Mathew Bailey

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 12th August 2026, following the Inquest on the death of Mathew Charles Bailey. 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 has the power to take action to prevent future deaths. Your specific concern was: “Some doctors and nurses at your Trust’s hospitals do not understand (a) the importance of maintaining fluid charts for patients with urinary or kidney infections; and (b) the importance of looking for venous thromboembolism (VTE) assessments in patients notes and acting on them.” In response to your concern (a); staff understanding the importance of maintaining fluid charts for patients with urinary or kidney infections
• The Acute Kidney Injury (AKI) team delivers targeted education and training across a range of staff groups to support the early identification and management of AKI. Training is offered to Band 5 Nurses, although completion is not currently essential to role. In August 2026, a dedicated one-off AKI training session was delivered to Foundation Year 2 doctors, with education being then incorporated into the ongoing Foundation Year 1 teaching programme, using recent case studies to demonstrate areas for improvement. In addition, AKI focused training is included within the nursing preceptorship programme, and fluid balance management is covered as part of the HCA care certificate.
• Fluid balance monitoring is included in the weekly senior nursing quality checks undertaken by all adult inpatient wards and this is reported through the nutrition and hydration steering group.
• There is further work ongoing to explore if the details from fluid balance can be pulled electronically through into the daily ward round document, to provide data more easily to the medical teams reviewing the patient.
• In addition to this the Acute Kidney Injury (AKI) nursing team pull a report form our electronic blood system of all patients with a new AKI stage 2 or 3 and aim to review them on the ward on the same day and they will also liaise with the renal team to review patients they have concerns about. The parent teams are also encouraged to refer patients directly to the renal team.
• The AKI nurses are also available to wards for support and advice via a bleep system. Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD

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• The AKI bundle document is currently on a work program within the digital team to be incorporated into Electronic Patient Record (EPR) which would improve the ability to audit and monitor it’s completion. In response to your concern (b); the importance of looking for venous thromboembolism (VTE) assessments in patients notes and acting on them
• In June 2026, enhancements to the EPR system were implemented to support VTE management. These updates included the introduction of a standalone VTE risk assessment and improvements to the patient tracking board, enabling staff to more easily identify whether a patient has received the required assessment. A "Top Tips" document was developed and shared as part of the associated communications.
• The Trust Thrombosis Committee was reinstated earlier this year with the delegated authority to develop and monitor the guidelines and Trust performance for the prevention and management of hospital associated venous thromboembolism within the trust. The terms of reference include: o To monitor rates of VTE risk assessment across the Trust benchmarked against national standards. o To receive Care Group reports detailing instances of Hospital Acquired Thrombosis and ensure identified learning is disseminated across the Trust. o To ensure the required audits are completed o To consider the findings from relevant clinical audits, critical incident analysis and significant adverse event investigations within the Trust and make recommendations for further action as necessary. o To work collaboratively with the Medicines Safety Committee on any matters relating to the safe and effective use of medicines for the prevention and treatment of thromboembolic events.
• For further information and assurance, a comprehensive VTE dashboard has been developed and reports on compliance with initial VTE risk assessments, findings from the mechanical VTE audit, and compliance with the prescribing of prophylaxis for patients where this is clinically indicated. The dashboard can be filtered by Care Group, Ward and Site to enable detailed local review and monitoring. Please let me know if you require any further information.