Dear Dr Earland RECEIVED 3 JUN Z08' Charles Ward Deceased Inquest 25 March 2014 Coroner's Rule 28 Report Thank you for your letter dated 14 April received on 16 April 2014 enclosing a cOpy of your Rule 28 report: note you had requested a response in section of your report by 2 June 2014. note the concerns identified during the course of the Inquest those being; non-contemporaneous record keeping and failure to record and deliver up all medical records to the Coroner and disposal of the nasogastric tube in question making your investigation much more difficult: am pleased to note that you received the SIRI report and action plan relating to this incident showing that all actions were complete. will therefore not forward another copy with my letter as understand this already forms of your file also understand that you were provided with the Trust's current Nasogastric Tube Policy during the course of the Inquest was sorry to hear that on this occasion, no contemporaneous note was made by the staff_nurse_in question involved in this patient's care during the shift when the patient became unwell staff nurse in question who gave evidence at the Inquest; has been reminded that contemporaneous record keeping is necessary at all times. He is aware of the confusion and difficulties this caused to your service, the pathology service and the police_ understand that Staff Nurse made a detailed record when he next came back on shift 24 hours later but this did not immediately find its way to the original notes which were by then with the_pathology service apologise on behalf of the Trust for this error understand that Staff Nurse in his evidence at the Inquest did reflect on this and apologised for this error and understands consequences this has caused. ExecPASIAMPICorrespondence/2014/Dr Earland
29.05.14 WZK856 04/13 May the part the the

Royal Devon and Exeter NHS NHS Foundation Trust The requirement for contemporaneous record keeping is given high profile within the Trust: Following feedback from the Care Quality Commission and the Trust's own review processes_ our staff accept, understand and recognise the importance of excellent documentation; Improved documentation can be directly linked to the quality care for our patients_ Our work around "Understanding Care" will have a focus on care planning; which is how we document the care our patients should receive and how this enables improved communication between professionals and with the patient and family. "Understanding Care" is work stream of the Trust's Nursing & Midwifery Strategy: Each year a work stream is created and this year it is documentation: We' are our Care Quality Assessment Tool (CQAT) process, to ensure that documentation is given a higher priority in scoring: Case notes are audited through various review processes to ensure compliance with standards and remains a very high priority within the Trust. In relation to the disposal of the nasogastric tube in question, understand that as this patient did not die immediately following the discovery of this incident; the NG tube was not retained in this particular case_ Mr Ward was having ongoing care in ICU and when it became apparent that the NG tube itself was not faulty, it was not retained: In retrospect, it would have been helpful and appropriate for this tube to been retained_ In the latest incident reporting policy, understand that this will be more explicit in relation to retaining equipment and devices; Awareness will be raised within the Trust in relation to these issues_ am very sorry that this death occurred and the Trust has taken this matter very seriously and learnt lessons from these failings _ hope this additional information will reassure you that sufficient and satisfactory steps have been taken to ensure contemporaneous record keeping and full records being forwarded to you are in place In addition, when to retain equipment and devices is reviewed as an ongoing process. If | can provide you with any further information, please do not hesitate to contact me_

Dear Dr Earland_ Roger Clive DUGGAN Deceased Inquest: 5 March 2014 at County Hall; Topsham Road, Exeter Coroner's Rule 28 Report Thank you for your letter regarding the above inquest under Paragraph 7 of Schedule 15 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Please find the Trust's response below: Recommended Action Yqur Reculation 28 Report states that there is a case for examination of the staff response to calls on 10 February 2013 and an assessment of whether further training in the evaluation of psychiatric emergencies is required. Response Following notification of the incident by Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG) the Trust conducted an investigation into the ambulance response to calls. This investigation was completed in May 2013 and forwarded to NEW Devon CCG for inclusion within the Serious Incident investigation which they led on. A_ meeting chaired by NEW Devon CCG, and attended by agencies involved, subsequently took place to discuss the findings of the investigation and develop an action plan. A copy of the investigation report is appended to this letter; unfortunately this Trust was aware that the inquest into Mr Duggan's death was taking all not

place as we would have been able to provide you with a copy of that report and details of other actions that have taken place since the incident which would have addressed the concerns raised in the Regulation 28 report The investigation concluded that there appeared to be a misunderstanding by the Crisis team on the correct procedure for requesting ambulance transport for patients who required assessment or have pre-arranged admission which subsequently led to communication difficulties Following the meeting chaired by NEW Devon CCG, information was disseminated regarding the correct process for arranging transport and would have resulted in an appropriate ambulance response. In order to provide some context into theroleof the Emergency Medical Advisor (EMA) who received the telephone calls from would like to explain the triaging system that the Trusts Clinical Hub uses to categorise incoming calls: The triage system used by the Trust is called 'NHS Pathways' and all 999 calls to the Trust are triaged using this system. When a call is received by the Clinical Hub the caller is questioned and the outcome of those questions determines the classification according to the patients clinical need: This is to ensure that emergency medical help is sent to life-threatening incidents without delay: The system aims to have a clinically robust and consistent, yet compassionate and understanding; approach to telephone triage and it is designed to effectively identify the level of care needed_ The system is also able to signpost callers to more appropriate care pathways and therefore more tailored to the caller's requirements_ An alternative pathway includes a wide range of healthcare alternatives that is considered a more appropriate option than conveying a patient directly to Accident and Emergency Departments by ambulance: There are broad range of professional health care providers who are accessible to members of the public to treat and advise patients, for example GPs; out of hours providers, minor injury units, treatment centres and pharmacies. The Trusts investigation identified that not all the appropriate 'NHS Pathways' questions were asked by the EMA and that should have sought further advice from Clinical Supervisor within the Clinical Hub. As of the investigation the EMA completed a reflective practice on their involvement in this case. Following this incident; in July 2013, the Trust upgraded its version of 'NHS Pathways' to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate: Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway; this training is also provided for all new Clinical Hub staff as part of their 'NHS Pathways' training and includes scenarios_ In order to monitor the Trust's response to patients with Mental Health concerns and develop robust policies, procedures and guidelines to improve the quality of care provided, a Mental Health Group has recently been established. This Group is chaired by a Trust Clinical Development Manager and is attended by managers from areas of the Trust; they part key

including the Clinical Hub. A copy of the draft terms of reference is attached for your information. hope the information contained within this letter provides you with assurance that steps have been taken by the Trust; in liaison with the local health community; to learn from this tragic event If you require any further information, please do not hesitate to contact me.