Dear Mr Harris, Re: Regulation 28 Report to Prevent Future Deaths – Paul Timothy Dunne who died on 2 January 2020. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13 March 2025 concerning the death of Paul Timothy Dunne on 2 January 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Paul’s family and loved ones. NHS England are keen to assure the family and yourself that the concerns raised about Paul’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Paul’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised concerns around mental health staff and hospital staff in the Accident and Emergency (A&E) department writing their clinical records in different systems and hospital staff not having access to mental health records. You raised that this meant mental health staff attending A&E are asked to make a double entry in the A&E records which, if not completed, as was the case during Paul’s care, can have fatal consequences. You heard evidence that the introduction of a combined electronic health record system (known as EPIC) has been very slow. My response to you focuses on the areas of concern within NHS England national policy or programme remit.

NHS England is committed to improving the maturity and quality of Electronic Patient Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts to effectively procure and implement their chosen EPR system, and to agree and progress any convergence of EPR systems within their local systems.

NHS England is also committed to supporting the sharing of critical clinical information across NHS organisations. Since 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold (known as the core information standard) between providers within their own Integrated Care System Co-National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

4 June 2025

footprint, through their local Shared Care Record (ShCR). ShCR supplies must be assured against the Professional Record Standards Body’s (PRSB) Core Information Standard, which has been specified by NHS England. Where local ShCRs are used therefore, the core information standard will be available. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between SHCRs across England. This initiative has been commenced but does not have a defined timeframe as it is dependent on funding which has not yet been confirmed. It aims to enable any authorised health and care professionals to have access to safe, reliable and accurate records, regardless of the patient’s location or where care is provided. It is, however, up to local care record organisations and participating NHS Trusts to agree what information, in addition to the core information standard, is held and shared through the local ShCR. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local ShCR.

NHS England’s Frontline Digitisation Team advise that the Princess Royal University Hospital implemented the EPIC Electronic Patient Record (EPR) on 6 October 2023 (as part of the King’s College Hospital NHS Foundation Trust’s implementation of the EPR). Oxleas NHS Foundation Trust use the Rio EPR system.

Integrated Care Boards (ICBs) / Systems, the responsible commissioners for the majority of services administered by NHS Trusts, should have in place a digital strategy. This would usually recognise and acknowledge the requirement to share information across frequently used patient pathways. The responsible system in this matter, South East London Integrated Care System (SEL ICS), has a digital strategy in place which includes the sharing of health information across health and care pathways. Currently, the London Care Record is the key solution that can be used to access a shared care record. Further details on SEL ICS’s digital strategy can be found here.

My colleagues from the London region have been in contact with South East London Integrated Care System, who have informed us that King’s College Hospital NHS Foundation Trust (KCH) conducted a Serious Incident review of Paul’s care, with the final report dated 12 January 2021. Within the report, KCH made recommendations including the following: ‘The Trust must discuss a process whereby Oxleas team record their assessments on Electronic Patient Records (EPR) going forward so that the King’s team have access to their notes and decisions.’

Oxleas NHS Foundation Trust have also informed us that, in order for them to have access to KCH’s EPIC EPR, their staff would need to have an honorary contract with KCH. At present, 16 of the 21 staff within Oxleas’ Mental Health Liaison Team (MHLT) have access to EPIC, and those who do not currently have access are in the process of obtaining access. The mitigation for this is that the MHLT will always have someone on shift who has access and can assist with uploading the required information to EPIC.

The recently updated MHLT policy outlines the required documentation the MHLT will provide to acute trusts, as set out below:

‘5.3 Documentation on Acute Trust electronic systems

5.3.1 The MHLTs will transfer appropriate clinical documentation to the Acute Trust electronic recording system. This is to ensure all clinicians involved in the patient’s care [are] aware of key information relating to presentation, formulation and plan and is crucial for sharing and minimising risk.

5.3.2 For iCare (QEH) – the ‘Clinical Notes’ section will be updated throughout the person’s admission to QEH and the ‘depart’ section will be updated at the point of discharge from MHLT as this contributes to the GP Discharge Letter.

5.3.3 The MHLTs will ensure there is clear documentation on:
• impression/formulation and management plan
• current risk status and risk management plan, including advice regarding contingencies, as well as advice regarding any requirement for enhanced nursing observations, secure staff supervision and actions to take if [a] person expresses [an] intention to leave the department
• legal status
• diagnosis.

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 Paul, 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 Mr Harris,

Care Quality Commission: Response to Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mr Paul Timothy Dunne.

Thank you for your Regulation 28 Report to Prevent Future Deaths dated 18 February 2022 about Mr Paul Dunne's death. I am replying on behalf of the Care Quality Commission.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Dunne’s death, and I offer my sincere condolences to his family and loved ones. Your report’s circumstances are concerning, and I am grateful to you for raising these matters.

In the Regulation 28 Report to Prevent Future Deaths, the following concerns were raised to the CQC:
1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director, who was spokesperson for the Mental Health Trust, did not seem to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is alarmingly manager of these nurses, did not recognise the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect, in court, she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161

document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he rather lamely said that he could perhaps hang around for a bit longer.

2. The Mental Health Trust.
• Staff and it appears the director, even at the time of the inquest, did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.

In response to the individual points raised:
1. We recognise the distress and concern these events have caused and acknowledge the importance of accountability where there are apparent shortfalls in professional conduct or decision-making. However, it is important to clarify that the Care Quality Commission’s regulatory remit, as established under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014), is focused on assessing and holding providers rather than individual staff accountable for meeting fundamental standards of care. While we do not have the authority to investigate or act against individual healthcare professionals, we expect providers to ensure that their staff are competent, appropriately trained, and supported to deliver safe and effective care. Where there are indications that individual knowledge gaps or lapses in professional judgment reflect broader systemic or cultural issues within a provider, such as inadequate supervision and training, poor risk management protocols, or ineffective governance, we may examine these as part of our regulatory activity.

Concerns such as those described contribute to our ongoing monitoring of the provider’s performance. Where patterns might suggest systemic failings, we carry out further monitoring, engagement and assessment activities and/or require the provider to take specific actions to address risk and improve quality.

2. Our regulatory focus is on the systems and governance arrangements providers have to deliver safe, effective, and coordinated care. Concerns regarding the apparent misunderstanding or inconsistent application of key policies, such as those related to missing persons or staffing for 1:1 monitoring, fall within this remit when they indicate potential provider-level failings. In particular, any indication that staff and senior leaders, including directors, did not recognise the applicability of trust-wide risk and safety policies is a matter of concern. We expect all providers to ensure that relevant policies are clearly communicated, understood by staff, and implemented consistently across services and that staff from different NHS trusts are supported to work together and understand how their policies and procedures support joint working to deliver safe and effective care. This includes ensuring that staff working in shared care environments, such as mental health liaison teams in acute settings, operate under a coherent

and aligned set of standards. We also note your concerns about using different risk assessment tools by staff from different trusts (King's College Hospital NHS Foundation Trust and Oxleas NHS Foundation Trust) and the lack of audit or oversight of absconsions or mental health liaison activities.

We will take these concerns into account as part of our ongoing monitoring of the providers. We may consider them alongside other intelligence to assess whether further regulatory action is warranted through monitoring, engagement and assessment activities. Where there is evidence of systemic risk or breaches of the fundamental standards of care, CQC may take steps including assessments and enforcement action, or require provider improvement plans.

Currently, information shared from members of the public, providers, system partners and stakeholders feeds into our provider monitoring system. The Care Quality Commission local integrated assessment and inspection teams are monitoring and engaging with Oxleas NHS Foundation trust and King's College Hospital NHS Foundation trust through continuous monitoring, regular engagement, and risk-based assessments. We gather intelligence from various sources, including patient and service user feedback, notifications, incident reports, and information from partner organisations, to assess the quality and safety of care. Regular engagement meetings with trusts provide opportunities to review performance, discuss concerns, and seek assurance on improvements. We also attend relevant committee meetings such as Oxleas NHS Foundation trust’s mortality surveillance committee, where the trust reviews patient and service user deaths to improve patient safety and learning from incidents.

Internally, at the CQC, we will incorporate any proposed trust actions and information from incidents, notifications, and Regulation 28 Prevent Future Deaths reports into our ongoing monitoring with the service and any subsequent engagement work or assessment planning. We will ask Oxleas NHS Foundation trust for the action they intend to take because of this Prevent Future Deaths Report and monitor those actions as part of our ongoing monitoring and engagement with them. Information such as this will be reviewed via our internal Specific Incidents Guidance (SIG), which requires and identifies the process for the initial assessment of information relating to specific incidents of potential avoidable harm based on the details of the incident. The SIG guidance refers to Regulation 28 Prevent Future Deaths reports and other correspondence from providers and system stakeholders, such as coroners, as being capable of amounting to information requiring an initial assessment under the SIG process. Inspectors supported by operations managers assess if the incident gives rise to potential further monitoring, assessment and/or enforcement functions as appropriate and if the incident suggests the harm sustained was avoidable, may have resulted from a breach of a prosecutable fundamental standard and was the result of the registered person.

Where the information, such as a PFD report, triggering the initial assessment, does not provide sufficient evidence to inform a reliable answer to these questions under SIG, we may undertake further enquiries. When risks are identified, the CQC may carry out targeted or unannounced assessments and, if necessary, take regulatory action such as issuing requirement notices or enforcement measures to ensure the trust meets fundamental standards of care and drives improvement.

We are grateful for the information you have shared. It is invaluable in helping us monitor the quality of care provided across services and to ensure that providers are meeting the standards expected under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014). We appreciate the coroner raising these concerns with us. We will continue to monitor the trusts and any information we receive in line with our internal processes and methodology. If you have any further queries, please do not hesitate to contact us further.