safety and quality are central priorities for the Trust. Accordingly, the issues highlighted in the PFD have been subject to thorough review by both the Patient Safety Team and the Executive Team.

The Trust has further considered the PFD in collaboration with colleagues at Guy’s and St Thomas’ NHS Foundation Trust (GSTT), recognising that all EPIC-related development and configuration is undertaken on a cross-Trust basis following the joint procurement of the EPIC electronic patient record system. Since EPIC Go-

Live in October 2023, a number of quality improvement pieces of work have been undertaken to improve patient safety & quality, through an initial ‘stabilisation phase’ of urgent work, followed by an ‘optimisation phase’ of improving functionality across a number of domains. We are conscious that further improvements are required and we are not complacent with regard to pace and scope of this work. Improvements in medical notes documentation commenced over the last few months, in particular a ‘Problem List Etiquette Guide’ has been produced, which outlines expectations for the use of problem lists and associated documentation fields. Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks. Subject to final approval, it is anticipated that the DQG will be operational from early 2026 and will report through existing EPIC governance and oversight structures. The draft terms of reference can be found in Appendix 1 (attached). It is planned to signed off the scope and membership of the meeting across both Trusts in January. In the meantime, the Problem List Etiquette Guide will be tabled and discussed at the Clinical Directors Meeting and the Governance Lead Forum in early 2026 so that learning in relation to the PFD can be facilitated.

We trust that this response provides assurance that the matters raised in the PFD have been carefully considered and that appropriate actions are being taken to reduce the risk of similar incidents occurring in the future. The Trust will continue to monitor the effectiveness of these actions through its established governance and reporting arrangements.

Should you require any further information or clarification in relation to this response, the Trust would be pleased to provide this.