Allan Taylor

Dear Mr Place Regulation 28 Report to Prevent Future Deaths Mr Allan Taylor write further to your correspondence dated 11 March 2025 regarding your concerns identified during the Inquest into Mr Taylor's death: Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns: Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other Iocal Trusts manage safe observation and care of patients This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline wili be implemented across the organisation during 2025 with a plan to evaluate the impact of this guideline after six months_ During the Inquest, you identified a concern that there is a risk that future deaths will occur unless action is taken: The matters of concern were: 1_ Guidelines for Level 2 EICO were not complied with 2 . There was a lack of escalation to the Matron or Site Manager
3. Had Mr Taylor received the Level 2 EICO, assistance could have been provided to him which may have prevented his fall e cellence in all that we do May Alac N May

Following the internal investigation there has been significant learning identified which has been reflected within the actions as indicated above including clearer guidance for staff, importance of family involvement, escalation and documentation, training, and the use of professional judgement; In Mr Taylor's case, he was required to be in a side room due to testing positive for Clostridium Difficile: The allocation of a patient to a side room with infectious conditions is always balance of risk between their individual needs and the protection of other patients in the open bay areas. The nursing staff responsible for his care did not feel, at that time, that he required EICO level 2 as he had become settled_ Whilst we recognise the importance of professional judgement; given this is guidance and not policy; the staff failed to record their decision and the reasons for not escalating this further to the Matron or Site Manager Mr Taylor was assessed to have mental capacity on admission to hospital, however two days later he fell and the staff responsible for his care believed he then lacked capacity: followed the trust policy by completing an MCA1 and 2 and Deprivation of Liberty Safeguard, safeguarding referral was then made to the Local Authority. would like to assure you that this improvement work is progressing well, and we intend to embed this ETOC guideline and will monitor the training achievements as are introduced_ As you will note, the Trust is addressing the shortfalls highlighted during the Inquest to prevent future deaths in similar circumstances_ Progress of the actions detailed in this letter will be overseen by Melanie Johnson, Executive Director of Nursing, Midwifery and Allied Health Professionals, who will also keep me briefed and report progress to the Trust's Patient Safety and Quality Committee_ trust this information provides assurance to you that the Trust has taken appropriate action to address your concerns with a view to improving patient care and safety and reducing the risk of any similar adverse incidents in the future_ would also like to take this opportunity to offer my sincere condolences to Mr Taylor's family on behalf of myself and the Trust_