From the Lord Prior of Brampton Parliamentary Under Secretary of State for NHS Productivity (Lords) Department of Health Case 1001818 Mr J. Pollard Richmond House 79 Whitehall Senior Coroner London Coroner' s Court SWIA ZNS 1 Mount Tabor Street Tel: 020 7210 4850 Stockport SKI 3AG 2 DEC 2015 Psua' Thank you for your letter of 4 November 2015, following the inquest into the death of Hilda Haughton: I was sorry to hear of Mrs Haughton's death and wish to extend my condolences to her family. I was concered to read of the injuries sustained by Mrs Haughton whilst she was a patient at Tameside Hospital. I note that you have requested a direct response from the hospital in relation to the improper use of cot rails on Mrs Haughton's bed and a lack of candour shown by hospital staff to the family: I expect Tameside Hospital to address these concerns, and I have asked to see a copy of its response to you: The issue you raise for the Department concerns the speed of closing for fire doors held open by electromagnetic devices, in hospitals in England. The system means that hospitals can programme the at which their fire doors automatically close in the event of a fire or other emergency. However; the faster the closing time, the greater the force with which the doors close. You report that Tameside Hospital in the wake of Mrs Haughton'$ death; increased the closing time of their fire doors from three seconds to six seconds to reduce the speed and force with which the doors close. However you question whether this is an adequate response and suggest that the potential dangers of fire doors, held open with similar types of door fastener; need to be raised with all hospitals. fully speed has,

The relevant British Standard covering the requirements for such devices is BS EN 1154: 1997 Building hardware Controlled door closing devices Requirements and test methods. This British Standard allows a degree of flexibility in the speed at which doors should close of between 3 and 20 seconds. It is not therefore in the Department'$ power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards Having considered the circumstances of this particular tragic incident and made reference to the British Standard; the Department has issued an Estates and Facilities Safety Alert to the NHS in England: The Alert reference is EFA/2015/006 and was published via the Department'$ Central Alerting System on Thursday, 3rd December 2015. The alert will also be published by the devolved health administrations in Wales, Scotland and Northern Ireland (who have been consulted on the content of the alert) on the same The purpose of the alert is to raise awareness of the circumstances of the incident you have reported and to set out necessary action to be taken, within defined timescales, to reduce the risk of similar incidents in the future: The actions set out in the alert are not restricted to fire doors held open by electromagnetic devices, and are intended to cover all self-closing fire doors. This alert follows an earlier safety alert issued to the NHS in 2004, which stated that: remote or unsupervised release of self-closing fire doors injure occupants. The responsible person should only carry out fire alarm tests andlor remotely release self-closing fire doors if arrangements (so far as is reasonably practicable) are in place to safeguard the occupants from injury, eg. by a door striking the occupant A copy of the Estates and Facilities Safety Alert is attached for your inforation. [am grateful to you for bringing the circumstances of Mrs Haughton'$ death to my attention and hope that her family can take some comfort from the actions the Department is taking to reduce the risk of a similar occurrence in the future: L L: DAVID PRIOR day: Any - may Mu) S~^

Dear Mr Pollard Inquest: Hilda Haughton write in response to your Regulation 28 Report dated 29 October 2015, issued at the conclusion of the inquest touching upon the death of Hilda Haughton, which took place between 26 and 27 October 2015. In your report you have raised one concern with Tameside Hospital NHS Foundation Trust about a fall which occurred on 6 2015 on Ward 41 at Tameside General Hospital. Your concern is that there was "lack of candour" by the hospital staff in respect of that fall. this response provides you with the reassurance you require to this concern. hope that your concern can be addressed firstly with specific reference to the incident referred to on 6 May 2015, as well as by explaining to you the Trusts attitude and culture regarding openness and candour: Incident on 6 2015 wish to take this opportunity to make it clear that the incident on 6 2015 did not invoke the Statutory Duty of Candour under Regulation 20 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An unwitnessed fall occurred on or around 04.50 on 6
2015. The medical records demonstrate that following this Mrs Haughton was given head-to- Everyone Matters ^ i . Your May hope May May May

The Trust's attitude towards candour The Trust has been proactive in relation to ensuring Duty of Candour; Trust policies been reviewed and consideration continues to be given regarding statutory obligation when reviewing and updating policies and procedures. The Trust was comprehensively inspected by the CQC in this year and commented in their report that were particularly pleased with the progress the Trust had made with candour and with the governance processes put in place to support this_ along with my leadership team have strong leadership ethos regarding candour and believe that leading by example is in demonstrating the Trust's commitment in relation to candour. My Director of Quality and Governance and both regularly meet with families and patients to discuss their experiences and to apologise when go wrong During February and March 2015 the Trust ran several workshops which were delivered by external facilitators and were attended by a wide range of staff which focused on investigations, Root Cause Analysis and incorporated communication and supported the culture of reporting and openness_ We trained over 75 staff in this and Open and Duty of Candour was central to the training: In order to ensure the Trust is transparent and learns from incidents, complaints and claims we commissioned significant number of independent expert reports to ensure transparency and openness with our patients, relatives and carers which we share with them and with our staff for learning: The Trust's processes for openness and candour encourage local meetings with medical and nursing and support staff with patients, families and carers to discuss management plans and promote effective communication and early resolution of any questions or concerns_ The Trust has commissioned number of patient experience films with our patients and their relatives to ensure that their perspective and their experiences are shared with staff and that we learn from these. One of the consistent messages in these is the importance of communication and hOw this effects the patients and families perception and how this influences their view of the Services in relation to openness and candour: These are available on the Trust intranet and public internet and focus on both negative

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