Dear Mr Potter,

RE: Regulation 28 Prevention of Future Deaths Report: Ian Hegarty, Ref 2024-0583

I write in response to the inquest dated 23rd October 2024 and the Regulation 28, Prevention of Future Deaths report to the trust dated 28th October 2024.

We are sorry that Mr Hegarty died at the Royal London Hospital after a fall that caused him to sustain a fractured neck of femur. At the time of his fall, nursing staff reported it as an incident on our risk management system, Datix, and it was then reviewed under the Patient Safety Incident Response Framework (PSIRF). We have taken his fall very seriously and as discussed at the inquest, we are undertaking a Patient Safety Incident Investigation (PSII).

PSII’s are undertaken to identify opportunity for learning and improvement through providing a clear explanation of how the organisations systems contributed to his fall. This is currently being undertaken by senior investigators at the Royal London Hospital. We have allocated a member of staff as the compassionate engagement lead to support Mr Hegarty’s family through this process and to ensure that they can be involved in the investigation process as they wish.

Once the investigation is complete, the findings from the PSII will be used to identify actions that will lead to improvement in the safety of the care future patients will receive. Agreed actions will be recorded on Datix, so that their completion can be tracked. His family will be offered a copy of the report to see the action that will be taken.

Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES

Telephone:

Private & Confidential Mr Ian Potter Assistant Coroner Coroner Area Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP

I would like to assure you that falls are a patient safety priority for the hospital and we have a Quality Improvement workstream in place for reducing the number of in-patient who fall during an admission. This is led by one of our Associate Directors of Nursing with support from the hospital Quality Improvement team. It feeds into our Harm Free Care agenda where we are encouraging all our clinical teams to share learning so that improvements are made across all our in-patient wards. This chart shows the reduction in falls that we are continuing to see at the Royal London Hospital and that we are continuing to monitor monthly through the Safety Committee and performance reviews:

Once the investigation into Mr Hegarty’s fall is completed, the learning will be discussed as part of this improvement workstream. While this investigation is on-going, I would like share the assurance plan for the Specialist Medicine division. This was developed in April 2024 and is focusing on several areas of improvement including the assessment of falls and enhanced care. Please find the document attached.

I hope this provides you with the assurance that we have taken the events in Mr Hegarty’s care very seriously but I would be very happy to discuss or clarify any of the above points if you wished.