Essex Partnership University NHS Trust
NHS Trust
Action Taken
AI-generated response summary
• The Trust stated that ward managers use training trackers to monitor staff compliance with mandatory training, including basic life support, and support staff in booking required training. • The Trust confirmed that staff are inducted on processes for summoning help in medical emergencies, and that NEWS2 training has been undertaken by staff. • The Trust reported that a Physical Health Task and Finish Group has been formed, and a Physical Health Secondary Care planning cycle has been piloted with a view to Trust-wide implementation.
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Dear Mr Simblet
Carol Taylor (RIP)
I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 12th June 2025 in respect of the above, which was issued following the inquest into the death of Carol Taylor (RIP) .
I would like to begin by extending my deepest condolences to Mrs Taylor’s family. The Trust sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to the concern raised in the hope that this provides both yourself and Mrs Taylor’s family with comprehensive assurance of changes that have been made at the Trust to address the concern you have raised.
Concern 1) There was no system that prevents staff that are non-compliant with mandatory training, including basic life support training from being able to work on EPUT in-patient wards
Response: Ward managers are able to access and review the skills of staff on the ward, which includes bank worker training compliance, via a training tracker. If there is a staff shortage then requests may be made for bank and agency staff, identifying the skill set required to ensure those booked onto shift hold the necessary skills / training to deliver the required care competently.
A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all mandatory training, including basic life support training brings the significant risk in relation to having the necessary number of staff on shift however compliance with mandatory training is vital. To address this Ward Managers actively manage compliance with mandatory training.
Ward managers have access to training trackers which are checked on a monthly basis during substantive staff member’s 1:1 support meeting. As soon as a training is showing as Amber which shows that training will be non-complaint within three months, staff are supported by the Ward Manager/Supervisor to book into that training before it expires. Bank staff training compliance is checked by the ward manager/charge nurses when they are booked. If they are non-complaint for training, this is escalated to the temporary staff manager. Staff who are found not to be compliant are supported during their 1:1 support meeting with their supervisor
to book onto trainings by their supervisor or ward manager. Mandatory training is reviewed by the Clinical Manager/Matron on a monthly basis with Ward Managers in their management meeting. We hold a locality performance and accountability meeting with Ward Managers and Clinical Leads chaired by Associate Director with a focus on Mandatory Training compliance and performance.
Mandatory training is monitored through the Quality of Care and Accountability Framework meetings on a monthly basis. The Accountability Framework meetings are chaired by an Executive Director and attended by supporting executives and directors and the Care group leadership team who present their performance for the month, mandatory training is a key focus.
Concern 2) This is a particular concern generally, but especially in hospitals such as St. Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population.
Response: Following on from our reply under concern 1 above, all staff working on EPUT wards and clinical areas, are inducted on the process for summoning help in a medical emergency. This is covered in the Basic Life Support (BLS) and Immediate Life Support (ILS) training and is also highlighted on the attached two documents.
The Royal College of Physicians NEWS2 training has been undertaken by staff working at these sites and staff are signposted to the additional ‘364 Recognising & Managing Deterioration’ training which is available for all staff to access via the online learning portal. The Assessing a Critically Unwell Patient and ‘Non-Contact Physical Observations’ aide memoirs have been implemented Trust wide, in order to support staff members to carry out a robust ‘Head to toe’ physical health assessment of a patient. The situation, background, assessment and recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst the ‘Calling (9)999 in a Medical Emergency’ document assists with communication when contacting the Ambulance Service. Each Ward has a nominated Resus Link Practitioner to aid in sharing lessons identified and safety alerts and helping to facilitate regular medical emergency simulations within the clinical areas. These important resources and previous lessons identified were presented to EPUT staff via an online ‘Learning Matters’ event which was delivered on 25th June 2025 and the event was recorded for future access.
In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the Inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.
I hope that I have provided some reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe.
Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.
We understand that a copy of this reply will be shared with the family.
Carol Taylor (RIP)
I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 12th June 2025 in respect of the above, which was issued following the inquest into the death of Carol Taylor (RIP) .
I would like to begin by extending my deepest condolences to Mrs Taylor’s family. The Trust sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to the concern raised in the hope that this provides both yourself and Mrs Taylor’s family with comprehensive assurance of changes that have been made at the Trust to address the concern you have raised.
Concern 1) There was no system that prevents staff that are non-compliant with mandatory training, including basic life support training from being able to work on EPUT in-patient wards
Response: Ward managers are able to access and review the skills of staff on the ward, which includes bank worker training compliance, via a training tracker. If there is a staff shortage then requests may be made for bank and agency staff, identifying the skill set required to ensure those booked onto shift hold the necessary skills / training to deliver the required care competently.
A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all mandatory training, including basic life support training brings the significant risk in relation to having the necessary number of staff on shift however compliance with mandatory training is vital. To address this Ward Managers actively manage compliance with mandatory training.
Ward managers have access to training trackers which are checked on a monthly basis during substantive staff member’s 1:1 support meeting. As soon as a training is showing as Amber which shows that training will be non-complaint within three months, staff are supported by the Ward Manager/Supervisor to book into that training before it expires. Bank staff training compliance is checked by the ward manager/charge nurses when they are booked. If they are non-complaint for training, this is escalated to the temporary staff manager. Staff who are found not to be compliant are supported during their 1:1 support meeting with their supervisor
to book onto trainings by their supervisor or ward manager. Mandatory training is reviewed by the Clinical Manager/Matron on a monthly basis with Ward Managers in their management meeting. We hold a locality performance and accountability meeting with Ward Managers and Clinical Leads chaired by Associate Director with a focus on Mandatory Training compliance and performance.
Mandatory training is monitored through the Quality of Care and Accountability Framework meetings on a monthly basis. The Accountability Framework meetings are chaired by an Executive Director and attended by supporting executives and directors and the Care group leadership team who present their performance for the month, mandatory training is a key focus.
Concern 2) This is a particular concern generally, but especially in hospitals such as St. Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population.
Response: Following on from our reply under concern 1 above, all staff working on EPUT wards and clinical areas, are inducted on the process for summoning help in a medical emergency. This is covered in the Basic Life Support (BLS) and Immediate Life Support (ILS) training and is also highlighted on the attached two documents.
The Royal College of Physicians NEWS2 training has been undertaken by staff working at these sites and staff are signposted to the additional ‘364 Recognising & Managing Deterioration’ training which is available for all staff to access via the online learning portal. The Assessing a Critically Unwell Patient and ‘Non-Contact Physical Observations’ aide memoirs have been implemented Trust wide, in order to support staff members to carry out a robust ‘Head to toe’ physical health assessment of a patient. The situation, background, assessment and recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst the ‘Calling (9)999 in a Medical Emergency’ document assists with communication when contacting the Ambulance Service. Each Ward has a nominated Resus Link Practitioner to aid in sharing lessons identified and safety alerts and helping to facilitate regular medical emergency simulations within the clinical areas. These important resources and previous lessons identified were presented to EPUT staff via an online ‘Learning Matters’ event which was delivered on 25th June 2025 and the event was recorded for future access.
In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the Inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.
I hope that I have provided some reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe.
Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.
We understand that a copy of this reply will be shared with the family.