Garth Pretorius

Dear Professor Marks, Re: Regulation 28 Report to Prevent Future Deaths – Garth Pretorious We write in response to your Regulation 28 Report dated 8 May 2026. Firstly, we would like to express our sincere condolences to Mr Pretorius’s family for their loss. We recognise the importance of responding fully to the concerns raised. We note the Coroner’s concern that two different triage approaches are being used within the Emergency Department at Hull Royal Infirmary, and the associated risk to patient safety if there is inconsistency in the application of triage processes. The Trust acknowledges the importance of a consistent, reliable and evidence-based approach to triage. In response, we confirm the following: Implementation of the Manchester Triage System The Trust is strengthening the consistent application of the Manchester Triage System through an expanded programme of training and assessment. Clinical Nurse Educators are actively delivering this programme to ensure that all staff undertaking triage are appropriately trained and competent in the use of the system. Progress is being made to ensure improved consistency and reliability in triage decision-making. Training in the Manchester Triage System is being delivered to 155 members of staff through a comprehensive three-stage programme comprising e-learning, a face-to-face workshop, and

a final competency sign-off. This robust training pathway has been designed to ensure staff develop and demonstrate the knowledge and skills required to undertake triage safely and effectively. Currently, 42% of the workforce has completed the training programme in some capacity. Given the size of the workforce and the requirement to maintain operational service provision, achieving full compliance represents a considerable organisational challenge. Nevertheless, a phased implementation plan is in place, and the organisation remains on track to have all staff trained and signed off as competent by the end of the year. Role of Senior Clinical Assessment Where operationally feasible, the Trust positions senior clinical decision-makers at the front door of the Emergency Department between 08:00 and 00:00. These clinicians (Emergency Medicine Consultants or Higher Specialty Trainees) provide early senior assessment, which is known to improve safety, patient flow and clinical decision- making. In these circumstances, triage categorisation may be undertaken through immediate senior clinical assessment rather than formal application of the Manchester Triage System. This approach reflects the principle that the Manchester Triage System is intended to support, rather than replace, senior clinical judgement and experience. Ensuring Safe and Consistent Practice The Trust recognises that variation in practice must be minimised. The expanded training programme and focus on competency assessment are intended to ensure that all staff understand the appropriate use of the Manchester system alongside clinical judgement. This work is ongoing and forms a key part of improving the consistency, safety and reliability of triage processes within the Emergency Department. The Trust has taken, and continues to take, substantive action to ensure the universal, reliable application of the Manchester Triage System, supported by training, governance and audit. In parallel, we are addressing wider systemic factors identified through detailed investigation, including emergency department flow, communication, recognition of deterioration, and the timely management of sepsis.

We are committed to ensuring that these actions are embedded, monitored and sustained, and that the learning from Mr Pretorius’s death leads to meaningful improvements in the safety and quality of care provided to patients.