Dear Miss Crawford, The Death of Richard Scott-Powell - A Regulation 28 Report Further to the email of 19th April 2022, sent on your behalf by , I have pleasure in providing this response. We accept your findings that our record keeping and monitoring of Mr Scott-Powell showed variability, with some entries mentioning that his vital signs were ‘okay’ (but without recording the actual measurement), and with a NEWS2 score that was not followed by appropriate escalation. NEWS2: Holy Cross has a high number of patients who have prolonged disorders of consciousness, spinal cord injury and other conditions where standard NEWS2 scores cannot be applied reliably. Specifically, vital signs for a patient who is NOT unwell may fall outside of what is considered to be the normal range, resulting in abnormal NEWS2 scores. At least 2/3rd of patients at Holy Cross fall into this category. A NEWS2 chart was employed on 13th January 2021, with two measurements recorded at 2.50am and 6.00am. It has not been possible to ascertain why this monitoring approach was adopted for Mr Scott-Powell, a patient with spinal cord injury, but a high NEWS2 score should, in any case, have triggered closer investigation. The NEWS2 chart was set aside after the second set of measurements at 6.00am and was not used again. Training (clinical decision making / patients at risk) - As part of a wider range of learning and development courses, training is provided to the ward team to facilitate clinical decision-making and escalation as follows: Clinical Decision Making (Registered Nurses), Identifying Patients at Risk (Health Care Assistants), NEWS2 (Registered Nurses and HCAs) and Sepsis (Registered Nurses and HCAs). The first two courses are in-house, with NEWS2 and Sepsis being online courses (containing standard methodologies/protocols). We are in the process of repeating training in these areas for all relevant staff.

The Congregation of the Daughters of the Cross of Liege. Registered Charity 1068661. A company limited by guarantee and registered in England. Registered Company Number 3492921. Registered Office Address: 29 Tite Street, Chelsea, London, SW3 4JX. In light of the above, we  have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy. We are also implementing an Electronic Patient Record System in the second half of 2022/23. This will provide better standardisation over paper records, and will require measured values to be entered (rather than a narrative ‘okay’). Finally, at the time of Mr Scott Powell’s diagnosis of Covid-19 (13th January 2021), the ward was beginning to manage a growing number of positive cases among patients, while at the same time experiencing staff reductions due to self- isolation and Covid infection. It was a time with multiple emergent challenges, and was unprecedented. We strive for continual improvement and believe that the actions proposed will improve our response should a similar situation arise. With kind regards,

Chief Executive