Dear Mr Urpeth, Regulation 28 Response Ann Pickering We write in response to your correspondence dated 4 July 2022, received on 7 July 2022, enclosing a Regulation 28 Report following the inquest touching the death of Mrs Ann Pickering on 24 June 2022. May we offer the family of Ann Pickering our sincere condolences for their loss. The response to the Regulation 28 Report has been prepared and agreed jointly between Barnsley Hospital NHS Foundation Trust, who manage Barnsley Hospital, (BHNFT) and South West Yorkshire Partnership NHS Foundation Trust who manage Kendray Hospital (SWYPFT). The term "service user and patient" are used interchangeably throughout the response. This is to reflect the terminology utilised within each Trust's policies and procedures. In order to respond to your concerns under Section 5 of the Regulation 28 Report we have adopted the same numbering for your ease of reference:
1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. Thank you for clarifying that the date referred to above is 17 June 2021. It is recognised by both organisations that the communication between SWYPFT and BHNFT around 17.6.21 was not a standardised consultation and referral process and that improvements are required so that both organisations have clarity on roles and responsibilities. BHNFT and SWYPFT are improving and clarifying the process which includes a protocol that details operational delivery of a safe and effective pathway, which will include:
• A clear referral pathway between SWYPFT and BHNFT, including escalation processes where there is a difference of clinical opinion about the need for transfer.
• Clarity with regards to advice versus referral and when to access emergency care in a general hospital setting. 1

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• Escalation processes that involve both SWYPFT and BHNFT Safeguarding advisors ensuring timely and person-centred decisions are made. An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1 ). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities - for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1 ).
2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer. It is recognised by both organisations that improvements are required so that there is clarity on roles and responsibilities around timely decision making and transfer of service user from SWYPFT to BHNFT. We have also addressed this in concern 1 above. The specific detail of these actions is also included in the collaborative action plan (EXHIBIT 1 ).
3. Despite recogmsmg an NG tube was required, one was not inserted until the 30.6.21 In addition to collaborative working between SWYPFT and BHNFT, a review of BHNFT's existing nutrition policy and agreement on meeting a patient's nutritional requirements particularly for detained patients, including where there is a need for restraint will be undertaken jointly. Nutritional support will be provided in a timely manner by staff from the respective Trusts being clear about their roles and responsibilities in their own organisations, and collectively so that delays do not arise. A standard operating procedure to clarify this along with clear timescales will be in place by 30 November 2022 (EXHIBIT 1).
4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. In addition to the points above, collaborative working between BHNFT and SWYPFT has taken place to address this point, this includes: (a) Amending the service level agreement between BHNFT and SWYPFT to reflect SWYPFT Section 17 Policy, specifically the section relating to 'service users residing in other hospitals'; (EXHIBITS 1 &2). (b) Amending BHNFT and SWYPFT service level agreement to include section 17 leave arrangements from SWYPFT to BHNFT. (EXHIBIT 2); 2

'•'Li /i-1 lh'J;f..j South West Barnsley Hospital Yorkshire Partnership NHS Fou.,dation Tn11st NHS Found ·on Trust (c) Developing a co-produced protocol that details the operational delivery of the above, also in (EXHIBIT 1 ). (d) Identification of lead clinical staff, including clear plans for which clinician is responsible for each aspect of a patient's management, where they are under a section and transferred to BHNFT (S17 Leave). Enclosed with the response to the Regulation 28 Report is the jointly agreed action plan, timescales and governance arrangements to ensure that Part 5 of your concerns are fully addressed. (EXHIBIT 1). We hope that this response provides assurance to you and the family of Mrs Pickering, that the concerns identified have been taken seriously and addressed by th e two organisations.