Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ellen Ocean Woolnough who died on 28 July 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28 March 2024 concerning the death of Ellen Ocean Woolnough on 28 July 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ellen’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Ellen’s care have been listened to and reflected upon. 

I note that your Report has also been addressed to Norfolk and Suffolk NHS Foundation Trust who are the appropriate organisation to answer the majority of the concerns raised in your Report. NHS England has engaged with the Trust on the issues raised in your Report about Ellen’s care and and have been sighted on the action plan and statement submitted to you at inquest. We note from the Trust that their actions include:

• A Quality Improvement Programme led by their Chief Nurse which will focus on improving clinical standards and implementing a positive culture change.
• Re-evaluation of the Trust-wide training standard and model for risk assessment/ Skills Training on Risk Management (STORM).
• The implementation of a new Trust-wide Crisis Rehabilitation Home Treatment Team (CRHTT) Standard Operating Procedure (SOP) and handover document in May 2024.
• Changes made to the Patient Safety Screening Form which include a prompt to consider whether calls are available for retrieval.

I would refer you to the Trust’s response to your Report for further details and actions taken. NHS England have also been asked to be sighted on their response.

Regarding concern iv) and the changes to the way that the Trust is now investigating patient safety incidents and the implementation of the Patient Safety Incident Response Framework (PSIRF), my colleagues from the national Patient Safety Team at NHS England reviewed your Report and have provided input.

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

22nd May 2024

The PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The PSIRF has replaced the Serious Incident Framework (2015) and represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. It is a key part of the NHS patient safety strategy.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:
• Compassionate engagement and involvement of those affected by patient safety incidents
• Application of a range of system-based approaches to learning from patient safety incidents
• Considered and proportionate responses to patient safety incidents
• Supportive oversight focused on strengthening response system functioning and improvement.

NHS England would refer the coroner to the Trust for further details about their implementation of PSIRF.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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 Coroner Stewart Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the death of Ellen Woolnough I write to you in respect of Ellen Woolnough who died on 28 July 2022. Her inquest concluded on 13 February 2024. At the end of the inquest, you raised concerns outlined in this response within a prevention of future deaths notification. I would like to reiterate to you and to Ellen’s family our sincere regret and apologies for the death of Ellen whilst under our care. Please see below our response to your requests for further information:
1. STORM© training continues to be rolled out, although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff. Following a pilot of STORM© training in 2022, roll out was undertaken in specific service areas across the Trust. It is not currently an essential or mandatory training requirement for CRHTT clinicians. STORM© training is not a universal training programme within the Trust’s training offer to ensure clinicians, inclusive of CRHTT staff, are competent and have the relevant skills for assessing and responding to clinical risks. The current clinical risk training offer for CRHTTs, is inclusive of mandatory suicide awareness training, Ligature training, Oliver McGowan Autism Training, Safeguarding level 3 trainings, and physical healthcare training. Throughout May 2024, senior meetings between the Trust’s Education Department, Chief Nursing Officer and Directors have been undertaken, to review and refresh the NSFT Education Strategy, inclusive of reviewing the STORM© training offer and any further roll out across the trust. A final decision will be made in June
2024. The Trust has recently been reviewing and updating their Clinical Risk Assessment and Management Policy. This Policy is currently progressing through Trust internal governance processes and is due to be published end of June 2024, with a Policy implementation plan to be progressed during July/August 2024. This will provide additional support to staff clinical risk assessment practice. NSFT Trust Management Norfolk & Suffolk Foundation Trust County Hall Martineau Lane Norwich NR1 2DBH Tel: Date: 22 May 2024

- 2 - This policy details a suite of essential training for clinicians to evidence they have the required skills and competencies for assessing and responding to clinical risks. The Clinical Risk Assessing and Management training offer is inclusive of Record Keeping, Assessment, Formulation and Safety Planning Training, as applicable in differing areas of specialist mental health clinical practice.
2. Whilst the downgrade policy concerning urgent referrals has been tightened up, key parts of the process, such as the handover document between shifts, is still to be introduced. At the time of inquest we were in the process of introducing an updated hand over document. I can confirm that the use of the updated handover document is now embedded practice in our East CRHTT. To secure assurance that we are adhering to required practice when a referral is being considered for regrade, we have commenced an audit of the hand over document. An audit commenced week commencing 13.05.24. This audit will continue on a monthly cycle for assurance and improvement purposes . Audit results will be reported to the Team and Care Group Quality Assurance Group for monitoring and to support further improvement. For broader assurance purposes the audit findings will be presented to the Trust Safety group and onward to the Trust Board Quality Committee.
3. The Trust Standard Operating Procedure (SOP) addressing the downgrading of urgent referrals, which I was told was revised in 2023, has not been provided to the Court and has not been implemented by the Trust. Please find attached the updated Trust wide CRHTT SOP which was confirmed and introduced on 17th May 2024. This aligns to the Trust standard described within the Clinical Harm Review standard operating procedure (version 4) which was implemented February 2024. Both documents highlight the required process when considering regrading an urgent referral. The requirement to discuss referral regrade with another clinician is clearly described within the Clinical Harm Review SOP and is included within the updated Trust wide CRHTT SOP. These documents ensure staff are clear on the required approach. We will evaluate compliance against this standard through local management monitoring with additional second level assurance provided through an audit that will be completed by the Patient Safety and Quality Team by mid-July 2024. This will enable us to provide assurance that all decisions to regrade a referral are being made by two clinicians in line with Trust standard. This will be reported to the Care Group Quality Assurance Group for monitoring purposes and to support improvement. For further assurance purposes the report will be presented to the Trust Safety group and onward to the Trust Board Quality Committee.
4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and
5. The failure by NSFT to preserve important evidence, in the form of recordings of calls between Ellen and the NSFT crisis call handler, at a time when it was on notice that this evidence would be important and relevant for the conduct of the Inquest, remains a concern. Following recognition of the concern raised, we immediately changed the patient safety screening form that we send out to clinical teams on notification of an incident. We added additional points to

- 3 - this screening form, to prompt the clinical team that are providing an initial description of the events that have occurred, to consider whether any patient calls are available for retrieval, so that they can be secured for investigation and inquest purposes. We have strong processes in place to ensure that the retrieval of these calls is undertaken in a consistent and IG compliant manner by members of the Patient Safety team. Recognising that we have an extensive network of phone lines, we have also taken steps to secure assurance that the phone lines that we need recording, across the crisis pathways, are appropriately enabled. Through a detailed scoping exercise, we identified the need to extend our current recording facility in one of our CRHTT areas. This went live on 15th May 2024. All phone lines which have been designated as requiring recording facility have now been enabled. The tragic death of Ellen has identified a number of key learning points for the Trust. As described above, a number of actions have been undertaken that address your concerns. Further to this, quality improvement in our CHRTT will remain a key focus.