Bruce Caulfield

Dear Mr Morris Re: Inquest into the death of His Honour Bruce Caulfield DOB: 2 April 1945 – DOD: 19 August 2025 Response to Prevention of Future Deaths Report I write in response to the Prevention of Future Deaths Report issued to Manchester University NHS Foundation Trust (“the Trust”), pertaining to Wythenshawe, Trafford, Withington and Altrincham (WTWA) Hospitals, dated 5 February 2026, following your conclusion of the inquest on 4 February 2026 into the death of His Honour Bruce Caulfield. I am grateful for the opportunity to respond to the matters of concern identified following the inquest. On behalf of the Trust, I offer our sincere condolences to His Honour Bruce Caulfield’s family. I asked the WTWA Hospitals Medical Director, and Director of Nursing, , to oversee the three matters of concern you have raised. We have considered the evidence heard at inquest, the Assurance Report previously disclosed to the Court (pages A20–A45

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services and appendices), and have undertaken further review at WTWA Hospitals and Trust level to ensure that appropriate assurance can be provided. We regret that the information previously available did not provide you with sufficient assurance. Each matter is addressed in turn below, and I have also outlined the actions taken and learning embedded. MATTER OF CONCERN 1 In relation to the events leading up to His Honour’s death at Trafford General Hospital on 19th August 2025, you are concerned as to how long transpired between a family member expressing concerns about a significant change in his condition and requesting a review by a doctor, and any medical review actually taking place. This concern has been reviewed by , Associate Medical Director for WTWA Hospitals. At 06:53 hours on 19 August 2025, His Honour’s clinical observations were undertaken and documented in accordance with the Trust’s Adult Early Warning Score (EWS) Policy. These observations resulted in an EWS of 1, which under Trust policy indicates clinical stability and would not routinely trigger an urgent medical review unless there was a documented change in condition. At 11:51 hours on 19 August 2025, a ward round was undertaken and , Resident Doctor, documented that His Honour was drowsy and rousable and recorded a medical management plan for the day. The morning of the 19 August 2025, His Honour had been hoisted into a chair at 08:30, supported with breakfast, and administered prescribed oral medication at 10:00, with regular nursing interaction documented throughout. We fully recognise and acknowledge the family’s account that concerns were raised that morning. This was not contemporaneously documented in the clinical record until the ward round took place. We accept the evidence heard at inquest and recognise that the absence of documentation represents an important learning point. Discussions are taking place throughout March 2026 led by , through team meetings and other forums, such as team brief, to ensure that all ward teams, which include Medical, Nursing, and Allied Health Professional (AHP) colleagues, understand that any concerns raised by relatives must be documented in the patient’s clinical record and treated as clinically relevant information, irrespective of EWS score. Family concerns with regards to patient deterioration will be referenced within local ward level safety huddles and documented. To be assured this has been discussed and cascaded to all teams across WTWA Hospitals, this action will be monitored at the WTWA Quality and Patient Safety Group, which is chaired by .

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services will oversee an action for all ward areas to re-read the Trust’s EWS policy, with specific reference in the policy regarding recognition and escalation of neurological change, including new or increased drowsiness. This will be overseen through the WTWA Quality and Patient Safety Group also. The Trust is rolling out Martha’s Rule, a national NHS patient safety initiative that empowers patients and families to request an urgent review and second opinion should they have concerns regarding the clinical condition of the patient. Oak Ward at Trafford Hospital has been identified as a pilot ward within the adult services roll-out. The pilot will commence in April 2026 and will be overseen by a Trust led oversight group and hospital site Quality and Patient Safety Groups. MATTER OF CONCERN 2 Having considered all of the evidence before the inquest with the utmost care, you are concerned that the approach to intentional rounding at Wythenshawe hospital in conjunction with other relevant nursing practices is insufficient to ensure vulnerable patients (such as those with cognitive impairment or the inability to eat or drink without assistance) receive adequate hydration and nutrition whilst on the wards. This concern has been reviewed by Chief AHP for the Trust. I regret that the evidence presented at inquest did not provide you with sufficient assurance regarding the points that you have outlined in the second matter of concern. As you may be aware, ‘intentional rounding’ is a term used to describe a practice in care delivery to patients during their hospital admission; it is a structured proactive nursing process where staff check on patients at regular intervals to address any key needs such as pain, communication and placement of items such as a call bell. Although the terminology ‘intentional rounding’ was used with regards to care provided on Doyle Ward, it is not a term that is widely used across WTWA Hospitals to describe what is a more comprehensive approach to care delivery, which includes assessment and implementation of care. This approach is provided to all patients, including those patients who require support with nutrition and hydration, and those patients with a cognitive impairment. Each inpatient area has an identified ‘nutrition board’ which is updated every shift for every patient. This board indicates to the team on the ward those patients who require assistance with eating and drinking including those that require support with feeding. This also includes identification of dietary needs such as diabetes or those in receipt of a modified diet. Where patients are identified as cognitively impaired, vulnerable and/or experience challenges with dexterity, reasonable adjustments are considered to ensure that patients are empowered in their care and recovery; this includes

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services adapted cutlery, modified menus and ‘finger foods’ where appropriate. The oversight of food and drink delivery at ward level is provided by the Registered Nurse, and this is incorporated into the current Trust wide mealtime standards. These standards are monitored using visual observation and audited via the Trust Clinical Accreditation Programme, as well as the mealtime peer audits. Nutrition and Hydration Screening and Monitoring Following His Honour’s admission to Doyle Ward on 23 July 2025, he was placed on food charts on 24 July 2025. This measure allowed staff to track his nutrition status closely and respond promptly to any emerging concerns. An audit of 49 patient records at Wythenshawe Hospital, completed in February 2026, found that 89% of relevant patients had food charts commenced appropriately. This enhanced audit will continue for the next three months to provide further assurance of consistent practice across WTWA hospitals. As part of His Honour’s nutrition and hydration management, he was placed on the ‘red tray system’ on 24 July 2025. The red tray is a visible prompt for staff, indicating that the patient is at high risk of malnutrition and requires assistance with eating or drinking. During his admission, His Honour required encouragement and support with both eating and drinking. It is documented that assistance was provided by staff, and there is noted documentation of family members being present at mealtimes. Assistance included direct feeding during mealtimes and frequent prompting to take fluids. All such interventions were documented in HIVE, the Trust’s electronic patient record system.

The Trust follows the MFT Adult Nutrition Screening Policy for Inpatients in the Acute Setting, which is informed by NICE Clinical Guideline 32 on nutrition support for adults. The Malnutrition Universal Screening Tool (MUST) is used to identify patients at risk of malnutrition and ensure timely and appropriate interventions are implemented. His Honour underwent a MUST assessment on 27 July
2025. The outcome of this assessment appropriately triggered a referral to the dietetic service, and His Honour was subsequently reviewed by a dietician on 30 July 2025. It is acknowledged that, in accordance with policy, the initial MUST assessment should have been completed within 24 hours of admission.

Compliance with MUST screening is monitored monthly via the Integrated Performance Report. This is reviewed by the WTWA Nutrition and Hydration Group, with oversight at the WTWA Quality and Patient Safety Group and the Management Group. Compliance rates for completed MUST screens for patients admitted to WTWA were 91.7% in February 2026 and 92.4% in January 2026. Performance is monitored in real time through HIVE to support active learning. A targeted action plan, overseen by the WTWA Nutrition and Hydration Group and chaired by the WTWA Hospitals

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services Deputy Director of Nursing is in place with trajectory plans to achieve 100% compliance by the end of March 2026.

His Honour had a hydration assessment carried out on 24 July 2025, which led to the commencement of fluid monitoring, with his intake and output documented. The Trust adheres to the MFT Fluid Balance Policy for Adult areas, which mandates hydration assessments to identify patients at risk and implement appropriate interventions, including the use of input/output charts. Compliance with hydration documentation is monitored through a live dashboard on HIVE. In January and February 2026, 95% of patients at WTWA had a hydration assessment completed within 24 hours of admission. This compliance is overseen by the WTWA Nutrition and Hydration Improvement Group.

Training Nutrition and Hydration Awareness training compliance for clinical staff is 98.6% at WTWA and 94.7% on Doyle Ward. Food Service Process Training, which includes the quality, safety and experience of food services for patients, is currently at 93.6% compliance, with Doyle Ward achieving 100%. Patient experience data relating to nutrition and hydration has been consistently above 90% since July 2025 and had increased further to 93.4% in January 2026. This feedback includes the quality and standard of food provided as well as the service from the staff. There is a multidisciplinary approach to nutrition and hydration, which includes working alongside housekeeping staff who are dedicated to each ward. The role of the housekeeper is to support the Ward Manager with the quality of patient food, and dining, and they are a key link and connection into the catering teams across the Hospitals. Shared learning for the housekeepers is undertaken via the WTWA Housekeeper Forum, which is chaired by a Matron to ensure collaborative working and consistency in the application of food standards. Monitoring and Audit The quality and safety of food and drink services provided to patients at WTWA is monitored through a variety of structured processes. These measures are designed to ensure that all patients receive appropriate nutrition and hydration throughout their stay whilst also providing the opportunity for learning and continuous improvement. These measures are set out as follows:

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
• Trust Clinical Accreditation Process

The Trust Clinical Accreditation process is a peer review of clinical areas across the Trust, and forms part of a wider assurance and learning framework. The process triangulates data from several sources including patient safety, patient experience, and clinical effectiveness and follows key lines of enquiry. This is triangulated with visual observation to conclude an overall accreditation position ranging from bronze (requires improvement) to gold (outstanding). The accreditations include a review of the Trust’s mealtime standards as well as a qualitative review of patients with a cognitive impairment, those who may lack capacity, and the application of safeguarding processes such as Mental Capacity Act (MCA), Deprivation of Liberty Safeguarding (DoLs), and best interest decisions. All accreditations are led by a Director of Nursing or Deputy Director of Nursing from another hospital in the Trust. Once the accreditation has been completed the clinical area receives a report which includes recommended actions to support continual improvement. Any immediate quality and safety concerns are highlighted at the time to the relevant Director of Nursing for action and oversight. During 2025, Doyle Ward achieved silver award status, which indicates the area is achieving a good standard.
• Patient Experience Feedback

Patient experience feedback forms an integral part of the Trust's quality and assurance framework. This feedback includes reports of incidents, complaints, and general patient observations inclusive of and not limited to nutrition and hydration. These inputs provide valuable insights into the quality of food and drink services and highlight any areas for improvement and /or good practice. This information is utilised to support improvements which are monitored through the WTWA Nutrition and Hydration Group and WTWA Patient Experience Group. The WTWA patient experience data relating to nutrition and hydration provision has been consistently above 90% since July 2025 and had increased further to 93.4% in January 2026. This feedback includes the quality and standard of food provided as well as the service provided by staff (as noted above). A patient experience report is presented quarterly to the WTWA Management Group chaired by , WTWA Chief Executive Officer. An area of focus is to ensure appropriate patient and carer representation on our Patient Experience Group, and this is being progressed by . This will help us to ensure that programmes of work undertaken are meaningful and reflective of the patient’s voice.

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
• Quality Care Round Audit

Internal auditing is carried out using the Quality Care Round audit, which reviews various aspects of patient care, including nutrition and hydration, the application of MUST risk assessments, food and hydration charts and fluid balance documentation. It also considers patient safety, communication and privacy and dignity, reasonable adjustment practices and DoLs documentation. This audit aims to ensure that care standards are upheld and that patients’ needs are met across WTWA. The Quality Care Round audit has consistently exceeded the Trust target of 95%, since April 2025. This data is presented for scrutiny, oversight and assurance at the WTWA Management Group.
• Peer Dining Audits Peer dining audits are another important monitoring mechanism; these are WTWA internal audits carried out by Matrons for areas that they do not directly manage, which forms an independent review; any feedback required on the day is directly to the Ward Manager and Matron directly responsible for the area. These audits focus upon six key elements that assess how effectively WTWA meets the needs of all patients, including those requiring assistance with eating and/or drinking. The audits evaluate compliance with established standards and identify opportunities for ongoing improvement in patient care. The six key indicators are identified below.
• Are patients who need assistance or who are on a food chart having meals served on a ‘red tray’?
• Is assistance being provided to open packages and cut up food if required including reasonable adjustments for patients?
• Are food and drink care plans updated?
• Food and fluid balance charts completed if required.
• Preparation prior to meal service.
• Patient feedback at the point of meal service.

In response to the concern raised, data from the last six months has been reviewed relating to the points noted above. The review, undertaken across 28 wards, demonstrates 100% compliance in the first three indicators (above). Overall average compliance across all six indicators demonstrated 85% compliance. These audits are undertaken in 6 inpatient ward areas as a minimum, monthly and are discussed with the respective Heads of Nursing and overseen by the WTWA Nutrition and Hydration Improvement Group. To ensure further improvement, areas of focus are as follows and are reported through the governance structures outlined within this response:

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
• Additional monitoring is being provided through quality and safety walk rounds led by the Director or Deputy Director of Nursing with feedback provided in real time.
• Ward Manager and Matron walk arounds are in place and are now being formalised as part of increased assurance mechanisms to focus on mealtime preparedness and patient feedback in real time.
• Increased volume and frequency of peer audits from March 2026 reporting into the weekly Senior Nurse Huddle chaired by , and oversight into the WTWA Nutrition and Hydration Group.

The WTWA Clinical Group’s governance structure ensures that nutrition, hydration, and food service safety are overseen by the WTWA Quality and Safety Group, via the groups described including the WTWA Nutrition & Hydration Group. This is also overseen by the Trust Food and Drink Oversight Group, and the Trust Nutrition & Hydration Oversight Group, which both report into the Trust Quality and Safety Management Committee. In addition, the quality and compliance of dementia care is overseen through the WTWA patient experience group which reports into the WTWA Quality and Patient Safety Group.
• Senior Nurse Review Process and Staffing Assurance

The Senior Nurse Review is undertaken by Senior Nurses at Matron level and above for those patients identified as being vulnerable. This includes patients with a cognitive impairment such as dementia, or those patients who require assistance with eating and drinking. These reviews take place for patients on admission, and thereafter a plan of care is overseen by the Senior Nurse. This is supported by a clear escalation process from Ward level through to the Director of Nursing as well as wider members of the multi-disciplinary team, including medical staff and AHPs. The review frequency is indicated from the initial review of the patient, with the Matron maintaining daily oversight. The process is supported through a daily report within HIVE, ensuring there is visibility of actions identified to support patients’ needs and assurance of completion. has daily oversight of the Senior Nurse Review process, and compliance of documented Senior Nurse Reviews for WTWA is currently 95%. The compliance of Senior Nurse Reviews is monitored through the Senior Nursing meetings, which are attended by the Heads of Nursing, with assurance provided to the WTWA Quality and Patient Safety Group. In the event of any staffing challenges being identified, to ensure the delivery of care standards, there are clear escalation processes in place including twice daily staffing meetings chaired by a Head of Nursing or Lead Nurse, with monitoring of acuity and dependency of the wards using the nursing safe

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services care tool, and professional judgement; this also supports with decisions around redeployment of staff, monitoring of skill mix and utilisation of bank staff when required. MATTER OF CONCERN 3 Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these, you were concerned that comparable measures may not be in place across the Trust as a whole. I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.

Every ward follows a formalised nurse handover process between shifts, supporting continuity of care across the 24-hour period. AHP services are delivered on a specialty basis, ensuring consistency of clinical input. AHP staff attend daily board rounds, strengthening multidisciplinary communication and ensuring shared understanding of patient needs and risks.

For patients sitting out for the first time, or where fatigue risk is identified, AHP staff undertake structured assessments including medical history, baseline function, muscle strength, sitting balance and cognition. Recommendations regarding transfer method and seating are documented in HIVE and verbally handed over to nursing colleagues. Nursing staff implement these recommendations in conjunction with moving and handling risk assessments and ongoing observation.

To provide further assurance, a comprehensive audit was undertaken at Wythenshawe Hospital in February 2026 across six wards, involving 12 patients representing four distinct specialities. This included a full review of HIVE documentation. The audit specifically evaluated the reliability and consistency of current AHP physiotherapy assessments and nursing review processes. The findings confirmed a consistent approach to documentation within the patients’ HIVE record and effective communication between AHP teams and ward staff. Key assurance points included physiotherapy assessments being documented in every ward audited, and nursing teams consistently reviewing these assessments during ward handovers and board rounds. This audit will be extended across the

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services Trust throughout March 2026, with findings reported through the Hospitals’ Quality and Patient Safety Groups.

As a Trust we remain committed to developing and embedding a culture of physical activity across the Trust, as demonstrated through our ‘Active Hospitals’ programme which was formally launched in October 2025. This approach supports patients to remain active during their hospital stay and aims to prevent the avoidable harm associated with hospital-acquired deconditioning. Staff encourage patients to complete daily active actions aligned to their acuity and individual ability. Promoting physical movement supports recovery, maintains independence, and improves mental wellbeing. Progress of the Active Hospitals programme is monitored by a Trust-wide group, with senior leads identified for each hospital site. Ten inpatient areas across WTWA Hospitals including Doyle and Oak Ward are participating in this programme.

I trust that this reply has assured you of our commitment to continuous learning and improvement. are, in parallel to this response, in contact with His Honours family via Mrs Caulfield to extend their support directly and answer any further questions or concerns they may have around His Honour’s care.