Dear Mrs Whitby Response to Regulation 28 report to prevent future deaths following the_inquest into the death ot Samantha Jane Angel write to provide the Trusts response to your regulation 28 report issued following inquest into the death of Samantha Jane Angel. For ease of reference the matters of concern identified by you during the inquest are stated in italics below followed by the Trusts response.
1. The delay in resolving the investigation commissioned into the deceased's behaviour at work 2 The ease with which the circumstances leading to the allegation were made public amongst the deceased's work colleagues and the consequences of that.
3. The recognition that the distress caused to the deceased by the publication of the circumstances, should be a factor in accelerating a conclusion to an investigation, not just the consequences of any findings of an investigation if negative to the deceased. Trust Response
1. The delay in resolving the investigation commissioned into the deceased's behaviour at work
3. The recognition that the distress caused to the deceased by the publication of the circumstances; should be a factor in accelerating a conclusion to an investigation; not just the consequences of any findings of an investigation if negative to the deceased: With regard to concerns 1 & 3 the Trust responds as follows: Since Samantha's sad death the Trust has made a number of improvements to the way it handles and investigates Human Resources (HR) issues. A summary of those changes was submitted to HM Coroner in the form of a statement from Nicole Cornelius, former Chief Chair: Chief Executive:| Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham , PO6 3LY Registered charity number: 1047986 Working To drive excellence in care for together our patients and communities the

NHS Portsmouth Hospitals University NHS Trust People Officer at the Trust. Below is a summary of those points together with details of further improvements which have been made since submission of that statement:
1. We have refreshed the leadership within the HR Operational Team, appointing a new Head of Employee Relations and Inclusion to focus on providing methods to support our managers and their supporting HR staff to enable them to keep checking on cases and to ensure that staff welfare remains paramount Concurrently, the new Head of Service , a senior role, collaborates with the team to establish reporting metrics and Performance Indicators (KPIs) for all HR case work
2. We are utilising our partnership with the IOW Trust to explore the integration of their Case Management System or a separate joint Case Management System to enhance our investigative processes_
3. In the meantime, we are our existing resources, namely the Electronic Staff Record and Excel, to manage our caseload effectively. At any given time, we handle 35-40 cases with the support of a proficient HR Advisory Team comprising 7 qualified professionals. In line with our commitment to enhancing our investigative processes, significant improvements are in development in the recording and monitoring of cases These enhancements provide comprehensive overview of our total casework; facilitating more efficient prioritisation and systematic review based on the length and complexity of each case. By refining our recording and monitoring systems, this enables us to strategically prioritise cases based on various factors, including their length, complexity, and urgency:
4. The HR Advisory Team utilise the just culture approach and understand the critical importance of assessing the necessity for an investigation before a manager proceeds with that course of action, often highlighting the viability of informal actions or learning interventions as an appropriate alternative to a formal investigation. Ongoing efforts include providing refreshed training sessions for managers, utilising anonymised cases that underscore the significance of sound decision-making and adept case management:
5. In looking ahead to the future, our long-term vision includes a strategic and thorough assessment of our policies and processes to solidify and promote a culture centred on fairness and continuous learning: This involves a proactive and comprehensive review of all existing policies and procedures to ensure align with the principles of a just and learning culture. Our plan encompasses a structured approach to embedding this culture throughout the organisation, focusing on fostering transparency, accountability, and a commitment to ongoing improvement: By revisiting and revising our policies, we aim to create a supportive and empowering work environment where employees feel encouraged to learn from experiences, share feedback openly, and contribute to a culture of continuous development: This long-term strategy involves the implementation of tailored training programmes, workshops, and awareness campaigns to reinforce the values and behaviours associated with a just and learning culture_
6. Regular reviews of cases are routinely conducted by our HR operational team and a monthly review of cases completed by our professional standards committee ensures ongoing oversight of case progress. Our letters which go out to employees during informal Chair; Chief Executive: Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 Working To drive excellence in care for together our patients and communities Key using they

NHS Portsmouth Hospitals University NHS Trust and formal processes routinely contain information about support and wellbeing services available, including access to "Care First" for confidential counselling and mediation services. In addition, employees under investigation are assigned a wellbeing contact who will check in with the employee throughout the duration of the investigation: 7 . Further enhancing our initiatives, we are developing a comprehensive training programme for our HR advisory team, specifically focusing on areas such as safeguarding and fostering equality in the workplace. To bolster our investigative capabilities, we are expanding our pool of trained investigators across the Trust; a move intended to enhance the efficiency and effectiveness of our hearing procedures. While external investigators are occasionally engaged for cases involving urgent or serious issues, the associated costs inhibit routine utilisation
8. The introduction of a Protected Time Agreement and Protocol for Investigating Officers underscores our commitment to prioritising the health and wellbeing of all parties involved in investigations. Notably, the Protocol outlines steps for immediate action to address signs of distress Or wellbeing concerns during the investigation process: It is designed to establish a framework that ensures Investigating Officers have dedicated time to effectively conduct investigations, review documents, interview involved parties, and prepare reports in accordance with disciplinary and grievance processes. It also emphasises the importance of ensuring the wellbeing of all individuals involved in the investigation process: Included in the protocol are the following points:
1. Observation and Action: Investigating Officers are tasked with observing signs of distress, anxiety, or other issues that may impact the mental or physical health of any party during the investigation process: Immediate action is required to address these situations promptly: 2 Supportive Measures: If signs of distress or concerns regarding health and wellbeing are identified, appropriate steps should be taken to offer support and assistance. This can include referring individuals to internal support services, HR representatives, occupational health services, or external counselling services as necessary
3. Escalation Process: In cases where distress or wellbeing concerns are significant and require urgent attention, the Investigating Officer is instructed to escalate the matter promptly to the designated authority in the Human Resources department_ 4_ Documentation and Sensitivity: Instances where concerns are raised for the health and wellbeing of individuals involved in the investigation should be documented properly and handled with sensitivity, confidentiality, and professionalism to ensure effective support and resolution
2. The ease with which the circumstances leading to the allegation were made public amongst the deceased's work colleagues and the consequences of that: With regard to concern 2 the Trust responds as follows: Chair Chief Executive Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham PO6 3LY Registered charity number: 1047986 Working To drive excellence in care for together our patients and communities

NHS] Portsmouth Hospitals University NHS Trust
1.The Trust has an established risk management system (Datix Cloud IQ, known as Datix or DCIQ) and this includes a category for staff to report staff on staff incidents. In some cases, there may be direct conversations which are not reported onto the system, and instead discussed with Managers andlor the Human Resources team who will log this: When an incident is submitted there is a pop up on the narrative section to remind staff not to include any personal identifiable data (PID) information in the free text box, however staff on occasion continue to do this AIl training that is provided, and in the guidance documents, it is clearly stated not to use PID in free text boxes: The reviewers of incidents are advised to ensure that PID is removed when an incident review commences and to remind the reporter not to do this if it has been included. As a result of learning from this case, a new message has been added to the front page of the system that all reporters of incidents see when they log in: "Please be aware that Personal Identifiable data (PID) MUSI NQLbe included in the description and action taken fields of any incident that you are reporting"
2.The distribution list for incident forms includes those members of staff who require visibility of the incident in their area of work or speciality to enable them-as part of their role and responsibilities-to review; investigate , have awareness of, and manage incidents. For example, the Accredited Security Management Specialist is notified in order that can give specialist input and offer advice regarding any reviewlinvestigations related to violence and aggression In response to concerns raised regarding the notification list, we have requested Governance Leads to review their notifications lists to check for accuracy, this is planned for completion by the end of July:
3.In partnership with the Trust Communications Team; we have also initiated a communications and engagement plan for all staff to remind them of the importance of not including PID, in the "description" and "actions taken" fields of any incident reported on DCIQ: This plan includes direction and guidance regarding not circulating details, including PID of incidents have visibility of, in Iine with Caldicott Principle 4: Access to confidential information should be on a strict need-to-know basis: The Trust wide messaging will be via 'Trust Talk' _ weekly electronic newsletter delivered to all staff with a Trust email account; various Trust authorised social media accounts and across associated social media platforms and finally the Trust screensaver which has reach across all Trust computers: Chair Chief Executive: Portsmouth Hospitals University NHS Trust; Trust HQ, Queen Alexandra Hospital, Southwick Hill Road; Cosham, PO6 3LY Registered charity number: 1047986 Working To drive excellence in care for together our patients and communities they ' they

NHS Portsmouth Hospitals University NHS Trust Sam's death was a tragedy for her; her family and friends; and colleagues as well as the Trust which lost a valued employee: hope that the contents of this response provides HM Coroner with appropriate assurance that the Trust has learnt from Sam's sad death and is working hard to provide the wellbeing support needed to those employees involved in HR investigations: