Dear Mr Pollard, Re: Regulation 28: Report to Prevent Future Deaths following Inquest into the death of Wilfrid Pearson (Deceased) write further to your letter received on the 54h March 2016 enclosing Regulation 28 Report issued at the conclusion of the inquest touching upon the death of Wilfrid Pearson, which took place on 22nd February 2016. am, of course, sorry that you had cause to issue this report: hope to be able to address your concerns, as set out in section 5 of your report; to your satisfaction, in this letter. have addressed the areas of concern, adopting the same numbering in section 5 of your report as follows: You stated: The protocol for the observation, diagnosis and treatment of Status Epilepticus was written by the Consultant Neurologist who gave evidence to me. There was some doubt as to whether the document had been properly updated ad whether and how it was promulgated to all the relevant medical staff including locum doctors am informed that since Mr Pearson's admission in April 2014 nearly years ago, Dr Douglass has revised the Trust's Status Epilepticus Policy on two occasions, Firstly in direct response to the admission of Mr Pearson and additionally at the time of review in
2015. The policy has been revised to assist clinicians in able to more easily review and understand the appropriate steps to take when patient presents with Status Epilepticus: The revisions were made by direct reference to recent guidance o Status Epilepticus published in the Lancelet Medical Journal, Please find enclosed a copY of our current policy: As well as making improvements to the Trust's local policy, steps have been taken to ensure all clinicians at the Trust have awareness of the policy: It has been included as part of the training of Junior Doctors, and has been discussed with the Trusts medical teams: The policy is also easily available for clinicians on the Trust's intranet.

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Tameside Hospital NHS] NHS Foundation Trust The Trusts Education Department have confirmed that Status Epilepticus Policy will now be included as part of the Junior Doctor Grand Round (this is the training programme that all Junior Doctors must complete): The Trust's intranet has search facility for documents which directs staff seeking guidance to documents including the Status Epilepticus Standards. The search also directs staff to the NICE Guidance Quality Standards for Epilepsies. The medical and nursing notes left much to be desired in terms of their clarity, accuracy and completeness am disappointed that HM Coroner found the medical and nursing records left much to be desired and am sorry that you found this to be the case: HM Coroner will be aware that individual nursing and medical clinicians are responsible for their own professional standards The Trusthas a standard for medical record keeping and expects records to be timed and reflect an actual chronology: The Clinicians carrying out the assessment should document the time the assessment was carried out as well as the time of the medical This is our Trust standard and the Trust encourage and promote this: The Trust has, since Mr Pearson's admission, revised some of the nursing documentation and reinforced the role of Ward Managers a Matrons in monitoring the quality of documentation completed by staff. The Trust's Clinical Audit programme, the Trust's Clinical Lead for Clinical Audit has been working with doctors in training and audits have been undertaken which include aspects of medical clinical documentation: There was no understanding of the need for and method of escalation of the care to the HDU or ITU and indeed according to the expert witness instructed by the Trust the impression is that the ITU doctors did not consider that the brain protection was a high priority in Mr Pearson's case The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient's clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admissionlescalation and this was revised in 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to staff on the Trust's intranet: The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection: They have been reviewed by the CQC as an independent third party in April 2015. There appears to have been a stress on the junior medical staff and was told that the ITU Registrar refused to attend the Ward but it is not normal for the ITU registrar to refuse to attend and one of the junior doctors said that we were short staffed and overstretched: This seems to have added to the omissions of care which were apparent: The Trust recognises observations made by HM Coroner that in many NHS Trusts nationally medical staffing is challenging and that due to the national availability of staff there has been a reliance on locum medical staffing at Tameside Hospital particularly in emergency and acute medicine areas. The Trust also acknowledges that the quality of care patients receive is dependent on the support and continuity of substantive staff who know the hospital and the policies and procedures: This is why we have taken medical staffing seriously:

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Tameside Hospital Wil NHS Foundation Trust Since the time of mr Pearson's admission the rotas for medical staffing have been reviewed t0 maximise appropriate levels of senior cover and to monitor the levels of medical stafiing: These take into account the mix in relation to substantive staff and locum staff. The Trust maintains an ongoing recruitment programme and has been working with Health Education North West and junior doctors to improve the experience of junior doctors in training and to attract medical staff long term: Additionally the engagement and support provided to Junior Doctors and cover provided by Consultants has been actively reviewed by the Medical Director alongside other work which forms part of the processes for the medical staff revalidation programme. The Trust also implemented more robust monitoring of study leave and staff sickness these include 'keep in touch' and ways in which staff who are on sick leave can be supported back to work even if are not clinically active to provide advice and guidance to colleagues_
5. The deceased "absconded": He was brought back to the ward by security: was told that no DOLS order was made or even contemplated, and he was not subject to compulsory detention under the Mental Health Act; therefore one has to ask where they derived the Legal Authority to detain the patient? Again am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient: would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered, The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in 2014 and who also monitors that processes are followed. The works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCAIDOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS this is open lo all staff in the Trust: In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promoted the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins 'Catch up with Karen' and posters have been distributed and displayed across the The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS. Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity: We have been deemed to have improved these significantly: am sorry you had cause to issue this Regulation 28. wouldlike to take this opportunity to emphasise that do take your concerns very seriously: hope that have responded to your concerns and reassured you of all that the Trust has already undertaken and is currently undertaking, in order to prevent the recurrence of a similar set of circumstances in the future_

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Tameside Hospital NHS] NHS Foundation Trust Should you have any further questions arising from the contents of this letter, please do not hesitate to contact me_