Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Patricia Curtis who died on 2 April 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4 December 2024 concerning the death of Patricia Curtis on 2 April 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Patricia’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Patricia’s care have been listened to and reflected upon.

Your Report raises the concern that hospital discharge notes are not uniform across hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to a potential delay in providing life-saving care and treatment.

Individual Trusts are responsible for their own discharge policies. However, the Hospital Discharge Service guidance and operating model, published by the Department of Health and Social Care (DHSC) in August 2020 and last updated in January 2024, details the national discharge requirements for all NHS Trusts, community interest companies, private care providers of acute care, community beds and community health services and social care staff in England. The guidance, which is based on successful discharge to assess principles, aims to ensure that all individuals are discharged from hospital in a safe, appropriate and timely way.

A set of role-based hospital discharge actions cards are also available, which summarise the responsibilities for key roles and staff members within the hospital discharge process.

NHS England has engaged with the Royal Papworth Hospital NHS Foundation Trust regarding your Report. We note that, in response to your concerns, their Discharge Planning Group have taken steps to improve their processes for ensuring that next of kin are updated on patient transfers. They advise that there were no concerns regarding the quality or format of their discharge summaries.

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

22 January 2025

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 Patricia, 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 Gray,

Thank you for the Regulation 28 report of 4 December 2024 sent to the Secretary of State / the Department of Health and Social Care about the death of Patricia Curtis. I am replying as the Minister with responsibility for hospital discharge.

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

The report raises concerns over the lack of uniformity of discharge notes across hospital trusts and the consequential risk that when patients are transferred to another clinical setting, clinicians could be missing the essential patient information they need to provide timely care and treatment.

As the Minister responsible for hospital discharge, I recognise the importance of ensuring people are discharged from hospital and transferred to another clinical setting in a safe way. Doing so will help to ensure that people are able to receive the life-saving investigations and treatment they need without delay.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Individual trusts are responsible for their own discharge policies. I am therefore grateful to NHS England for advising that, since the report, they have engaged with Royal Papworth Hospital NHS Foundation Trust. I welcome the steps taken by the trust’s Discharge Planning Group around involvement of next of kin in patient transfers. I look forward to engaging with NHS England to understand how this develops.

While individual trusts are responsible for their own discharge policies, national statutory hospital discharge guidance has been published (last updated January 2024) which details the national discharge requirements for all NHS Trusts, commissioning bodies, local

authorities, and relevant sectors, such as care providers. The guidance sets out how local areas should plan and implement hospital discharge services in order to support safe and timely discharge for all individuals, including the sharing of accurate timely information across organisational boundaries.

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