NHS Leicestershire Partnership NHS Trust
NHS / Health Body
Action Taken
The Trust has implemented several changes, including ensuring carers' views can be documented with consent, incorporating carer perspectives into safety plans, and updating risk assessment documentation to include carer input. They also provide support to carers via signposting and offer a Carers pack, and are launching a course for carers through the Leicestershire Recovery College. (AI summary)
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Dear Assistant Coroner Ms Connell,
Regulation 28 Report following an inquest into the death of Mr James Ralph Cochrane I am writing following receipt of the Regulation 28 Report dated 5 September 2025, relating to the inquest into the death of James Cochrane which concluded on 27 August 2025. I would like to express my deepest condolences to Mr Cochrane’s family and friends. Leicestershire Partnership NHS Trust (the Trust) takes these matters very seriously and wishes to assure the Cochrane family and the HM Coroner that the concerns raised about the care Mr Cochrane received have been listened to, reflected upon and action has been taken as a result. In your Regulation 28 Report to prevent future deaths, you set out a number of areas of concern and I would like to detail the changes and improvements made in each of those areas, appending evidence where I believe it is helpful. Concern 1: The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work, and training has been done to encourage staff to listen to carers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals. Response: The Trust acknowledges the importance of listening and capturing carers views during assessment and routine follow ups and therefore has ensured that these views can be documented (with consent
Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery from the patient) in the care and safety planning processes within Community Mental Health (CMH) services. Attached at Appendix 1 is a nursing intervention care plan and in Appendix 2, there is a collaborative care plan; these documents can be accessed and are held within the electronic patient record (SystmOne) and they have sections throughout the plans where carers views can be captured on the difficulties the patient is facing, the patient’s wellbeing and needs, the patients physical, social inclusion and spiritual needs. These forms are accessible to all clinicians and services whenever they access the patient’s electronic records to ensure continuity of care wherever the patient may present. This information is also ultimately used to inform the patients care and treatment plans and decisions during multi-disciplinary and multi professional team meetings and discussions. In addition, Leicestershire Partnership NHS Trust is rolling out the nationally recognised Carers Trust Triangle of Care (TOC) framework and currently community mental health teams are completing self-assessments (due 31 October 2025), which include benchmarking current practice and identifying any actions needed to include carers throughout a patient’s journey of care. The Trust also follows the Culture of Care programme and implements guidance embedding the 12 Culture of Care standards. These commitments are interlinked and fundamental to carers’ involvement as an integral aspect of patient care. The Trust has also embedded the Patient and Carer Race Equality Framework (PCREF) that supports our services with the delivery of high standards of care via simple and effective patient and carer feedback mechanisms and that ultimately minimises racial inequalities. In August 2025, Leicester City service Age UK joined us to share information and support for carers in the city and in June 2025, Voluntary Action South Leicestershire (a County carer commissioned service) did the same. The Trust further invited MOSAIC, who are another local voluntary community sector service offering support to carers across the system and they have picked up a lot of the services from the carers centre closure in January 2025. Monthly newsletters from these services are also shared with the Trust’s Triangle of Care Leads and cascaded to teams and services. Concern 2: The extent to which staff should consider evidence provided in alternative formats such as video evidence. It was acknowledged during the inquest that recordings from mobile phones can provide helpful evidence of a patients’ presentation. I understood that a question had been raised internally at the Trust as to what extent such evidence should be viewed, and used to inform decisions, however a final decision has not been made. Given the use of mobile phones etc in
Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery modern society, I am concerned that there is no clear guidance to staff as to how such evidence should be used. Response: The Trust acknowledges the importance of safely maximising technological resources to improve the care and support we provide to our patients (and their families / carers) wherever they may present, to ultimately enhance patient safety and improve overall outcomes for all. In September, our Data Privacy Team created a One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers, or friends (Appendix 3) which provides advice and guidance to support our clinical staff who see patients in the community. This will be shared locally with all mental health teams by the end of November 2025 and was shared in trust-wide communication on 26 September 2025 (Appendix 4). Also, the Trust’s Electronic Health Records Policy (including Record Keeping Management) will be updated to reflect the One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers or friends will be updated by the end of November 2025. Concern 3: Support offered to carers who are providing support to mental health patients. It was acknowledged that carers have an important role. I heard evidence regarding mechanisms that have been put in place via SystmOne to record carers views, but it is unclear as to what checks are in place to ensure that carers are equipped to support patients in their home environment. Response: We acknowledge the important (and sometimes challenging) role that carers have when supporting patients in their home environment. When staff attend patients in the community, the Trust advises staff to ask carers if they require support mechanisms they have in place in light of their own role as carer. This is reflected in the nursing intervention plan (Appendix 1) and the collaborative care plan (Appendix 2) to ensure documentation of the carer’s views and responses. We hold the view that where a carer identifies the need for additional support to look after their loved ones and in particular, due to the presenting circumstances of the patient, the Trust would refer the carer to social care for a carer’s assessment. The Trust further offers a variety of support to carers via signposting to a range of local statutory and voluntary services: For instance, when patients are accepted onto the community mental health services’ caseload, a Welcome Pack (Appendix 5) which includes signposting for carers and Mental Health and Wellbeing
Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery Support Booklet (Appendix 6), which includes references to the Joy app and support for carers, is sent to the patient via post or email on assessment. Also, a Carers pack (Appendix 7) is available on the Trust’s website, and an individual identified as caring for someone (whether that’s an official carer or someone who wouldn’t declare themselves a carer but has caring responsibilities) is given a carer’s pack (regardless of whether the patient is accepted onto the caseload). Furthermore, in the autumn 2025 term, a course for carers is being launched through the Leicestershire Recovery College as an additional offer to carers. I trust that the proposed actions that we have described above do, collectively, provide assurance that the Trust is taking a number of immediate measures to respond to the concerns set out by HM Coroner in her Report, with a focus on avoiding a recurrence of the circumstances around Mr Cochrane’s death. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Regulation 28 Report following an inquest into the death of Mr James Ralph Cochrane I am writing following receipt of the Regulation 28 Report dated 5 September 2025, relating to the inquest into the death of James Cochrane which concluded on 27 August 2025. I would like to express my deepest condolences to Mr Cochrane’s family and friends. Leicestershire Partnership NHS Trust (the Trust) takes these matters very seriously and wishes to assure the Cochrane family and the HM Coroner that the concerns raised about the care Mr Cochrane received have been listened to, reflected upon and action has been taken as a result. In your Regulation 28 Report to prevent future deaths, you set out a number of areas of concern and I would like to detail the changes and improvements made in each of those areas, appending evidence where I believe it is helpful. Concern 1: The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work, and training has been done to encourage staff to listen to carers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals. Response: The Trust acknowledges the importance of listening and capturing carers views during assessment and routine follow ups and therefore has ensured that these views can be documented (with consent
Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery from the patient) in the care and safety planning processes within Community Mental Health (CMH) services. Attached at Appendix 1 is a nursing intervention care plan and in Appendix 2, there is a collaborative care plan; these documents can be accessed and are held within the electronic patient record (SystmOne) and they have sections throughout the plans where carers views can be captured on the difficulties the patient is facing, the patient’s wellbeing and needs, the patients physical, social inclusion and spiritual needs. These forms are accessible to all clinicians and services whenever they access the patient’s electronic records to ensure continuity of care wherever the patient may present. This information is also ultimately used to inform the patients care and treatment plans and decisions during multi-disciplinary and multi professional team meetings and discussions. In addition, Leicestershire Partnership NHS Trust is rolling out the nationally recognised Carers Trust Triangle of Care (TOC) framework and currently community mental health teams are completing self-assessments (due 31 October 2025), which include benchmarking current practice and identifying any actions needed to include carers throughout a patient’s journey of care. The Trust also follows the Culture of Care programme and implements guidance embedding the 12 Culture of Care standards. These commitments are interlinked and fundamental to carers’ involvement as an integral aspect of patient care. The Trust has also embedded the Patient and Carer Race Equality Framework (PCREF) that supports our services with the delivery of high standards of care via simple and effective patient and carer feedback mechanisms and that ultimately minimises racial inequalities. In August 2025, Leicester City service Age UK joined us to share information and support for carers in the city and in June 2025, Voluntary Action South Leicestershire (a County carer commissioned service) did the same. The Trust further invited MOSAIC, who are another local voluntary community sector service offering support to carers across the system and they have picked up a lot of the services from the carers centre closure in January 2025. Monthly newsletters from these services are also shared with the Trust’s Triangle of Care Leads and cascaded to teams and services. Concern 2: The extent to which staff should consider evidence provided in alternative formats such as video evidence. It was acknowledged during the inquest that recordings from mobile phones can provide helpful evidence of a patients’ presentation. I understood that a question had been raised internally at the Trust as to what extent such evidence should be viewed, and used to inform decisions, however a final decision has not been made. Given the use of mobile phones etc in
Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery modern society, I am concerned that there is no clear guidance to staff as to how such evidence should be used. Response: The Trust acknowledges the importance of safely maximising technological resources to improve the care and support we provide to our patients (and their families / carers) wherever they may present, to ultimately enhance patient safety and improve overall outcomes for all. In September, our Data Privacy Team created a One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers, or friends (Appendix 3) which provides advice and guidance to support our clinical staff who see patients in the community. This will be shared locally with all mental health teams by the end of November 2025 and was shared in trust-wide communication on 26 September 2025 (Appendix 4). Also, the Trust’s Electronic Health Records Policy (including Record Keeping Management) will be updated to reflect the One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers or friends will be updated by the end of November 2025. Concern 3: Support offered to carers who are providing support to mental health patients. It was acknowledged that carers have an important role. I heard evidence regarding mechanisms that have been put in place via SystmOne to record carers views, but it is unclear as to what checks are in place to ensure that carers are equipped to support patients in their home environment. Response: We acknowledge the important (and sometimes challenging) role that carers have when supporting patients in their home environment. When staff attend patients in the community, the Trust advises staff to ask carers if they require support mechanisms they have in place in light of their own role as carer. This is reflected in the nursing intervention plan (Appendix 1) and the collaborative care plan (Appendix 2) to ensure documentation of the carer’s views and responses. We hold the view that where a carer identifies the need for additional support to look after their loved ones and in particular, due to the presenting circumstances of the patient, the Trust would refer the carer to social care for a carer’s assessment. The Trust further offers a variety of support to carers via signposting to a range of local statutory and voluntary services: For instance, when patients are accepted onto the community mental health services’ caseload, a Welcome Pack (Appendix 5) which includes signposting for carers and Mental Health and Wellbeing
Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery Support Booklet (Appendix 6), which includes references to the Joy app and support for carers, is sent to the patient via post or email on assessment. Also, a Carers pack (Appendix 7) is available on the Trust’s website, and an individual identified as caring for someone (whether that’s an official carer or someone who wouldn’t declare themselves a carer but has caring responsibilities) is given a carer’s pack (regardless of whether the patient is accepted onto the caseload). Furthermore, in the autumn 2025 term, a course for carers is being launched through the Leicestershire Recovery College as an additional offer to carers. I trust that the proposed actions that we have described above do, collectively, provide assurance that the Trust is taking a number of immediate measures to respond to the concerns set out by HM Coroner in her Report, with a focus on avoiding a recurrence of the circumstances around Mr Cochrane’s death. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.