Dear Ma’am,

Regulation 28 report to prevent future deaths – Mr Delwyn Preece (

Thank you for your Regulation 28 Report to Prevent Future Deaths concerning the death of Delwyn Preece and for your offer to extend our deadline for reply. As indicated, we wanted to respond to time recognising the harm suffered by his family, and diligent work here since.

On behalf of the Trust, I again extend our sincere condolences to Mr Preece’s family. Please be assured that your report has been given the highest priority and serious consideration at executive level. My colleagues, our Chief Nurse, and Chief Medical Officer, have developed a response plan which I, among others have then tested for sufficiency, pace and impact. We have already implemented a series of changes in response to this case, even prior to the issuance of your report, and we will maintain oversight of these improvements through our quality and safety governance processes. Our approach is focused on strengthening systems, standards and oversight so that learning translates into tangible improvements, rather than attributing blame to individuals. The Board, meeting in public, considers all PFD notices and response plans: and will visibly track the actions outlined here.

Section 17 Leave – Strengthened Documentation and Patient Safety

The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to informal patients) has been revised to clarify and strengthen documentation requirements around leave. Importantly, these changes were put into effect before your report was issued. We have mandated that:

• Pre-leave assessment: Before any patient goes on leave, a thorough pre-leave mental state and risk assessment must be conducted and documented.

• Post-leave review: Upon the patient’s first return from leave, staff must record a timely review of the patient’s condition and any issues arising from the leave.

• Proportionate documentation for short, repeated leaves: For subsequent brief leave episodes (such as multiple short “fresh air” breaks on the same day), documentation can be proportionate, unless there is a material change in the patient’s presentation. This adjustment is to ensure that staff can comply with the policy in practice while still maintaining safety oversight.

• Recording key details: For every period of leave, the patient’s appearance and clothing, along with the expected return time, must be noted to support prompt escalation if the patient does not return as expected.

These amendments ensure a safer and more auditable standard of practice, especially for informal patients who may take frequent short leaves. The revised approach retains the essential safety intent of our previous policy while making it realistically deliverable and enforceable in day-to-day care. The Section 17 leave policy document has been formally updated and version-controlled under the authority of , Chief Medical Officer.

Inpatient Clinical Documentation – Contemporaneous Entries and Retrospective Recording

The Trust has also reinforced strict standards for clinical record-keeping in our inpatient services. All entries in patient records must be contemporaneous – meaning written as soon as possible after care is delivered – rather than batch-written at a later time. Nursing staff have been explicitly instructed to avoid so-called “long day entries” at the end of a shift. Instead, there should be distinct documentation across morning, afternoon, evening and night shifts to reflect the patient’s ongoing status and care. These expectations have been clearly communicated and embedded into our documentation policy.

Retrospective entries (notes added after the fact) are now expected to be rare and promptly handled. If, in an exceptional circumstance, a clinician must add a note retrospectively, the entry must be clearly marked as “retrospective”, must state the reason for the delay, and should be completed as soon as possible – within the same shift whenever feasible. This standard aligns with our existing policy guidance that records should be completed as soon as practicable after an event, and that any delayed entry be explicitly identified and justified. By tightening these practices (and discouraging any retrospective entries beyond 24 hours in 24-hour inpatient settings), we aim to preserve the integrity and reliability of the clinical record for patient safety and continuity of care.

Systems and Oversight Enhancements – Real-Time Recording and Audit Processes

We are bolstering our systems to better support these documentation standards. The Trust has increased the availability of point-of-care electronic devices on wards so that staff can document care in real time at the patient’s bedside. This practical step is intended to make timely record-keeping more achievable in busy clinical environments.

In particular, we are implementing reports to flag any clinical notes entered more than 24 hours after the event, enabling targeted management review and additional support or training where needed. These system improvements will give us greater oversight and help ensure compliance with documentation standards across the organisation.

We also recognise that in some community services, immediate electronic documentation is not always practical. Even so, any entries in community records must still be transparently identified as retrospective and include a justification for why real-time entry was not possible. The distinction between continuous inpatient care and intermittent community contact is acknowledged, but the principle of transparency in record timing remains consistent.

Investigation and Audit Trail Awareness

It is essential that those reviewing incidents and conducting investigations are fully informed about interpreting record-keeping timestamps. We have reiterated to our investigation teams how our electronic patient record system (SystmOne) denotes retrospective entries. A clock symbol in the system clearly flags an entry that was made later than its event time, and on-screen hover text displays the actual date and time when the entry was added. We have emphasised that investigators must be trained to recognise and understand these audit trail indicators to ensure no retrospective entry goes unrecognised during a review. This measure is part of our commitment to robust internal learning: by improving investigator competence in using these system tools, we further safeguard the quality and accuracy of our investigations and, ultimately, patient safety.

Effective Implementation and Ongoing Oversight

We have widely publicised internally the need for us to act and change. I issue a weekly video message to staff, which is typically watched by 1,000 of our 4,100 people, and which spoke to the issues you found and our response; our bi-monthly Learning Matters magazine has included material to the same effect. I know that working instructions from our Chief Nurse to ward managers have been issued.

But the three principal routes to oversight are as follows:

• The introduction of our trust wide always measures (of which there are five) will give us visibility on key 100% compliance issues daily. Always measure 5 will require teams to record any care or service that is not accessible or available, including untaken leave.
• Our audit of contemporaneous documentation has already begun, and a focused audit on S17 leave both for detained and informal patients will take place in Q2 (August) and again in Q4 (February – testing the revised policy framework we have already implemented.
• The Board’s Mental Health Act committee will alter its reporting and approach for this year to have a specific additional focus on informal patients, in addition to its primary scrutiny of lawful detention.

Nothing above detracts from the sadness we feel at Mr Preece’s passing, but we do believe we have a meaningful and structured response intended to prevent others suffering. Should you require any further information or clarification on the measures outlined above, please do not hesitate to contact me.