NHS North East and North Cumbria
Integrated Care Board
Action Taken
• The standard ICB Nursing Needs Assessment form has been re-issued to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW). • The ICB has requested that CNTW remove the allergy section from their version of the form. • The ICB will work with CNTW to ensure that staff are aware of the correct form to use and the importance of accurate record keeping. (AI summary)
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Dear Mrs Combes,
Re Regulation 28 Report to Prevent Future Deaths - Oriel Vasey
Thank you for your Report to Prevent Future Deaths dated 4th March 2026 concerning the death of Mrs Oriel Vasey on 5th March 2025. In advance of responding to the actions raised in your report, I would like to express my deep condolences to Mrs Vasey's family.
The response from the North East and North Cumbria Integrated Care Board (NENC ICB) to your concerns is as follows:
Concerns: This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.
Following an internal investigation, I can confirm that the form in question is an 'assessment of nursing needs' proforma, designed by the ICB. The purpose of the form is to bring together the information from a patient's assessment of needs and in order to make recommendations regarding eligibility for NHS All Age Continuing Healthcare (AACC) funding. The version of the form held by the ICB does not request any allergy information and there is no section to record allergies.
The form used by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) appears to have been adapted to include a section on allergies.
2
This adapted form was completed by a member of staff at CNTW who used a form already completed for another patient and overwrote that patient's details with those of Mrs Vasey's, mistakenly leaving the information to the previous patient's allergy history in situ.
To future safeguard against this reoccurring the ICB have implemented several actions as follows:
• The standard ICB Nursing Needs Assessment form has been amended to make it clear the form is the property of the ICB and should not be modified.
• The new form has been circulated to all All Age Continuing Care teams across the ICB's geographical footprint including version control.
• The updated form has been circulated to NENC NHS Trusts and will be available on the ICBs website.
• We have spoken with CNTW, and they have assured us that the adapted form has been taken out of circulation.
• The ICB will check the use of the correct form in all our panels to ensure no other adaptions have been made by partner agencies and will continue to do so periodically.
In summary, to address the concerns raised, the only form available from the ICB does not contain allergy information, and it explicitly states the form must not be modified.
Thank you for bringing this important patient safety concern to my attention and please do not hesitate to contact me should you require any further information.
Re Regulation 28 Report to Prevent Future Deaths - Oriel Vasey
Thank you for your Report to Prevent Future Deaths dated 4th March 2026 concerning the death of Mrs Oriel Vasey on 5th March 2025. In advance of responding to the actions raised in your report, I would like to express my deep condolences to Mrs Vasey's family.
The response from the North East and North Cumbria Integrated Care Board (NENC ICB) to your concerns is as follows:
Concerns: This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.
Following an internal investigation, I can confirm that the form in question is an 'assessment of nursing needs' proforma, designed by the ICB. The purpose of the form is to bring together the information from a patient's assessment of needs and in order to make recommendations regarding eligibility for NHS All Age Continuing Healthcare (AACC) funding. The version of the form held by the ICB does not request any allergy information and there is no section to record allergies.
The form used by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) appears to have been adapted to include a section on allergies.
2
This adapted form was completed by a member of staff at CNTW who used a form already completed for another patient and overwrote that patient's details with those of Mrs Vasey's, mistakenly leaving the information to the previous patient's allergy history in situ.
To future safeguard against this reoccurring the ICB have implemented several actions as follows:
• The standard ICB Nursing Needs Assessment form has been amended to make it clear the form is the property of the ICB and should not be modified.
• The new form has been circulated to all All Age Continuing Care teams across the ICB's geographical footprint including version control.
• The updated form has been circulated to NENC NHS Trusts and will be available on the ICBs website.
• We have spoken with CNTW, and they have assured us that the adapted form has been taken out of circulation.
• The ICB will check the use of the correct form in all our panels to ensure no other adaptions have been made by partner agencies and will continue to do so periodically.
In summary, to address the concerns raised, the only form available from the ICB does not contain allergy information, and it explicitly states the form must not be modified.
Thank you for bringing this important patient safety concern to my attention and please do not hesitate to contact me should you require any further information.