Dear Mr Rebello Re: In the matter of Marjorie McEvoy - Response to Regulation 28 Report We refer to the matter of Marjorie McEvoy which was heard on 2 February 2024. At the conclusion of the inquest, you considered your duty under Regulation 28 was engaged, and issued a report accordingly. The Trust would like to start by once again offering its sincerest condolences to the family and friends of Mrs McEvoy for their loss. The Trust recognises that the death of a loved one is a sad situation, and takes every opportunity to identify organisational learning opportunities wherever required. Trust response to concerns raised The Trust is a learning organisation and always wishes to improve patient care and safety. The Trust recognises the importance of the Prevention of Future Deaths process for improving the national picture of patient care, and hopes that this response can assist as part of that national discussion. The concern you raised in your report was: During the course of this investigation it became apparent that the clinical notation by advanced nurse practitioners were inadequate in that they did not explain the patient's presentation to enable escalation of care. These notes should be to a similar standard as those of doctors. Following the issue of your report, the Trust can confirm that it has taken the following actions:
1. On 12 February 2024, the Trust held a debrief meeting with all staff involved in the inquest. This briefing discussed the inquest findings and learning points, including your concern, above.