Calderdale and Huddersfield NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has implemented the national Oliver McGowan mandatory training programme (91.83% of staff have completed Part 1) and is enhancing Learning Disabilities and Mental Capacity Act training into Trust induction and preceptorship training. Since the conclusion of the inquest, the Trust has undertaken a further self-evaluation through a Quality Summit. (AI summary)
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Dear Mr Oliver,
Re: Prevention of Future Deaths Report – Mr Myles Scriven
I am writing on behalf of Calderdale and Huddersfield NHS Foundation Trust in response to the Prevention of Future Deaths Report relating to the tragic death of Mr Myles Scriven. We wish to express our deepest condolences to Myles’ family and acknowledge the profound loss they have experienced. We welcome the opportunity this review has provided to reflect, learn, and strengthen our systems to support patients with learning disabilities and autism.
As outlined in the Trusts evidence provided during this case, we already have a robust framework of governance and oversight in relation to this important agenda. The Learning Disabilities group, which is responsible for the operational delivery of our learning disabilities strategy, reports into the Quality Committee which is a subgroup of our Trust Board, as well as the Health Inequalities Group.
We recognise that in this case despite excellent compliance with training and our efforts in relation to describing the expected pathway of care for all patients with learning disabilities, we did not see the outcome or impact that was expected for Myles and his family.
We have taken this opportunity to scrutinise existing processes to agree a response that we anticipate will be able to demonstrate our ongoing compliance with expected standards of care as well as the impact that this has on experience and outcomes for patients and their families.
Governance and oversight
We have a well-established Learning Disabilities group that has developed our existing strategy and drives operational delivery of this. This group has previously been led by our Nurse Consultant for learning disabilities, supported by representatives from each clinical division. The group includes members who have learning disabilities which provides an expert lens on all activities to ensure that actions meet the needs of this patient group.
The approach to quality improvement has been revised to ensure that each division describes priorities with measurable actions that can be monitored in relation to impact and effectiveness. Representatives will be held to account for delivery of priorities through this group.
We have strengthened the medical leadership into this group and have welcomed as the medical lead for learning disabilities. is taking a key role in reinforcing messages with medical colleagues across the organisation and is supporting our renewed audit program. We have also appointed who is our Deputy Chief Nurse to work with the as the co-chair of this group to support senior nursing leadership and oversight.
This triumvirate will be responsible for ensuring that any issues identified through the revised audit program are addressed at a service and individual level.
also attends the Patient Experience and Involvement Group to report on activities against our strategy. We have recently welcomed a colleague with Learning Disabilities into our patient experience team. This individual supports colleagues to understand the lived experience of people with Learning Disabilities and takes a lead role on many of our strategic ambitions, particularly in relation to learning and the delivery of bespoke training as well as Part 2 of the Oliver McGowan training. We are building a library of digital stories that will further support understanding in relation to patient experience and outcomes.
As part of our response to the implementation of the Patient Safety Incident Response Framework we have developed a Lessons Learnt Forum. This group is becoming established with a focus on how we can evidence shared learning across the wider organisation.
The Chief Nurse will be chairing a new Quality Assurance Group from September 25 that will report directly into a sub committee of the board. This group will be responsible for oversight of compliance against expected standards of care for all patients including effective record keeping. Findings from the revised audit program will be fed into this group for action.
An important action from this case has been the changes we have made to our learning from deaths process specifically for people with Learning Disabilities, this will have oversight from the Medical Director through the clinical outcomes group,
which reports to the trust Quality Committee which is a sub-committee of the Trust Board.
Clinical Oversight
To support clinical oversight of patients with learning disabilities we are further developing the learning disability dashboard within KP+ (Qlik Sense) digital system. This is a data analytics/reporting tool which has the LD flag built into reporting fields which allows the Trust to identify patients with a learning disability so that clinical teams can use this data to allow prioritisation of care needs and oversight of care delivery.
A flag is added to the electronic record of a patient with a learning disability and any reasonable adjustments identified are recorded within the flagging system. The VIP hospital passport is used to capture relevant information regarding a patient’s care needs and any additional support or communication needs the individual patient has. The revised dashboard will also include compliance in relation to the data collated through the revised audit program, for information and action and to inform divisional priorities.
The clinical operational site team ensure that the Situational Report (SIT REP), which has a learning disability section, is updated daily. This ensures patients with additional needs are in the right environment, the right transfers happen, monitoring any delays and escalating as needed. The data is shared through site meetings, happening on multiple occasions throughout the day.
Each clinical team has access to expert advice from our Learning Disabilities Consultant Nurse. We recognise that with a growing caseload it is not always possible for her to oversee every patients care which is why we are developing our expertise within the wider senior nursing team. We are undertaking a scoping exercise to understand whether our existing resource meets current needs and will be in a position to update on this review in the next 6 months.
All colleagues have access to our Multi Professional MDT meeting which meets on a weekly basis. The purpose of this meeting is to request expert support and advice in the management of any patient with complex needs. Further work will be undertaken to evaluate the impact of the MDTs inputs and ensure that all colleagues are aware of the referral criteria for this meeting.
Standards of Practice and Quality Improvement
The organisation has a network of Learning Disabilities champions who receive enhanced training, education and supervision in relation to this agenda. Whilst we will continue to support existing individuals with an interest in this role, we will be developing all our senior ward, department and community leads to become champions as the accountable leaders in those areas. We are reviewing the training provided to this group to ensure that it addresses the key issues identified through this case as well as audit findings.
We have a Patient Centred Care Group that is a sub - group of the Patient Experience and Involvement Group. This group is led by an Associate Director of Nursing and is responsible for the development of evidence based practice in relation to the delivery of person centred care. We are currently piloting ‘behind the bed boards ‘to replace existing boards. These boards describe what is important to patients and provide an opportunity for patients and families to capture key information, questions or concerns for their clinical team. The boards also act as a prompt for patients, relatives and our teams to capture important information in relation to reasonable adjustments or care needs. The boards will be rolled out across all areas by December 2025 with an associated plan to evaluate their impact.
The Trust has been running a structured quality improvement project, called the Well Organised Ward programme for 12 months. This programme is an improvement initiative designed to enhance the efficiency, safety, quality and effective coordination of inpatient care. It centres around four key principles: daily board rounds to ensure shared understanding of patient needs; a clear plan for every patient, led by a designated coordinator or nurse in charge; strong multidisciplinary team (MDT) leadership involving a diverse range of professionals; and a planned date for discharge to support timely transitions of care. By embedding these practices, the programme promotes consistency, improves communication, and enables staff to spend more time delivering direct, person-centred care. The program reports into our executive board and is supported by a set of metrics that demonstrates each areas compliance against the standards.
The Trust operates a 24/7 clinical site model with experienced senior nurses on site at all times. This model supports oversight of patients with learning disabilities supporting clinical teams to deliver care with specific responsibility for auditing practice in line with expected standards The clinical site matron team have oversight during the out of hours and weekend periods with ward and department Matrons assuming this responsibility in hours.
As an early adopter of Martha’s Rule we are progressing this across adult and children’s services to ensure that patients families and carers are able to escalate safety concerns for an immediate review and response from a clinical team. The Trust is undertaking continuous evaluation and is part of the national and regional programme of work and research for this important initiative.
We have already identified through our enhanced audit program that changes are needed to the current learning disability care plan. is working with our Chief Nursing Information Officer and stakeholders across Bradford and Airedale, who share our clinical record system, to revise the content and approach to completion of this care plan. This will be supported through a training program that clearly describes expectations for completion. Once the care plan is live in our electronic patient record the results will be added to our quality assurance dashboard for oversight and action.
Although we have a robust Mental Capacity Act policy that is aligned to national standards, we recognise that this needs strengthening in relation to the application of principles 1 and 2. This will be reinforced through training and monitored through the revised audit program which will focus on the 3 key principles in relation to this.
Assurance and audit
We have an extensive audit program that audits standards of care for patients with a learning disability aligned to national standards and toolkits. These audits are reported into board through various sub committees of the board.
In September 2024, the Chief Nurse commissioned an external audit by Audit Yorkshire to evaluate systems and processes for managing adult patients with a learning disability, with a particular focus on A&E waiting times and readmission rates. The audit returned an overall opinion of significant assurance, recognising the Trust’s strong monitoring of health inequalities data for people with learning disabilities.
An internal audit followed in April 2025, specifically examining themes and trends related to learning disabilities. This provided further assurance of good practice, while also identifying areas for improvement. Additionally, a Thematic Review of all incidents involving patients with learning disabilities between March 2023 and September 2024 revealed that 1% of all reported incidents related to this patient group. Further learning was identified through deep dives into falls, nutrition, and pressure ulcer cases, which are now informing targeted improvement work.
The Trust has also undertaken deep dive audits into emergency and acute care, mortality rates, and DNA (Did Not Attend) appointments for patients with learning disabilities. These findings have led to further improvement initiatives and collaborative work with West Yorkshire Association of Acute Trusts (WYAAT), particularly around reviewing neurology services to ensure the needs of people with learning disabilities are appropriately addressed.
We recognise through this process that audits in real time are required to address issues and provide ongoing assurance that the care is delivered in line with local and national standards. As highlighted in Ms McKie’s evidence, senior nursing leadership reviews now take place every weekend across both Huddersfield and Calderdale hospital sites. These reviews provide assurance that sustained improvements are being made.
Through a standardised audit process (incorporating the national 15 steps challenge of seeing care through patient and relative eyes) and direct ward engagement, nursing leaders verify compliance with legal and regulatory standards, ensure consistent use of care plans and hospital passports, and promote timely administration of critical medications for patients with a learning disability. This provides the opportunity to resolve any issues identified at the point of care with feedback given in real time to the team involved.
A more detailed audit is undertaken for patients with a learning disability on a weekly basis that provides an in-depth review of the care being delivered, focusing on patient, family and carer involvement and evidence of a senior review and implementation of any specialist recommendations. The findings from these audits will be discussed at the monthly Quality Assurance Group as well as the Learning Disabilities Group.
We are developing a monthly audit that will focus on application of the mental capacity act for patients with a learning disability that will be undertaken by our medical lead for learning disabilities and nurse consultant. This audit will be managed through existing governance structures but importantly will be used as an opportunity to recognise themes and trends and address practice at an individual level.
Training
The Trust has implemented the national Oliver McGowan mandatory training programme which is over a three year cycle.
To date, 91.83% of staff have completed Part 1 training via the e-Learning for Health platform.
Part 2 (Tier 1) webinar and (Tier 2) face-to-face training is underway, with structured evaluation captured at the point of delivery. A mid-programme audit is planned to ensure staff understanding and confidence, with any persistent gaps escalated to the national oversight body. is supporting the identification of key individuals with responsibility for leadership and oversight of care deliver for priority places on this training.
We are enhancing the Learning Disabilities and Mental Capacity Act training into Trust induction and preceptorship training for all staff groups and reviewing the existing training offer in Safeguarding and other training sessions that can should reference learning disability awareness. We recognise that this area requires ongoing focus and attention and are developing an approach to learning that will be delivered in the clinical setting such as bite sized learning and 7-minute briefings.
Scenario based approaches will also be adopted for our learning disabilities champions supported through robust clinical supervision.
Since the conclusion of the inquest, the Trust has undertaken a further self- evaluation through a Quality Summit. We are committed to ensuring that there is a continued focus on the additional learning identified through Myles case. We will be flexible and adaptive in our approach to ensure an appropriate response to continuous improvement.
As part of that commitment, we will provide you and the Senior Coroner with a further update in six months to share progress and developments.
Should you require any further clarification or additional information, please do not hesitate to contact me.
Re: Prevention of Future Deaths Report – Mr Myles Scriven
I am writing on behalf of Calderdale and Huddersfield NHS Foundation Trust in response to the Prevention of Future Deaths Report relating to the tragic death of Mr Myles Scriven. We wish to express our deepest condolences to Myles’ family and acknowledge the profound loss they have experienced. We welcome the opportunity this review has provided to reflect, learn, and strengthen our systems to support patients with learning disabilities and autism.
As outlined in the Trusts evidence provided during this case, we already have a robust framework of governance and oversight in relation to this important agenda. The Learning Disabilities group, which is responsible for the operational delivery of our learning disabilities strategy, reports into the Quality Committee which is a subgroup of our Trust Board, as well as the Health Inequalities Group.
We recognise that in this case despite excellent compliance with training and our efforts in relation to describing the expected pathway of care for all patients with learning disabilities, we did not see the outcome or impact that was expected for Myles and his family.
We have taken this opportunity to scrutinise existing processes to agree a response that we anticipate will be able to demonstrate our ongoing compliance with expected standards of care as well as the impact that this has on experience and outcomes for patients and their families.
Governance and oversight
We have a well-established Learning Disabilities group that has developed our existing strategy and drives operational delivery of this. This group has previously been led by our Nurse Consultant for learning disabilities, supported by representatives from each clinical division. The group includes members who have learning disabilities which provides an expert lens on all activities to ensure that actions meet the needs of this patient group.
The approach to quality improvement has been revised to ensure that each division describes priorities with measurable actions that can be monitored in relation to impact and effectiveness. Representatives will be held to account for delivery of priorities through this group.
We have strengthened the medical leadership into this group and have welcomed as the medical lead for learning disabilities. is taking a key role in reinforcing messages with medical colleagues across the organisation and is supporting our renewed audit program. We have also appointed who is our Deputy Chief Nurse to work with the as the co-chair of this group to support senior nursing leadership and oversight.
This triumvirate will be responsible for ensuring that any issues identified through the revised audit program are addressed at a service and individual level.
also attends the Patient Experience and Involvement Group to report on activities against our strategy. We have recently welcomed a colleague with Learning Disabilities into our patient experience team. This individual supports colleagues to understand the lived experience of people with Learning Disabilities and takes a lead role on many of our strategic ambitions, particularly in relation to learning and the delivery of bespoke training as well as Part 2 of the Oliver McGowan training. We are building a library of digital stories that will further support understanding in relation to patient experience and outcomes.
As part of our response to the implementation of the Patient Safety Incident Response Framework we have developed a Lessons Learnt Forum. This group is becoming established with a focus on how we can evidence shared learning across the wider organisation.
The Chief Nurse will be chairing a new Quality Assurance Group from September 25 that will report directly into a sub committee of the board. This group will be responsible for oversight of compliance against expected standards of care for all patients including effective record keeping. Findings from the revised audit program will be fed into this group for action.
An important action from this case has been the changes we have made to our learning from deaths process specifically for people with Learning Disabilities, this will have oversight from the Medical Director through the clinical outcomes group,
which reports to the trust Quality Committee which is a sub-committee of the Trust Board.
Clinical Oversight
To support clinical oversight of patients with learning disabilities we are further developing the learning disability dashboard within KP+ (Qlik Sense) digital system. This is a data analytics/reporting tool which has the LD flag built into reporting fields which allows the Trust to identify patients with a learning disability so that clinical teams can use this data to allow prioritisation of care needs and oversight of care delivery.
A flag is added to the electronic record of a patient with a learning disability and any reasonable adjustments identified are recorded within the flagging system. The VIP hospital passport is used to capture relevant information regarding a patient’s care needs and any additional support or communication needs the individual patient has. The revised dashboard will also include compliance in relation to the data collated through the revised audit program, for information and action and to inform divisional priorities.
The clinical operational site team ensure that the Situational Report (SIT REP), which has a learning disability section, is updated daily. This ensures patients with additional needs are in the right environment, the right transfers happen, monitoring any delays and escalating as needed. The data is shared through site meetings, happening on multiple occasions throughout the day.
Each clinical team has access to expert advice from our Learning Disabilities Consultant Nurse. We recognise that with a growing caseload it is not always possible for her to oversee every patients care which is why we are developing our expertise within the wider senior nursing team. We are undertaking a scoping exercise to understand whether our existing resource meets current needs and will be in a position to update on this review in the next 6 months.
All colleagues have access to our Multi Professional MDT meeting which meets on a weekly basis. The purpose of this meeting is to request expert support and advice in the management of any patient with complex needs. Further work will be undertaken to evaluate the impact of the MDTs inputs and ensure that all colleagues are aware of the referral criteria for this meeting.
Standards of Practice and Quality Improvement
The organisation has a network of Learning Disabilities champions who receive enhanced training, education and supervision in relation to this agenda. Whilst we will continue to support existing individuals with an interest in this role, we will be developing all our senior ward, department and community leads to become champions as the accountable leaders in those areas. We are reviewing the training provided to this group to ensure that it addresses the key issues identified through this case as well as audit findings.
We have a Patient Centred Care Group that is a sub - group of the Patient Experience and Involvement Group. This group is led by an Associate Director of Nursing and is responsible for the development of evidence based practice in relation to the delivery of person centred care. We are currently piloting ‘behind the bed boards ‘to replace existing boards. These boards describe what is important to patients and provide an opportunity for patients and families to capture key information, questions or concerns for their clinical team. The boards also act as a prompt for patients, relatives and our teams to capture important information in relation to reasonable adjustments or care needs. The boards will be rolled out across all areas by December 2025 with an associated plan to evaluate their impact.
The Trust has been running a structured quality improvement project, called the Well Organised Ward programme for 12 months. This programme is an improvement initiative designed to enhance the efficiency, safety, quality and effective coordination of inpatient care. It centres around four key principles: daily board rounds to ensure shared understanding of patient needs; a clear plan for every patient, led by a designated coordinator or nurse in charge; strong multidisciplinary team (MDT) leadership involving a diverse range of professionals; and a planned date for discharge to support timely transitions of care. By embedding these practices, the programme promotes consistency, improves communication, and enables staff to spend more time delivering direct, person-centred care. The program reports into our executive board and is supported by a set of metrics that demonstrates each areas compliance against the standards.
The Trust operates a 24/7 clinical site model with experienced senior nurses on site at all times. This model supports oversight of patients with learning disabilities supporting clinical teams to deliver care with specific responsibility for auditing practice in line with expected standards The clinical site matron team have oversight during the out of hours and weekend periods with ward and department Matrons assuming this responsibility in hours.
As an early adopter of Martha’s Rule we are progressing this across adult and children’s services to ensure that patients families and carers are able to escalate safety concerns for an immediate review and response from a clinical team. The Trust is undertaking continuous evaluation and is part of the national and regional programme of work and research for this important initiative.
We have already identified through our enhanced audit program that changes are needed to the current learning disability care plan. is working with our Chief Nursing Information Officer and stakeholders across Bradford and Airedale, who share our clinical record system, to revise the content and approach to completion of this care plan. This will be supported through a training program that clearly describes expectations for completion. Once the care plan is live in our electronic patient record the results will be added to our quality assurance dashboard for oversight and action.
Although we have a robust Mental Capacity Act policy that is aligned to national standards, we recognise that this needs strengthening in relation to the application of principles 1 and 2. This will be reinforced through training and monitored through the revised audit program which will focus on the 3 key principles in relation to this.
Assurance and audit
We have an extensive audit program that audits standards of care for patients with a learning disability aligned to national standards and toolkits. These audits are reported into board through various sub committees of the board.
In September 2024, the Chief Nurse commissioned an external audit by Audit Yorkshire to evaluate systems and processes for managing adult patients with a learning disability, with a particular focus on A&E waiting times and readmission rates. The audit returned an overall opinion of significant assurance, recognising the Trust’s strong monitoring of health inequalities data for people with learning disabilities.
An internal audit followed in April 2025, specifically examining themes and trends related to learning disabilities. This provided further assurance of good practice, while also identifying areas for improvement. Additionally, a Thematic Review of all incidents involving patients with learning disabilities between March 2023 and September 2024 revealed that 1% of all reported incidents related to this patient group. Further learning was identified through deep dives into falls, nutrition, and pressure ulcer cases, which are now informing targeted improvement work.
The Trust has also undertaken deep dive audits into emergency and acute care, mortality rates, and DNA (Did Not Attend) appointments for patients with learning disabilities. These findings have led to further improvement initiatives and collaborative work with West Yorkshire Association of Acute Trusts (WYAAT), particularly around reviewing neurology services to ensure the needs of people with learning disabilities are appropriately addressed.
We recognise through this process that audits in real time are required to address issues and provide ongoing assurance that the care is delivered in line with local and national standards. As highlighted in Ms McKie’s evidence, senior nursing leadership reviews now take place every weekend across both Huddersfield and Calderdale hospital sites. These reviews provide assurance that sustained improvements are being made.
Through a standardised audit process (incorporating the national 15 steps challenge of seeing care through patient and relative eyes) and direct ward engagement, nursing leaders verify compliance with legal and regulatory standards, ensure consistent use of care plans and hospital passports, and promote timely administration of critical medications for patients with a learning disability. This provides the opportunity to resolve any issues identified at the point of care with feedback given in real time to the team involved.
A more detailed audit is undertaken for patients with a learning disability on a weekly basis that provides an in-depth review of the care being delivered, focusing on patient, family and carer involvement and evidence of a senior review and implementation of any specialist recommendations. The findings from these audits will be discussed at the monthly Quality Assurance Group as well as the Learning Disabilities Group.
We are developing a monthly audit that will focus on application of the mental capacity act for patients with a learning disability that will be undertaken by our medical lead for learning disabilities and nurse consultant. This audit will be managed through existing governance structures but importantly will be used as an opportunity to recognise themes and trends and address practice at an individual level.
Training
The Trust has implemented the national Oliver McGowan mandatory training programme which is over a three year cycle.
To date, 91.83% of staff have completed Part 1 training via the e-Learning for Health platform.
Part 2 (Tier 1) webinar and (Tier 2) face-to-face training is underway, with structured evaluation captured at the point of delivery. A mid-programme audit is planned to ensure staff understanding and confidence, with any persistent gaps escalated to the national oversight body. is supporting the identification of key individuals with responsibility for leadership and oversight of care deliver for priority places on this training.
We are enhancing the Learning Disabilities and Mental Capacity Act training into Trust induction and preceptorship training for all staff groups and reviewing the existing training offer in Safeguarding and other training sessions that can should reference learning disability awareness. We recognise that this area requires ongoing focus and attention and are developing an approach to learning that will be delivered in the clinical setting such as bite sized learning and 7-minute briefings.
Scenario based approaches will also be adopted for our learning disabilities champions supported through robust clinical supervision.
Since the conclusion of the inquest, the Trust has undertaken a further self- evaluation through a Quality Summit. We are committed to ensuring that there is a continued focus on the additional learning identified through Myles case. We will be flexible and adaptive in our approach to ensure an appropriate response to continuous improvement.
As part of that commitment, we will provide you and the Senior Coroner with a further update in six months to share progress and developments.
Should you require any further clarification or additional information, please do not hesitate to contact me.