Rodney Foster

Dear Mr Reid Re Regulation 28 Report to Prevent Future Deaths Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 28th July 2026, following the Inquest on the death of Rodney Foster Stroud. In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT) and that you believe the trust have the power to take action to prevent future deaths. Your specific concern was: “Oral evidence given at the inquest revealed that in the opinion of a senior staff member, there is insufficient awareness of the requirements of the ‘Stay in the bay’ falls prevention initiative and Level 3 observations, which in their opinion, is a result of insufficient training on the subject.” In response to your concern, we would like to assure you that the trust does have a training programme around falls prevention and the compliance to this is monitored at the ward level:
• All staff must complete mandatory Health and Safety training (on a 3 yearly cycle) where the subject of non-clinical slips, trips and falls is covered. This is also provided at mandatory corporate induction.
• All registered healthcare professionals must complete the essential-to-role Falls e-learning available ESR every 3 years.
• All new Health Care Support Worker’s receive in person Falls training during induction where safety is discussed, in terms of staff not undertaking other duties while on stay in the bay duty, being off their mobile phones and if they need to leave or step behind a curtain to carry out personal care the importance that they ask colleagues to step in to cover them or ask for additional support, please see slide from training below: Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD

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• Additional in person Falls training is available on Tier 2 Dementia training and Preceptorship courses, where the enhancing of patient care whilst under enhanced / level 3 observations is discussed along with ideas and suggestions on how this can be achieved, we have provided an example slide below:
• Bespoke training can be provided by the falls team on request.
• There is also a supporting policy for both falls prevention and in-patient enhanced observations For further information and assurance, earlier in the year the Trust elected to be part of the 3rd cohort of the NHS England (NHSE) Enhanced Therapeutic Observations and Care (ETOC) programme. This is an ongoing national improvement programme focused on changing how hospitals deliver "enhanced care" (often called 1:1 observations, specialling, or enhanced observations). Rather than simply assigning someone to watch a patient, the programme aims to make those interactions therapeutic, person- centred, and clinically justified. The trust project is being led by an ETOC faculty with representatives from the Deputy Chief Nursing team, Safeguarding, Medicine, Surgery, Diagnostics, Governance, Workforce, Education, Patient experience and Frailty. We are pleased to have had excellent engagement from teams who are working collaboratively to ensure this represents a robust review of current ETOC processes and practices, and ensure that future provision is evidence based, safe and therapeutic. The most recent updates and achievements for the ETOC program are:
• Clinical assessment document has been approved by the group following stakeholder feedback and final review with the aim for this to be digital.
• Train-the-Trainer programme completed, resulting in ten new trainers for clinical holding and safer interventions.
• ETOC theory content completed, with pilot training session planned on 15th September
• Draft ETOC Passport and therapeutic engagement documentation developed and endorsed for further testing and plans to explore capturing this on electronic patient records.
• Governance framework and Gantt chart established to support programme oversight and progress tracking. We recognise that perhaps this new workstream around the new developing ETOC program has not yet been well communicated to all our more junior staff and your recommendations provide a useful backdrop for us to emphasise its importance. As a consequence, ward managers and matrons will be regularly briefed on this via their care group management structures, and each care group has a representative on the project team. Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD

[Page 3] Office of the Chief Executive Officer Going forward the roll out and progress of the project will be monitored via various governance processes and committees. Please let me know if you require any further information.