Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Winnie Harrop who died on 16 August 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 March 2025 concerning the death of Winnie Harrop on 16 August 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Winnie’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Winnie’s care have been listened to and reflected upon.

Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.

My response to the Coroner has been aided by engagement with NHS England’s National Clinical Director for Older People and our North West Regional Teams.

The safe discharge of older people with frailty should always be a bespoke process, depending on the specific context of both the patient and the place of residence. NHS England would discourage blanket discharge policies which address the responsibilities of care homes. There is substantial variability within the sector as to the competencies and equipment staff hold. However, when handing over care to any other care setting, including care homes, the correct policy should be that diagnosis, prognosis and future management are communicated by the discharging organisation. In the case of care homes, where competencies are not always straightforward and cannot be taken for granted, future management should not just be communicated but agreed with the duty manager for the home. If the home cannot meet the patient’s needs, as would seem to be the case in this instance, then it is incumbent for the NHS to continue to provide care.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

14 May 2025

The Department of Health and Social Care (DHSC), to whom your Report is also addressed to, has published statutory guidance on how health and care systems should support the safe and timely discharge of patients from hospital, which includes guidance on care homes. The guidance was last updated in January 2024. The guidance and supporting documentation can be found here: Hospital discharge and community support guidance - GOV.UK.

My colleagues from the North West region have been in contact with Tameside and Glossop Integrated Care NHS Foundation Trust, who have advised us that there is currently no Standing Operating Procedure (SOP) in place for discharges from the Emergency Department (ED). However, where any patients are being returned to a care home, the home are contacted and updated on all events that have occurred in the ED and staff ensure completion of a ‘Return to 24 hour care’ form’, which includes sections for interventions, results, treatments given and a plan. This form does not currently have any dates or version control, however the Trust have confirmed it is being updated and will include version control and review dates. Changes are expected to be approved by the Trust’s Quality and Safety Meeting later in May 2025.

The Trust advise that all patients have a discharge summary completed which outlines all key points of their hospital attendance and the management of their care during their admission within the ED. In addition, the Trust is currently reviewing and updating the safe sedation policy to include input from the ED. As per the Trust’s Patient Safety Incident Investigation (PSII) action plan, the immediate deployment in the ED of the Royal College of Emergency Medicine (RCEM) Guideline for Procedural Sedation in the Emergency Medicine (2024) has been completed. The Trust’s policy reflect the RCEM guidance.

As additional oversight, there are weekly discharge planning meetings that take place which include representation from social care in terms of appropriate management of discharges back to 24-hour care/care homes. There has been a meeting held with informatics to review discharge letters and discharge checklists and further work is ongoing, which will be presented to a Working Group to improve.

We understand that the Coroner was satisfied with the Trust’s action plan from the PSII that took place.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Winnie, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Gill,

Thank you for the Regulation 28 report of 19th March 2025 sent to the Secretary of State about the death of Winnie Harrop. I am replying as the Minister with responsibility for hospital and community discharge.

First, I would like to say how saddened I was to read of the circumstances of Ms Harrop’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns over a lack of clear health and social care guidance on hospital discharge, specifically under what circumstances it is appropriate to send a patient back to a care home.

There is in fact clear guidance on this issue, which can be found under section four of the published ‘Hospital discharge and community support guidance’. This statutory guidance dictates that support should extend beyond discharge itself, and that local areas should have agreed protocols for collaborating with onward care providers about an individual’s hospital discharge through the care transfer hub. This should include agreed pathways for raising any concerns post-discharge and how to resolve these, including where care providers are required to make changes to care plans.

Evidently, in Ms Harrop’s case, there was a new requirement for oxygen, and a need for a reassessment of her discharge plan. It is the responsibility of NHS England to engage with trusts to ensure that the statutory discharge guidance is followed. As such, in preparing this response, my officials have made enquiries with NHS England to ensure that we adequately and fully address your concerns. I have been made aware that they are preparing their own response to this PFD report, which will incorporate regional input to provide additional context and explanation for this very sad case.

Once again, I would like to offer my sincere condolences to Ms Harrop’s family. This situation is an unacceptable one, and I am truly sorry for the devastating and irreversible consequences this has had. I can assure you that my officials are working with colleagues in NHS England, to ensure this situation is avoided at all costs in the future, and that local systems follow and embed the existing guidance.

I hope this response is helpful. Thank you for bringing these concerns to my attention.