Elaine Jobe

Dear Dr Earland Re: Elaine Jobe (deceased) Inquest 9t0 13 June 2014 Regulation 28 Report to Prevent Future Deaths Thank you for your letter of 11 August 2014 which we received on the 13 August 2014 following the inquest into the death of Elaine Jobe. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust. As you will be aware the Trust undertook a Root Cause Analysis Investigation following the death, the Root Cause Analysis report contained a number of recommendations; all of which were accepted and the actions were completed. It is clear following review of your report and consideration of your recommendation that there remain improvements that can be made to prevent future deaths of this nature: have attached a report which details our response to your recommendation and each of your matters of concern: Whilst we have been able to complete actions that were identified in the original Root Cause Analysis additional actions which are detailed on the attached report are all expected to be completed by January 2015 and will be monitored through our quality assurance processes. hope that the actions described demonstrate our commitment to the learning we have undertaken: you required any further information please do not hesitate to contact me