Dorothy Breislin

Dear Mr Cooper write further to Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mrs Breislin. Matters_of_concern The_incident date was 27_January 2015 The_incident review report was not received in this office until 10 August 2017. Why_ the delayz can only apologise for the unacceptable delay in not only recognising that this was an Sl but for the delay in forwarding the final report to you. The Trust recognises that the Sl process at that time was poor. We are working hard to clear our backlog of Sl reports; which is being overseen by myself and the Director of Nursing and we are also implementing a new Sl process_ This incorporates training across the Trust on undertaking Sl investigations We currently have an Interim Director of Governance in post who is leading on this project and a new Risk Manager will be starting in February 2018. Whilst this is a work in progress, [hope you will be assured that the Trust is striving towards a much improved Sl process_ 2 S13 recites an apology_has been provided_verbally and in writing The_family asks who_made_the apology Also_when and_where as they are adamant have_never received one This Duty of Candour section is what should_have happened. have no evidence that any verbal apology was made and indeed a written apology should have been done, but was not. Again; can only apologise that what we should have done was Chairman: Dean Fathers MINDFUL Chief Executive: Jan Sobieraj (Mr) EMPLOYER 915aBL69 your they About

not done 3 confirmed on oath that none_of_the_Action Plan referred_ to_in the Appendices at 3 have_been implemented lfnot_in view of the incident date_why not? The VTE Nurse Manager and the Consultant Haematologist met up in August 2017 to discuss the changes and these were agreed: This was to be discussed at the September 2017 Thrombosis Committee meeting but the meeting was cancelled as both the Chair and Vice Chair were unable to attend. Unfortunately, due to an oversight the matter was not onto the November agenda. This was picked up in December 2017 when the form was sent to (Consultant Physician) to update the clerking proforma risk assessment; understand that the updating clerking proforma was to go to and be available for use in January 2018. have been advised that the revised risk assessment will be sent to Stores to re-print on Monday 29 January 2018 and then be circulated to the clinical teams