Clifford Rose

Dear Mr Osborne, Re: Regulation 28: Report to prevent future deaths Thank you for your Regulation 28 report dated 20 October 2022, following the Inquest into the death of Mr Clifford Rose. I am writing to provide CNWL’s response to the concern that you raised in that report. Firstly, we would very much like to extend our condolences to Mr Rose’s family and friends. The matter of concern was that: During the course of the evidence at the inquest it became apparent that detailed assessments of the needs of very vulnerable and perhaps elderly patients are being carried out over the telephone. In this particular case, it led to the deceased confirming that he was able to dress himself and that he was eating and drinking regularly. This was far from the correct position. I believe that consideration should be given to put in place a system whereby all assessments are carried out face-to-face and where appropriate should involve another member of the family. Assessments We thought it would be helpful to provide more information on the process in which referrals to Home First Therapy are managed. Referrals can be a request for a person to be assessed, or provide advice or equipment, and are received from a number of sources including acute hospitals, primary care and from patients themselves. All referrals are initially sent to the Adult Social Care Access Team (ASCAT) which is a single point of access hub managed by Milton Keynes Council. The Council triage the referral and if appropriate, forward on referrals to the CNWL Home First Therapy team. Once a referral has been received by the CNWL Home First Therapy Team, a senior clinician within the team completes an initial triage to ascertain whether it is a routine or urgent referral and then allocates it accordingly. Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700

All urgent referrals are seen face to face by a Home First Therapist. Routine referrals are sent to the OT Practice, which is an independent organisation contracted by CNWL to undertake a detailed information gathering from SystmOne and any identified carers, friends or relatives (see below) and an assessment of need with the patient. This activity is carried out by Health and Care Profession Council Registered Occupational Therapists. The information gathered enables the Home First Team to assign the most appropriate therapist to see the patient in a timely way. Some patients require a piece of equipment or advice. However, if the OT Practice recommend that a patient is seen face to face then this recommendation is accepted by the Home First Therapists and an appointment made at the earliest opportunity. Involvement of family members As an organisation, involving patient’s family and carers where appropriate, is extremely important to us. We have taken immediate steps to make the process more robust and ensure that patients are asked from the beginning of their care journey with us who they would like involved in their care. We are updating all first contact assessment templates on SystmOne to include a mandatory question, ‘Would you like us to involve a family member, carer or friend in your care?’, and a section to record the details of any nominated person. We are also adding to these templates another mandatory question, ‘Are you under the care of any other services?’ which will help identify patients who are receiving care from different providers and what the package of care is. This will, with consent from the patient, enable our teams to gather more information about them, particularly if there are concerns about a patient’s vulnerability or possible self-neglect, and escalate accordingly. Information gained from communications with family members, carers and friends will be considered when triaging the patient. These updates to SystmOne are due to be completed by the end of December 2022. To ensure that all staff are aware of the changes we have produced a ‘Lessons Learned flyer’ which will be shared with them and discussed at team meetings. We will also be sharing the learning and changes at the MKCHS Clinical Oversight Group. This group sits monthly. Thank you for bringing your concern to our attention. We hope that this response provides some reassurance to both you and Mr Rose’s family that the Trust has taken this seriously and that we are taking steps to address the issue raised. Should you have any further questions or concerns, please do not hesitate to contact me.