Royal Wolverhampton Trust Walsall Healthcare NHS Trust
Action Taken
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The Trusts have issued a mandatory instruction for all inter-hospital referral correspondence to be saved directly into the patient's electronic clinical record. They are also drafting a new inter-hospital referral policy and plan to implement a standardised digital referral system by Q4 2026 to improve audit trails.
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Dear Sirs, RE: RESPONSE TO THE REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Date of Inquest Conclusion: 30 July 2026 Date of Regulation 28 Report: 4 August 2026 Deceased: Mr Martin Alan Poole (Deceased) In accordance with the Chief Coroner’s PFD Publication Policy (2026), this response does not include the names of any living persons.
1. INTRODUCTION This formal joint response is submitted on behalf of Walsall Healthcare NHS Trust and The Royal Wolverhampton NHS Trust pursuant to Regulations 28 and 29 of the coroners (Investigations) Regulations 2013. The Trusts wish first and foremost to express their sincere condolences to the family and loved ones of the late Mr Martin Alan Poole. The Trusts take the findings of the Inquest and the Coroner’s concerns very seriously and are committed to ensuring that inter-hospital communication, referral management, and audit trails remain safe, reliable, and transparent.
2. MATTERS OF CONCERN IDENTIFIED BY THE CORONER In section 5 and section 9 of the Report to Prevent Future Deaths, the Coroner highlighted the following concern: "I have concerns about the Trusts referral process between Hospitals when an urgent referral is made by telephone only. There is a risk of no formal recording of the request including documentation and subsequent audit trails.
3. INVESTIGATION FINDINGS AND FACTUAL CLARIFICATION Following receipt of the Regulation 28 Report, clinical and executive leaders across both WHT and RWT carried out a joint review of the case records, electronic communication trails, and booking systems to establish the pathway undertaken:
[Page 2] Inpatient Assessment & Specialist Discussion (August 2025): Mr Poole was admitted to Manor Hospital (WHT) under General Surgery on 11 August 2025. Following a CT scan demonstrating an enlarged prostate and bilateral hydronephrosis, a telephone discussion took place between the surgical clinical team at WHT and the on-call Urology Registrar at RWT. A clinical management plan was agreed (including catheterisation to manage high- pressure urinary retention). Documentary Trail and Written Referral: The initial clinical conversation occurred by telephone, and the conversation was documented in the clinical notes by the referrer at WHT. Following this conversation, on the 15 August 2025, the on- call Urology Specialist Registrar at RWT sent a formal written email referral to the Urology secretarial booking team requesting that Mr Poole be booked into the Lower Urinary Tract Symptoms (LUTS) outpatient clinic. Receipt and Action at RWT: On 18 August 2025 at 09:16, the referral received from WHT was formally acknowledged on the Clinical Web Portal (CWP) system at RWT under Urology outpatient advice/consultation. Parallel GP Referral and Triage: A concurrent referral from Mr Poole's General Practitioner was received via the NHS Referral Assessment Service (RAS) on 19 August 2025. On 3 September 2025, this was triaged by a Consultant Urologist. Because the clinical findings at that time reflected benign prostatic enlargement with outflow retention rather than red-flag cancer symptoms, it was triaged and booked as routine rather than on a two-week cancer pathway. Although the referral was formally received, processed, and tracked within RWT systems, the joint internal review identified the cross-trust communication process could be improved. The email- based referral sent by the inpatient team was not automatically integrated or uploaded into the electronic patient record (EPR) at WHT or at RWT, leaving an incomplete record. We recognise that the use of email inboxes between trusts creates fragmentation, lacks standard workflow visibility, and makes real-time end-to-end auditing difficult.
4. ACTIONS TAKEN AND PLANNED To ensure robust audit trails for all inter-hospital referrals, the Trusts have instituted the following measures: Mandatory Electronic Clinical Referral Uploads (Immediate): A standard instruction has been issued to clinical and administrative teams requiring that any inter- hospital written or email correspondence regarding referrals must be saved directly into the patient’s clinicals notes/ electronic clinical record (EPR). An interhospital referral Policy/SOP is being drafted to define the interhospital referral process. Implementation of a standardised electronic Inter-Hospital Referral system (Timetable: Q4
2026): The Digital teams across both Trusts are working towards replacing the current manual email referral process with a digital clinical referral solution (such as Care Flow Connect which is in use across both Trusts). This platform will provide time-stamped digital confirmation when a referral is generated, received, triaged, and accepted. It will create a transparent, two-way audit log accessible to clinicians at both hospital sites and eliminate the vulnerability of untracked telephone- only or unstructured inbox communications. Audit and Compliance Monitoring: An audit will be established to evaluate cross-site referral compliance against the Policy/SOP, verifying that all non-elective outpatient referral requests possess an unbroken electronic audit trail from referral initiation through to clinic triage.
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5. CONCLUSION The Trusts would like to assure that the factual context provided clarifies the paper trail that existed in Mr Poole’s care, while acknowledging that the historical reliance on email created procedural gaps that requires modernising. The leadership of both organisations remain dedicated to embedding these digital referral workflows to ensure patient safety.
1. INTRODUCTION This formal joint response is submitted on behalf of Walsall Healthcare NHS Trust and The Royal Wolverhampton NHS Trust pursuant to Regulations 28 and 29 of the coroners (Investigations) Regulations 2013. The Trusts wish first and foremost to express their sincere condolences to the family and loved ones of the late Mr Martin Alan Poole. The Trusts take the findings of the Inquest and the Coroner’s concerns very seriously and are committed to ensuring that inter-hospital communication, referral management, and audit trails remain safe, reliable, and transparent.
2. MATTERS OF CONCERN IDENTIFIED BY THE CORONER In section 5 and section 9 of the Report to Prevent Future Deaths, the Coroner highlighted the following concern: "I have concerns about the Trusts referral process between Hospitals when an urgent referral is made by telephone only. There is a risk of no formal recording of the request including documentation and subsequent audit trails.
3. INVESTIGATION FINDINGS AND FACTUAL CLARIFICATION Following receipt of the Regulation 28 Report, clinical and executive leaders across both WHT and RWT carried out a joint review of the case records, electronic communication trails, and booking systems to establish the pathway undertaken:
[Page 2] Inpatient Assessment & Specialist Discussion (August 2025): Mr Poole was admitted to Manor Hospital (WHT) under General Surgery on 11 August 2025. Following a CT scan demonstrating an enlarged prostate and bilateral hydronephrosis, a telephone discussion took place between the surgical clinical team at WHT and the on-call Urology Registrar at RWT. A clinical management plan was agreed (including catheterisation to manage high- pressure urinary retention). Documentary Trail and Written Referral: The initial clinical conversation occurred by telephone, and the conversation was documented in the clinical notes by the referrer at WHT. Following this conversation, on the 15 August 2025, the on- call Urology Specialist Registrar at RWT sent a formal written email referral to the Urology secretarial booking team requesting that Mr Poole be booked into the Lower Urinary Tract Symptoms (LUTS) outpatient clinic. Receipt and Action at RWT: On 18 August 2025 at 09:16, the referral received from WHT was formally acknowledged on the Clinical Web Portal (CWP) system at RWT under Urology outpatient advice/consultation. Parallel GP Referral and Triage: A concurrent referral from Mr Poole's General Practitioner was received via the NHS Referral Assessment Service (RAS) on 19 August 2025. On 3 September 2025, this was triaged by a Consultant Urologist. Because the clinical findings at that time reflected benign prostatic enlargement with outflow retention rather than red-flag cancer symptoms, it was triaged and booked as routine rather than on a two-week cancer pathway. Although the referral was formally received, processed, and tracked within RWT systems, the joint internal review identified the cross-trust communication process could be improved. The email- based referral sent by the inpatient team was not automatically integrated or uploaded into the electronic patient record (EPR) at WHT or at RWT, leaving an incomplete record. We recognise that the use of email inboxes between trusts creates fragmentation, lacks standard workflow visibility, and makes real-time end-to-end auditing difficult.
4. ACTIONS TAKEN AND PLANNED To ensure robust audit trails for all inter-hospital referrals, the Trusts have instituted the following measures: Mandatory Electronic Clinical Referral Uploads (Immediate): A standard instruction has been issued to clinical and administrative teams requiring that any inter- hospital written or email correspondence regarding referrals must be saved directly into the patient’s clinicals notes/ electronic clinical record (EPR). An interhospital referral Policy/SOP is being drafted to define the interhospital referral process. Implementation of a standardised electronic Inter-Hospital Referral system (Timetable: Q4
2026): The Digital teams across both Trusts are working towards replacing the current manual email referral process with a digital clinical referral solution (such as Care Flow Connect which is in use across both Trusts). This platform will provide time-stamped digital confirmation when a referral is generated, received, triaged, and accepted. It will create a transparent, two-way audit log accessible to clinicians at both hospital sites and eliminate the vulnerability of untracked telephone- only or unstructured inbox communications. Audit and Compliance Monitoring: An audit will be established to evaluate cross-site referral compliance against the Policy/SOP, verifying that all non-elective outpatient referral requests possess an unbroken electronic audit trail from referral initiation through to clinic triage.
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5. CONCLUSION The Trusts would like to assure that the factual context provided clarifies the paper trail that existed in Mr Poole’s care, while acknowledging that the historical reliance on email created procedural gaps that requires modernising. The leadership of both organisations remain dedicated to embedding these digital referral workflows to ensure patient safety.