Edith Jones

Dear HM Senior Coroner Alison Mutch Re: Edith May Jones Date of Birth :22/05/1932; Date of Death: 17/10/2025 Address: 4 Windermere Road, Hyde, Tameside, SK14 4PU Place of death: Stamford Unit, Darnton Road, Ashton Under Lyne. Date of Inquest:17/04/2026 Response to Report to Prevent Future Deaths Thank you for your Report to Prevent Future Deaths dated 15 May 2026 concerning the death of Edith May Jones, who sadly died on 17 October 2025. First, I would like to offer my sincere condolences to the family and friends of Ms Jones. I understand that one concern has been directed to The Brooke Surgery ('the Practice'), namely: '5. The GP practice did not have an effective system to promptly triage referrals from the 111 service or information provided by a patient’s family.' On 28 August 2025, the Practice was notified that NHS 111 had been contacted regarding Ms Jones. A member of the Practice’s administrative team spoke with Ms Jones’ daughter to obtain further information, correctly recognised that clinical assessment was required and sought to contact the duty GP for advice through multiple channels. The duty GP was not immediately available as they were managing other clinically urgent matters, however, contact was promptly made with Ms Jones’ carers and further information was obtained from them within two hours. The following morning, a Nurse Practitioner from the Practice spoke with the carers and it was agreed that Ms Jones required escalation to hospital. The Practice has carefully reflected on this incident and has implemented a number of changes to strengthen its systems and ensure that potentially urgent information is consistently identified, prioritised and actioned by an appropriate clinician. In September 2025, the Practice introduced a revised on-call structure whereby each clinical session is supported by both a duty clinician and a second on-call clinician. This change, introduced as part of wider service development, has strengthened resilience within the clinical triage system, provided additional support for the escalation of urgent concerns and reduced reliance on a single clinician during periods of high demand. B1

On 9 June 2026, a Significant Event Analysis was completed, and the learning from this was shared with Practice staff at a clinical meeting on 18 June 2026. Following this, the Practice implemented a new External Clinical Communication and Triage Protocol ('the Protocol'), which sets out the Practice’s approach to the receipt, prioritisation, escalation and documentation of external clinical communications. The Protocol and its particulars were presented to staff at the clinical meeting on 18 June
2026. It has also been made available on the Practice’s internal knowledge platform, TeamNet, for staff review and future reference. The Practice intends to review the effectiveness of the Protocol in September 2026, and the management of NHS 111 referrals will form part of the Practice’s periodic governance and audit processes. If the Practice can be of any further assistance, please do not hesitate to contact me.

Dear HM Coroner

Name: Edith Jones

Date of birth: 22 May 1932

Date of death: 17 October 2025

Firstly, on behalf of the Trust, I would like to express my sincere condolences to the family of Mrs Edith Jones, for their loss.

We have carefully reviewed the concerns raised in your Regulation 28 Report, specifically in relation to the quality of documentation, senior oversight of the District Nursing Service (DNS) and how complex cases are managed and escalated and the triage process, to which we provide the following response.

Documentation

It was identified that there were lapses in documentation during the DNS involvement in the care and treatment provided to Mrs Jones for which we apologise.

As a District Nursing Service, where care is delivered to patients in either their own home or a community setting as part of a multi-disciplinary team, we understand the importance of documentation and the accuracy of records. Accurate records ensure continuity of care by way of a B3

review of previous assessments and interventions and to plan for on-going treatment. We regret that we were unable to deliver this level of scrutiny to Mrs Jones’ visits.

In September/October 2025, the District Nursing Service focused significantly on ways to improve documentation including, but not limited to, documentation quality, missing consultations, missing outcomes and audit reliability concerns. These areas of concern were further emphasised following the inquest of Mrs Jones. It was apparent that attempts to review and improve the service were not to the standard we strive to achieve and as such, since April 2026, the service had demonstrated organisational learning through a service wide documentation review, EMIS template review, enhanced documentation audits, review of clinical decision-making standards, Team Leader involvement in governance workstreams and a focus on escalation processes and triage quality.

Over the past 6 months, there have been significant improvements to strengthening documentations standards, audit processes and clinical record assurance across the whole of the District Nursing Service. In September/October 2025, the services identified challenges relating to documentation audits, inconsistent recording, missing consultations, and missing outcomes within EMIS. As such, documentation quality was recognised as a priority area requiring focused improvement. Since then, the service has implemented a comprehensive documentation improvement programme which has been further strengthened following this inquest. This work has included:
• Establishment of the District Nursing Documentation Group, led by and Team Leaders, to review standards and drive continuous improvement
• Review and refinement of EMIS templates to ensure documentation supports professional decision-making, risk assessment and clinical oversight.
• Increased focus on documenting clinical reasoning, escalation decisions and patient- centered care plans.
• Team Leaders taking an active lead role in reviewing records, supporting staff development and providing assurance regarding documentation quality.
• Use of audit findings to inform training priorities, learning activities and quality improvement programme
• Alignment of documentation audits with Quality Assurance Rounds, accreditation and governance processes to strengthen overall assurance frameworks

As a result of the above, and through reviewing the audit data via our accreditation processes, we have seen a substantial improvement across all District Nursing Teams in the Tameside locality. Hyde and Dukinfield, Mossley and Stalybridge (DMS) were previously amber, are now green. This demonstrates the District Nursing Service determination to enhance patient safety and provide improved governance oversight and accountability. It reflects a focused commitment to patient safety and demonstrates that the service is now operating with greater reliability and resilience across these localities. The District Nursing Service currently have no red scoring accreditation areas. B4

Quality Assurance Rounds are undertaken routinely at team level to provide strengthened oversight of day-to-day practice and an additional layer of assurance between formal accreditation cycles. Their purpose is to confirm that care remains safe, effective and consistently aligned with expected professional standards, while enabling early identification of emerging risks and reinforcing accountability for clinical quality. These rounds receive both divisional and organisational oversight, ensuring that findings, actions and improvements are visible across senior leadership structures and that any concerns are addressed promptly and monitored through established governance pathways. Through this process, the Division gains reliable assurance that high standards of care are being sustained and that improvements are embedded in a consistent and measurable way.

The Division have carried out a documentation audit which demonstrates a significant improvement between January and April, with compliance increased from 53.3% to 81.7%. This improvement was sustained in July, reaching 83.3%, indicating that improvements implemented within the first quarter have been maintained.

Senior oversight A significant achievement over the last six months has been the service's increased focus on the identification, escalation and management of deteriorating patients. During September/October 2025, the service recognised deteriorating patient training and compliance as a challenge, with concerns around implementation of new training requirements and a need to strengthen staff knowledge, competencies and assurance processes. At that time, Matrons were attending the Divisional Deteriorating Patient Group and seeking greater Team Leader involvement to support rollout and embed learning within practice. Since then, several developments have strengthened the service's response to deteriorating patients:
• Introduction of enhanced operational oversight through the “Team Leader of the Day” and “Coordinator of the Day” roles, providing clear escalation routes and senior clinical support for teams managing complex or deteriorating patients.
• Improved daily management of capacity, demand and acuity through the SITREP process and Out of Hours (OOH) handover meetings, enabling earlier identification of patients requiring urgent intervention and escalation. Each day is RAG rated as Red, Amber or Green dependent on the allocation of visits and the level of deferred activity. All Red rated days are escalated to the Divisional Nurse and AHP Director for support and action. Red days are also incident reported as a red flag staffing for organisational oversight.
• Focused review of documentation, clinical decision-making and escalation processes following the Prevention of Future Death (PFD) report, ensuring greater emphasis on professional judgement, recognition of clinical deterioration and timely escalation of concerns. B5

• Increased use of caseload reviews and triage processes to ensure patients with complex needs, frailty, end-of-life care requirements and changing clinical conditions are appropriately prioritised.

The District Nursing Service continues to embed daily safety huddles, now strengthened by enhanced senior oversight, providing a more reliable structure for identifying risk and supporting clinical teams. Leadership resilience has increased, with clearer operational control and a more coordinated approach to managing capacity, demand and patient flow across the service. These developments collectively reinforce the Trust’s responsibility to ensure that all healthcare services remain safe, effective and accountable, with appropriate governance mechanisms in place to identify concerns early and act promptly.

The Division has implemented a formal requirement that any deferred work or unmet need is escalated to a Band 7 Team Leader for review, discussion, and approval. This process ensures that decisions to move a visit or intervention to another time or day are subject to senior clinical oversight, reducing the risk of inappropriate delay and strengthening accountability for safe caseload management. Once approved, all deferred activity is re-prioritised and scheduled for completion the following day, ensuring patients receive timely care and that emerging risks are identified and mitigated. This structured escalation process provides clear governance, enhances visibility of workload pressures, and supports consistent clinical decision-making across teams.

The Division has also approved the introduction of a senior District Nursing Caseload Facilitator role, designed to provide strengthened oversight of caseload demand, patient flow and the consistency of care planning. This role will support teams to organise, review and prioritise caseloads more effectively, ensuring that all patients have clear plans, defined outcomes and timely progression through the service. At the time of writing, recruitment to this post is underway and interviews are taking place, reflecting the Division’s commitment to further enhancing safe practice, operational grip and accountable caseload management.

The Division has established a weekly pressure ulcer and complex wounds meeting, chaired on a rotational basis by either the Matron for Tissue Viability or the Divisional Nurse and AHP Director, to provide senior clinical oversight of patients whose wounds are non-healing, deteriorating or complex in nature. This meeting is attended by all District Nurse Team Leaders across the localities, ensuring consistent review, shared learning and coordinated action planning. Through this forum, patients with higher-risk wound presentations are discussed at senior level, with clear actions agreed, monitored and implemented to support safe practice, timely intervention and improvement in wound outcomes. This structure strengthens governance around wound care, promotes early identification of concerns, and ensures clinical teams receive the guidance and escalation support required to maintain patient safety and drive continuous improvement.

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The Division also carry out a Deteriorating Patient Audit. The result of that audit demonstrate that clinical monitoring standards for deteriorating patients remain consistently high, with April compliance at 93.3% and July at 92.3%. Physiological observation recording has strengthened further, improving from 93.8% in April to 98.5% in July, demonstrating enhanced reliability in core assessment processes. NEWS2 recording compliance has remained at 100% across both months, evidencing sustained adherence to national early-warning requirements. These metrics confirm robust clinical oversight, reliable recognition of deterioration, and continued improvement in the quality and consistency of patient observations.

The Divisional Deteriorating Patient Group continues to prioritise this metric through strengthened audit, clearer expectations, and systematic monitoring of pathway use across all teams. This focused oversight provides assurance that pathway utilisation is being actively addressed and that further improvement is anticipated as compliance becomes more consistently embedded in everyday practice.

The Division is delivering a structured improvement programme to strengthen the assessment and management of lower-limb wounds, with a clear focus on early recognition of non-healing wounds, timely escalation, and consistent use of the limb of concern pathway. This work aims to ensure that patients with compromised limb status are identified at the earliest opportunity and that appropriate interventions, including consideration of compression therapy where clinically indicated, are initiated without delay. To support this, the Division has established dedicated training clinics offering both theoretical teaching and supervised hands-on practice. The programme commenced in July, with five staff completing the training, and further cohorts planned over the next six months to build capability and improve healing outcomes for patients with lower-limb wounds.

Triage process

The Service has also reinforced its approach to referral management and triage. Since 2025, triage processes have evolved from development of standard operating procedures into embedded operational practice. Enhanced referral prioritisation, allocation processes and daily clinical oversight have improved patient flow, reduced delays and ensured patients receive care in the most appropriate setting. These developments have supported safer management of demand and increasing patient complexity.

In 2025, the service managed referrals via a separate Triage team, however, on review it was noted that this team lacked the awareness of capacity and demand in teams and this may have contributed to the increase in deferred activity. Therefore, the decision was made to disband this team and redistribute the resource back into clinical roles to strengthen the triage and decision within each District Nursing Team. This enabled prompt and timely decision making by the providing team and removed any delay or unnecessary additional triage burdens.

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Significant improvements have been made in the recognition and management of deteriorating patients. Greater operational leadership, improved triage arrangements, daily acuity monitoring and strengthened escalation processes have provided clearer pathways for clinical review and intervention. Learning from the PFD findings has reinforced the importance of documentation, clinical oversight and timely escalation, resulting in improved assurance surrounding care for frail patients, end-of-life patients and those with complex healthcare needs Workforce improvements It is known that there is a National shortage of district nurses and Tameside is not different. it is not unknown that in recent years that there have been several reported vacancies across the Service of varying levels of qualification and skill set. Recruitment gaps were contributing to workforce pressures, sickness management challenges, capacity concerns, and reliance on NHS Professionals staffing. There has been a concerted effort over the last 6 months to recruit to the vacant posts, and we are pleased to share:
• There were 3 new starters joined in April 2026.
• Four new starters joined in May 2026.
• Workforce numbers increased during May 2026, with an improvement in overall establishment.
• The service moved from experiencing frequent operational escalation and 23 red days in March to reporting no red days in April and May, reflecting improved workforce capacity and operational resilience.
• No staffing-related patient safety incidents were reported in April and May compared with 13 recorded staffing incidents in March. The service has further improved wound care practice through increased investment in workforce development, competency assessment and clinical governance. Learning from incidents, inquests and PFD findings has informed expansions in wound assessment, documentation standards and escalation processes. The development of Leg Ulcer Assessment Clinics and enhanced training in leg ulcer management and Critical Lower Limb Pathways has improved staff knowledge, strengthened multidisciplinary working and supported earlier identification of patients at risk of deterioration. The Divisional Nurse and AHP Director for Integrated Care recently set up the District Nursing Improvement Group providing strategic leadership and governance oversight for strengthening safety, quality and operational reliability across District Nursing. The groups programme of work is centred on improving the triage process to ensure consistent prioritisation and risk-based decision making, enhancing caseload management so workload is balanced, transparent and responsive and raising documentation standards to support accurate clinical records, defensible practice and effective information sharing. A further priority is embedding clearer expectations for recognising B8

and escalating concerns in a timely and appropriate manner, ensuring staff have the confidence and competence to act early when patient risk increases. Assurance will be generated at team level through a monthly highlight report underpinned by robust audit process, demonstrating measurable, sustained improvements and providing a clear governance line of sight from frontline practice to senior leadership. The Divisional Nurse and AHP Director is engaged at both a regional and national level with improving District Nursing services including being actively involved with the development of a national framework for deferred work which will be released by autumn. This will provide clear guidance and accountability for providers and commissioners in managing the patient risk associated with unmet need.

Significant changes have recently been made to the leadership structure within the community services, strengthening both operational oversight and clinical governance. The introduction of dedicated Leads for Nursing and AHP’s, each reporting to the Divisional Nurse and AHP Director. This has created clearer lines of accountability and enhanced professional leadership across District Nursing. This structure ensures that clinical decision-making, workforce support and quality improvement are guided by senior leaders with the appropriate expertise, enabling more consistent standards of care and more responsible management of emerging risks. Alongside this, a revised meeting structure has been implemented to ensure assurance and governance frameworks are robust, transparent and aligned with organisational expectations. Regular forums now provide a systematic route for sharing risk, reviewing performance and escalating concerns, ensuring that information flows effectively from frontline services to senior leadership and that clinical safety and quality concerns are both known and acted upon.

Workforce stability within the District Nursing Service has strengthened over recent months. Three new starters commenced in April 2026, followed by a further four in May 2026, resulting in a measurable improvement in overall establishment and operational capacity. This increased staffing resilience is reflected in the service’s escalation profile: the 23 red-rated days reported in March reduced to zero in both April and May, demonstrating significantly improved operational grip and reduced workforce-related pressure. Correspondingly, no staffing-related patient safety incidents were recorded in April or May, compared with 13 such incidents reported in March. Together, these indicators provide assurance that recent recruitment activity and strengthened workforce oversight have contributed to a safer, more stable and more reliable service.

Overall, the District Nursing Service has demonstrated a clear trajectory of improvement, delivering safer care, stronger governance, improved operational performance and enhanced workforce resilience. Through learning from incidents, inquests and external reviews, the Service has embedded a culture of continuous improvement which has resulted in measurable improvements in patient care, staff support, service delivery and organisational assurance. Whilst workforce sustainability, sickness absence and capacity and demand continue to require ongoing focus, the B9

service is in a significantly stronger position and is well placed to continue its improvement journey. The Trust remains committed to continuous improvement in patient safety and ensuring that learning from this case is embedded in practice.

Finally, is important to us that concerns are reviewed, and learning identified and shared across clinical teams as this helps us to strive to prevent harm and improve outcomes for our patients.

I do hope that this letter provides you with further reassurance, however, should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact Legal Services on