Dear Mr Osborne_ RE: Inquest touching the death of Lorraine Joyce Bird On the 10 August you wrote to NHS England requesting response to the Regulation 28 report in relation to Lorraine Joyce Bird: Firstly, would like to express my deepest sympathy to the Bird family. NHS England has received assurance from Colchester Hospital University NHS Foundation Trust and East and North Hertfordshire Trust on the actions taken following the Coroner Rule 28 Regulation Report for the death of Lorraine Joyce Bird Further full detail is provided in the letters of correspondence (attached) from Mrs Lucy Moore (Chief Executive, Colchester Hospital University NHS Foundation Trust dated 25 September 2015 and Mr Nick Carver (Chief Executive, East and North Hertfordshire NHS Trust), dated 15 September 2015. Specific assurances with regard to the concerns raised by the Coroner are addressed as follows: The Colchester Hospital University NHS Foundation Trust has worked closely with the Clinical Commissioning Group ("CCG") to develop pathway to enable local implementation of the guidance for the use of thromboprohylaxis in ambulatory patients requiring temporary limb immobilisation. AIl relevant parties both within the hospital and community High quality care for all, now and for future generations OCT 2015 7c

services have been actively involved in this process which has been signed off by Trust Thrombosis Management Board on the September 2015 and the North Essex Medicines CCG Medicines Management Committee on 29 September 2015. An Education programme for the Emergency Department has been introduced to support the implementation of the guidance. The new pathway across primary and secondary care will commence on the 2 November 2015 as funding is not an issue for implementation. The commissioning CCG will monitor through the Quality Review Meetings with the Trust implementation and compliance against the guidance. The East and North Hertfordshire NHS Trust have implemented appropriate clinical guidance and protocol for patients attending for treatment at the Plaster Room_ This interim guidance will be reviewed by the Clinical Commissioning Group (CCG) Medical Adviser, pending the outcome of the review of NICE guidelines by the Royal College of Medicine and the issuing of the full policy: The CCG will ensure the Trust provides update guidanceltraining to all clinical staff within the Plaster Room_ The commissioning CCG will agree and monitor through the Quality Review Meeting clear date for completion of the revised policy and implementation of it (interim guidance already in place): The commissioning CCG audit the Trust on compliance against the interim guidance and the Policy once completed alongside the associated documentation The commissioning CCG will agree a timeframe for the patient information leaflets to be updated and ensure that these are available to patients, in light of this new guidance. The Trust has reviewed all patient information available in the Plaster Room and has ensured it contains effective information to alert patients to potential complications and to recommend urgent contact with the Plaster Room or Emergency Department in case of pain or complications The Trust will update existing patient information regarding the importance of maintaining mobility whilst having a limb in a cast. Patient information will be updated in line with the NPSA guidance on suggested minimum mobilisation time which in turn can help prevent the complications of immobility, including thrombosis. The Trusts and commissioning CCGs have put in place systems to ensure that the risk of such a tragic incident reoccurring are mitigated and that all patient information and clinical guidance is updated and implemented in line with national protocol and guidance. As part of NHS England's role in CCG assurance and oversight; Midlands and East (Central Midland and East) will ensure compliance with the above corrective High quality care for all, now and for future generations will

actions through formal quarterly reviews with the CCGs and monthly NHS England assurance forums with the Nursing and Medical teams

From Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department Richmond House of Health 79 Whitehall London POCS 953428 SWIA 2NS Tel: 020 7210 4850 Dr E. Carlyon Senior Coroner The New Lodge 2 0 OcT 2015 Newquay Road Penmount Truro TR4 9AA Czlax Thank you for your letter of 7ih August 2015 following the inquest into the death of James Adams I was sorry to hear of Mr Adams' death and wish to extend my condolences to his family. I understand that since Mr Adams' death the working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved and that a Memorandum of Understanding has been drawn up. Your main concern in this case was the lack of acute psychiatric beds in Comwall and how this could continue to have a adverse impact on the care of mental health patients in this area: Commissioning mental health inpatient services is the responsibility of the local Clinical Commissioning Group (CCG) in this case the NHS Kernow CCG. It commissions services for Cornwall from the Corwall Partnership NHS Foundation Trust: Inote that you have sent your letter to both NHS England and Kernow CCG. I can advise that Sir Bruce Keogh; National Medical Director of NHS England, is responding to you on behalf of NHS England I commend Sir Bruce's reply: NHS England's role is to oversee the commissioning functions of CCGs. Kernow CCG has agreed to carry out a full review both of acute psychiatric beds in Cornwall and the staffing of the place of safety service and will produce an action plan and commissioning strategy. The implementation of this plan will be monitored by NHS England.

Iam grateful to you fc bringing the circumstances of Mr Adams' death to my attention and hope tha} you find this reply helpful. Iuu~ BEN GUMMER