Dear Sir,

Re: Inquest touching upon the death of Ms Donna Levy

I refer to your letter dated 31 August 2023 and the Regulation 28 report detailing your concerns about the risk of future deaths in light of the findings of the Inquest.

I should like to extend my sincere condolences to the family of Ms Donna Levy. This must have been an extremely difficult time and I hope that my response provides them, and you, with assurances that the North East London Foundation Trust is taking action to address the issues set out in your report.

At the conclusion of the Hearing into the death of Ms Donna Levy, you expressed the following concerns in respect of the care provided by NELFT:

1. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect.

2. The inquest heard that as Ms. Levy was believed to have capacity throughout this period, and consequently it was determined that there were no practical steps that could have been taken to improve the provision of care to her.

3. No formal Mental Capacity Act assessment was ever undertaken or considered.

4. No formal referral was made to mental health services regarding Ms Levy’s reluctance to take advantage of offered care.

5. The Trust responsible for community care did not undertake a Serious Investigation. The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time.

In respect of the specific concerns, expressed by you at the Hearing and within the Regulation 28 Report, the Trust has put actions in place that aim to address these specific areas for improvement in order to strengthen the safety of our services further. Please note that we have put together a joint Action Plan with London Brough of Redbridge which sets out these actions and I attach a copy of the same with this letter.

In order to improve the services provided by the North East London Foundation Trust it will:

• Engage will the London Borough of Redbridge in weekly Complex Case Discussion meetings involving all 5 Health and Social Services localities and areas of responsibility.

• Introduce two new and full-time senior band 8a nurses.

• Review, revise and disseminate the risk escalation process with health and social care staff.

• Devise a standardised operating procedure relating to how District Nurses conduct their daily handovers.

• Provide Professional Curiosity training for health and social care staff.

• Provide legal training on Court of Protection referrals for health and social care staff.

• Request and encourage GP involvement in discussions of complex cases and professional meetings.

• Provide mental capacity assessment training for all health and social care staff.

• Complete mental capacity assessments in complex cases.

• Undertake risk assessments to identify anxiety / depression scores.

• The Multi-disciplinary Leadership Team will increase the review of cases escalated via High Level Risk Reporting from twice a month to once a week.

• Undertake a review of this case at the Pressure Ulcer Assurance Group to identify any further gaps in care and learning.

• Ensure incident reports include concerns across integrated services.

• Ensure that the new NELFT Pressure Ulcer incidents management approach is embedded.

x Establish staff learning events for health and social care staff.

NELFT did not conduct a Serious Investigation into this matter because, as detailed on the 72- hour Report, it was understood that the incident had occurred within a hospital setting rather than a community setting. It was also understood that whilst Ms Levy was under the care of NELFT community services, the severity of her pressure ulcer had not met the threshold for a serious incident investigation under the previous serious incident framework. Unfortunately, too, we were not engaged in the Serious Incident Investigation that was carried out by the Barking, Havering and Redbridge University Hospitals Trust (BHRUT).

With the introduction of the new Patient Safety Incident Response Framework, this has now changed. This framework includes new processes such as the Patient Safety Incident Report Group Forum (PSIG) that provides for greater and more detailed review of whether an investigation is needed and what form that will take. The PSIG is a NELFT wide meeting headed by the Executive Chief Nursing Officer and attended by, but not limited to, representatives at various levels from the different Directorates, Directors, Assistant Directors, Operational Leads, the Legal Team and the Patient Safety Team.

As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as unstageable and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with thematic learning being reviewed through the PSIG and through the the Trust’s pressure ulcer assurance group for wider learning.

I hope that I have provided you with some assurance that North East London Foundation Trust is taking steps to address the concerns expressed in your report and that we are continuing to take action to improve patient safety and quality of care.

Thank you for raising this matter with North East London Foundation Trust. If I can be of any further assistance or if you would like a further update on the progress made to address your concerns, I would be happy to provide a further update.

I look forward to hearing from you.

Dear Mr Irvine,

Thank you for your Regulation 28 report to prevent future deaths dated 31/08/23 about the death of Donna Rose Lydia Levy. I am replying as Minister with responsibility for adult social care and safeguarding.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms. Levy’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding.

The report raises concerns about the level of care provided by community services, including no formal referral being made to mental health services. You also raise concerns that the North East London Foundation Trust responsible for community care did not undertake a Serious Investigation Review. The Department wants to see a focused and effective safeguarding system, where harm or risk of harm is identified, acted upon effectively and ultimately prevented. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission.

I understand the Trust responded to your report on 09/11/23 with actions it will take to improve patient safety and quality of care. These include: increasing nursing capacity; holding weekly multidisciplinary Complex Case discussion meetings; updating the risk escalation process; devising standardised operating procedure relating to how district nurses conduct their daily handovers; providing relevant training for health and social care staff; making the completion of mental capacity assessments in complex cases mandatory; undertaking risk assessments to identify anxiety and depression scores; increasing frequency of high risk cases reviews; ensuring incident reports incorporate concerns across integrated services; and introducing a new Patient Safety Incident Response Framework.

In addition, CQC reviewed the incident in line with their specific incident guidance and assessed that it does not meet the threshold for CQC to consider using its criminal

enforcement powers. However, they are keeping the incident under review with the Trust and will be asking for an update on their action plan in relation to this incident at their next engagement meeting. Local authorities have a statutory duty to investigate safeguarding concerns under the Care Act 2014. A new duty on the CQC to assess local authorities’ delivery of their adult social care duties under Part 1 of the Care Act 2014 came into effect on 1 April 2023. Linked to this new duty is a power for the Secretary of State to intervene where, following assessment under the new duty, it is considered that a local authority is failing to meet their duties. The Department are awaiting CQC’s findings from five pilot assessments that took place between July and early September 2023 and their proposed assessment framework. Furthermore, on 12 June 2023 the Safe Care at Home Review was published. This is a joint review led by the Home Office and DHSC into the protections and support for adults abused, or at risk of abuse, in their own home by people providing their care. This includes those who are unable to make safe decisions in their own best interests and the review considers the balance between choice and safety when dealing with someone who self-neglects. The Home Office and DHSC are making progress on implementing recommendations made by the review.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Yours,

HELEN WHATELY