Dear Ms Devonish

Further to the inquest you held on 29 August 2024 in to the death of the late Mr Charles Daniels, I am writing to you at your request for further information in relation to three matters of concern you have raised. I have asked , Associate Medical Director for Medicine and , Matron for Ward B5 at the time of Mr Daniels’ admission to review your concerns. The Trust have also liaised with Patient Transfer Service (PTS) who transported Mr Daniels.

I will address your concerns in turn:

1) Record keeping by the nursing team at Stepping Hill Hospital did not record the fluctuations in presentation relevant to the diagnosis of intracranial hypotension or to enable or confirm a review of his condition prior to discharge. has stated that intracranial hypotension is commonly associated with a headache that becomes severe when the patient is upright and disappears when the patient is laid flat. Nursing staff have documented that Mr Daniels did not complain of any pain and particularly no headaches in the last few days prior to his discharge from Ward B5 on 6 March 2024.

It is noted however that Mr Daniels did have fluctuating assistance needs. On 26 February 2024 the therapy assistant documented that Mr Daniels had taken the assistance of three to mobilise him to the chair and that he appeared to be leaning a little. He was subsequently reviewed by one of the medical team, a clinical assessment undertaken and no further action required. He was again seen by the therapy team two days later on 28 February 2024, where they have documented that Mr Daniels was mobilising with the assistance of one. The nursing entries within the patient record document that Mr Daniels required variable levels of assistance on 5 March 2024 from assistance of one with a frame to assistance of two prior to his discharge. We therefore recognise that Mr Daniel’s presentation with regard to his mobility did fluctuate throughout admission. ’s has further reviewed the record and has confirmed that Mr Daniels’ vital observations did not warrant any escalation to the medical team at any point from 4 March

2024 until his discharge on 6 March 2024 and in line with policy he was therefore not escalated for review prior to discharge. would like to confirm that a patient who is deemed medically optimised awaiting transfer (MOAT) and is stable does not require daily medical review, and certainly not by a consultant. By definition if MOAT a patient is deemed to have no requirement to be in an acute hospital bed and the only reason they remain admitted is due to a delay in being able to move them to a more appropriate location e.g. their own home or a care home. Wards at Stockport NHS Foundation Trust have white board rounds Monday to Friday where any change in condition for a patient would be escalated and discussed and would lead to a senior review if required. This provides senior oversight for all patients. Likewise a senior review can be requested out of hours if necessary.

In Mr Daniels’ case he was first documented as being MOAT and in need of discharge planning on 14 February 2024. There are then 12 medical reviews which all deemed Mr Daniels MOAT and for discharge planning between 15 February and 4 March 2024. As per Matron Evans’ review no further reviews took place between 4 to 6 March as observations did not report any reason for this to take place. We hope our review provides assurance with regards to this.

2) Neither the discharging nurse nor North West Ambulance Service personnel attending Stepping Hill on 6 March 2024, for the purposes of his discharge home, appear to have alerted a doctor to the significant deterioration in Mr Daniels’ condition since last assessed by a doctor on 4 March.

On the day of discharge, the Ward Sister recalls that Mr Daniels required the assistance of three to transfer but due to his variable requirements for assistance with mobility, this did not appear unduly out of character.

Mr Daniels’ national early warning score (NEWS) had been scored at zero from the evening of 31 January 2024 throughout the admission until his discharge on 6 March 2024. Therefore the team caring for Mr Daniels’ did not identify a significant deterioration, nor that the score required escalation for review.

The Trust have contacted Patient Transfer Service (PTS) who provided transport for Mr Daniels from Ward B5 on his discharge to home. Unfortunately for this type of transfer the crew do not record any written records of the transfer. However, the Group Head of Customer Experience has checked their incident management system and confirmed that no incident related to the transfer was recorded. It would be expected that if the crew had any concerns regarding the transfer, including a patient who presented as too poorly for transfer, then this would be incident reported. Patient Transfer Service has also confirmed that two crew members transported Mr Daniels, however the service has not been able to provide any additional information following our request.

3) He arrived home by ambulance to his family in physically poor condition and clearly very unwell, on a stretcher in a hospital gown and incontinent, causing considerable distress to the family, particularly after a nurse, the paramedics and his carer questioned how they would cope with his care at home.

has reviewed the nursing notes for Mr Daniels from 5 March 2024 and can confirm that there is no documentation to show that the nursing staff felt that Mr Daniels’ condition had deteriorated on that day. However, following concerns raised by Mr Daniels’ family on 6 March 2024 informed the therapists on the ward that it had taken three staff to assist Mr Daniels on his discharge home. Given that he had been mobilising with the assistance of one member of staff prior to this, we should have considered an

additional therapy assessment prior to discharge. We apologise that this was not considered. has further investigated by speaking to Ward Sister . Unfortunately, due to the time since this event the ward nursing staff are unable to recollect any discussion with family members relating to how Mr Daniels would cope at home. wishes to apologise for the distress this comment caused to the patient and family, but would like to reiterate that if staff had any concerns regarding the discharge, that this would have been postponed.

would like to apologise that Mr Daniels was sent home in his hospital gown and not in his own clothing, as this is something which the ward always encourages. The ‘Dressed is best’ campaign is encouraged across the Trust and compliance is monitored through monthly audits and reported via the Lead Nurse’s report at the Divisional Quality Group. would like to apologise for the poorly condition in which Mr Daniels’ family describe he arrived back home in. She is confident that had his condition appeared as described prior to discharge, then the discharge process would have been delayed and she would have ensured that Mr Daniels had a medical review. ’s has also reviewed Mr Daniel’s medical record in relation to continence. Nursing staff have documented that Mr Daniels was continent and was using urine bottles whilst in hospital and so no continence aids were deemed necessary for transportation purposes. ’ confirms that Mr Daniel’s was clean and dry prior to discharge home and the team are unable to explain why this occurred following discharge.

I would again like to express my apologies to Mr Daniel’s family in relation to concerns relating to Mr Daniel’s discharge. I would however like to provide assurance that a thorough review of his notes has been undertaken and that following this it is considered that Mr Daniel’s medical presentation, at the point of discharge, was appropriate for Mr Daniel’s to discharge to take place.

I trust that the above addresses your concerns. Please do not hesitate to contact the Trust if you require any further information.