Blackpool Teaching Hospitals NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust plans to roll out a digital solution called 'Alertive' from Q4 2025/2026 to send critical messages to staff with recorded acknowledgements, with future phases including policy document cascade beginning Q1 2026/2027. (AI summary)
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Dear Mr Holloway
Re: Regulation 28: Report to Prevent Future Deaths – Maureen Christy
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to offer my sincere condolences to the family of Ms Maureen Christy.
Thank you for raising your concerns with us and please find below the Trust’s responses to the issues raised in the report to prevent future deaths.
1. The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”.
2. The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
3. The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
4. Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.
Thank you for the opportunity to respond to the concerns raised. The Trust would like to acknowledge the seriousness of the issues highlighted and wish to provide context regarding the challenges faced during the COVID-19 pandemic and the steps taken to mitigate risks.
The COVID-19 pandemic presented unprecedented challenges for NHS hospitals. Guidance from national bodies evolved rapidly in response to emerging evidence and changing infection rates. This required hospitals to adapt operational practices at pace, often with very short implementation windows. Policies relating to infection prevention, patient care pathways, and staff safety were frequently updated, sometimes multiple times within a single week.
The speed and frequency of changes created significant operational pressures. Key challenges included:
• Volume and Complexity of Guidance: National directives were extensive and often required interpretation for local application.
• Rapid Dissemination: Ensuring all staff were aware of and understood new requirements in real time was critical but difficult given shift patterns and workforce pressures.
• Consistency of Practice: Maintaining uniform compliance across diverse clinical settings during periods of high demand was challenging.
To address these challenges, the Trust implemented a structured approach to policy dissemination:
• Central Coordination: A COVID-19 Response Group was established to review national guidance and translate it into local policy.
• Digital Communication Channels: Updates were cascaded via email bulletins, intranet alerts, and a dedicated COVID-19 resource hub accessible to all staff.
• Manager Briefings: Clinical and operational leads received daily briefings to ensure frontline teams were informed promptly.
• Safety Huddles and Ward Meetings: Key changes were reinforced through regular huddles and team meetings to support understanding and compliance.
• Training and Support: Where guidance required new clinical practices, rapid training sessions and e-learning modules were deployed.
Response
The Trust recognises the importance of learning from these experiences. Since the COVID pandemic, a number of refinements have been made to the Trust’s document control process, ensuring that these are reviewed, updated and approved within a robust process, and that new and updated documents are effectively communicated to staff.
Overseen by the Trust’s Audit and Clinical Effectiveness Committee, the Trust ensures that it has in place documents which are in date and appropriately risk stratified in terms of the critical content. When a document is approved following drafting or review, these are communicated to staff by e-mail via the Trust’s Team Brief which is co-ordinated by the Trust’s Communications Department. All policies are ratified through an appropriate committee attended by representation from our clinical divisions, with policy compliance reported back through our Audit and Clinical Effectiveness Committee. Divisions are supported by the relevant teams in the roll out of and changes that have a bearing on day to day process. An example of this would be the support offered to infection prevention and control nurses who guide the roll-out of any changes to the way we work and ensure appropriate oversight of IPC related policies and procedures.
The policies are then placed on the Trust’s intranet which is accessible to all staff. This includes the potential to search on key words / phrases etc to identify relevant policies and procedures. There is also a direct link between the Trust’s policies and the Trust’s corporate induction and mandatory training. This ensures that staff are appropriately trained and briefed on current practices.
The Trust has recognised that further steps could be taken in evidencing that staff have accessed and read all policies which are critical to their role. To create this enhanced oversight, the Trust has plans to roll out a digital solution from Q4 2025/2026 called ‘Alertive’, which allows key critical messages to be issued to all staff with staff acknowledgements of these messages recorded. Whilst the first phase of the implementation will focus on operational processes within the Emergency Department, future phases will include the scoping of the cascade of policy documents to staff, which will begin from Q1 2026/2027.
I hope this response provides you with the assurance you are seeking that the Trust has taken this matter seriously and that plans are in place to resolve the concerns raised.
If you require any further information, please let me know.
Re: Regulation 28: Report to Prevent Future Deaths – Maureen Christy
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to offer my sincere condolences to the family of Ms Maureen Christy.
Thank you for raising your concerns with us and please find below the Trust’s responses to the issues raised in the report to prevent future deaths.
1. The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”.
2. The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
3. The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
4. Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.
Thank you for the opportunity to respond to the concerns raised. The Trust would like to acknowledge the seriousness of the issues highlighted and wish to provide context regarding the challenges faced during the COVID-19 pandemic and the steps taken to mitigate risks.
The COVID-19 pandemic presented unprecedented challenges for NHS hospitals. Guidance from national bodies evolved rapidly in response to emerging evidence and changing infection rates. This required hospitals to adapt operational practices at pace, often with very short implementation windows. Policies relating to infection prevention, patient care pathways, and staff safety were frequently updated, sometimes multiple times within a single week.
The speed and frequency of changes created significant operational pressures. Key challenges included:
• Volume and Complexity of Guidance: National directives were extensive and often required interpretation for local application.
• Rapid Dissemination: Ensuring all staff were aware of and understood new requirements in real time was critical but difficult given shift patterns and workforce pressures.
• Consistency of Practice: Maintaining uniform compliance across diverse clinical settings during periods of high demand was challenging.
To address these challenges, the Trust implemented a structured approach to policy dissemination:
• Central Coordination: A COVID-19 Response Group was established to review national guidance and translate it into local policy.
• Digital Communication Channels: Updates were cascaded via email bulletins, intranet alerts, and a dedicated COVID-19 resource hub accessible to all staff.
• Manager Briefings: Clinical and operational leads received daily briefings to ensure frontline teams were informed promptly.
• Safety Huddles and Ward Meetings: Key changes were reinforced through regular huddles and team meetings to support understanding and compliance.
• Training and Support: Where guidance required new clinical practices, rapid training sessions and e-learning modules were deployed.
Response
The Trust recognises the importance of learning from these experiences. Since the COVID pandemic, a number of refinements have been made to the Trust’s document control process, ensuring that these are reviewed, updated and approved within a robust process, and that new and updated documents are effectively communicated to staff.
Overseen by the Trust’s Audit and Clinical Effectiveness Committee, the Trust ensures that it has in place documents which are in date and appropriately risk stratified in terms of the critical content. When a document is approved following drafting or review, these are communicated to staff by e-mail via the Trust’s Team Brief which is co-ordinated by the Trust’s Communications Department. All policies are ratified through an appropriate committee attended by representation from our clinical divisions, with policy compliance reported back through our Audit and Clinical Effectiveness Committee. Divisions are supported by the relevant teams in the roll out of and changes that have a bearing on day to day process. An example of this would be the support offered to infection prevention and control nurses who guide the roll-out of any changes to the way we work and ensure appropriate oversight of IPC related policies and procedures.
The policies are then placed on the Trust’s intranet which is accessible to all staff. This includes the potential to search on key words / phrases etc to identify relevant policies and procedures. There is also a direct link between the Trust’s policies and the Trust’s corporate induction and mandatory training. This ensures that staff are appropriately trained and briefed on current practices.
The Trust has recognised that further steps could be taken in evidencing that staff have accessed and read all policies which are critical to their role. To create this enhanced oversight, the Trust has plans to roll out a digital solution from Q4 2025/2026 called ‘Alertive’, which allows key critical messages to be issued to all staff with staff acknowledgements of these messages recorded. Whilst the first phase of the implementation will focus on operational processes within the Emergency Department, future phases will include the scoping of the cascade of policy documents to staff, which will begin from Q1 2026/2027.
I hope this response provides you with the assurance you are seeking that the Trust has taken this matter seriously and that plans are in place to resolve the concerns raised.
If you require any further information, please let me know.