Dear Mrs Lake Re: Mr Nyall Brown write in response to your prevention of future deaths report dated 15 April 2019 following the conclusion of the inquest into the death of Mr Nyall Brown. know you will share a copy of this response with Nyall's family and would like to express my condolences for their loss. Nyall's death is a tragedy and it is essential the Trust takes all opportunity to learn: The report recognised the investigation completed by the Trust and its identification of a number of areas of learning: It highlighted a further opportunity for learning following evidence received at the inquest, specifically that Nyall's care records were not reviewed to an appointment with him. The importance of having as much information as possible is critical to informing clinical judgement and outcomes during an appointment The Trust has commissioned learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager commencing in June 2019. Alongside a focus on the regulatory; legal and professional responsibilities each clinician holds with respect to record keeping and communication; the session will include content related to the importance of preparation ahead of appointments_ To positively influence the Trust's improvement work we are strengthening the clinical and service leadership in order to ensure there is the necessary breadth of skills and resource to lead safe and effective services_ Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience. The Trust has recruited to the majority of these roles which will be fully effective from September 2019. function of this new approach will be the accountability to share learning, implement and monitor recommendations from serious incidents_ The Trust will gain assurance these interventions are working through a number of indicators. This will include audit; user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement: Thank you for providing this report to the Trust.