Margaret Templeman

Dear Ms Mundy, Regulation 28 Report to Prevent Future Deaths – Mrs Margaret Rosina Templeman I write further to your Prevention of Future Deaths Report, dated 20 July 2026, following the Inquest hearing touching on the death of Mrs Templeman. We have considered your concerns and now set out our formal response to the following concerns raised:
1. Inadequate clinical record keeping
2. Failure to document communication and escalation
3. Reliability of patient safety assurances
4. Trust wide nature of the issue We recognise that adequate record keeping is absolutely essential to support safe and high- quality care for our patients and we are committed to making improvements in all the areas described in your report. NOVA New Electronic Patient Record (EPR) We are developing a new single digital patient record system called ‘NOVA’. This will integrate and replace our current record systems in all clinical areas and will be implemented at all our hospital sites. NOVA will provide real-time and accurate patient history to support clinical decision making. Clinicians will have the ability to add and access clear information in real-time to enable quicker and personalised care for our patients, reducing the need for paper-based processes and multiple systems. Once embedded, we expect NOVA will reduce the administrative burden on staff and improve the quality of the records kept with the aim of reducing the occurrence of poor record keeping. NOVA is currently in its testing stage, expected to run through the remainder of the year. As per current timelines, the system is expected to go live in June 2027.

[Page 2] Ward Accreditation Scheme We have recently launched our ‘Ward Accreditation’ quality improvement programme designed to recognise and reward inpatient wards that consistently deliver safe, effective, and high-quality patient care. The programme uses a tiered framework, with bronze, silver and gold standards representing increasing levels of achievement, quality and excellence. The accreditation award will be calculated using the average score across all 9 domains. Bronze 65-80% Silver 81-90% Gold 91-100% Platinum Gold for two consecutive years By the end of September 2026 twenty wards will be accredited, and all remaining wards will pass through the accreditation process by the end of the year. Ward Accreditation assesses nine key domains of performance; compliance with high-quality record keeping standards is a key focus in all domains. In the domain of “Getting the Basics Right’ we focus on nutrition and hydration, skin health and pressure injury prevention, bedrail assessments, care rounds and pain management. Patient records are scrutinised to ensure that all documentation is complete in these areas; records are reviewed to ensure they are legible and compliant with the relevant trust policies. The domain ‘Escalation & Planning’ identifies compliance with our policies and patient notes are assessed for evidence that the correct escalation processes have been followed and documented as they should be in each case. The ‘Medicines Management’ domain assesses whether medicines, controlled drugs and medical gases are stored, monitored, managed and documented safely. It focuses on secure storage, accurate recording of temperature and controlled drug checks, management of expired or unattended medicines, correct syringe storage, and safe handling of oxygen cylinders and medical gas systems to reduce medication-related risks and ensure regulatory compliance. We have a standalone domain solely focused on ‘Documentation’ to assess compliance with document security, information governance, and record-keeping standards. The domain measures the secure storage of patient records and protection of confidential information, while also assessing the quality of clinical documentation, including whether entries are complete, legible, dated and timed, attributable to the appropriate clinician, and demonstrate ongoing accurate documentation of patient care. Post accreditation visit, each ward receives an individual domain report, and a thematic analysis of the accreditation data including suggestions on which areas will require improvement. We are confident that issues relating to the quality of documentation and record keeping will be identified through the accreditation process and improve oversight and visibility of areas where we must focus our attention.

[Page 3] Wards attaining ‘gold’ status are identified as ‘pioneers’ for good practice and will mentor colleagues to improve performance, the second phase to this work will focus on supporting wards to improve and/or maintain their accreditation status. Audits Audit plays a key role in monitoring our compliance with documentation and record keeping standards. ‘Tendable’ is the Trust’s clinical audit tool used by all clinical areas to monitor performance against key metrics; Tendable produces a thematic analysis to identify areas of concern. We have a comprehensive programme of audits conducted on a monthly/quarterly basis depending on the required schedule; all clinical areas are assessed for their compliance with documentation requirements and reports are shared with the matrons to take action as required. Where a report identifies a deadline performance score below 50%, the report is shared directly with the Associate Director of Nursing for that area for escalation, oversight and accountability purposes. Ongoing performance is then managed through established governance channels. In addition to NOVA, Ward Accreditation, and our audit programme, we will continue to reinforce clear expectations of what is required for high-quality record keeping in our daily clinical huddles. If I can assist any further with these matters, please do not hesitate to contact me.