Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 37
NHS Humber Health Partnership Implement the Diamond Standard acute-care pathway for learning-disabled and autistic people across emergency, planned-admission and outpatient services.
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NHS Humber Health Partnership Embed learning-disability improvements across adult and children’s services and monitor training compliance.
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NHS Humber Health Partnership Operate Weekly Patient Safety Summit meetings to discuss patient-safety concerns with senior clinical, nursing, care-group and governance leads.
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NHS Humber Health Partnership Agree, implement and monitor Trust improvement actions arising from LeDeR learning at the internal learning-disability steering group.
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NHS Humber Health Partnership Establish partnership safety structures and escalation routes linking resuscitation, deterioration and sepsis groups to the Quality and Safety Committee.
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NHS Humber Health Partnership Update sepsis policies and screening tools in response to NICE guidance, including digital versions, and collect daily screening and management data.
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NHS Humber Health Partnership Continue auditing pain-assessment quality and analgesic provision, and plan conversion of the paper Abbey tool to an electronic version.
View source
NHS Humber Health Partnership Develop multi-professional deteriorating-patient training for high-risk areas and seek Board approval through a business case.
View source
NHS Humber Health Partnership Trial and embed the nationally recognised patient wellness questionnaire to support Martha’s Rule escalation.
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NHS Humber Health Partnership Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
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NHS Humber Health Partnership Adopt the Royal College of Emergency Medicine Learning Disabilities Toolkit in the Emergency Department.
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NHS Humber Health Partnership Provide a dedicated Learning Disability Liaison Nurse role with specialist support, advice and safeguarding expertise for patients, carers and clinical staff.
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NHS Humber Health Partnership Introduce a Trust Standard Operating Procedure incorporating Martha’s Rule and direct escalation to the Critical Care Outreach Team.
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NHS Humber Health Partnership Conduct annual safeguarding and learning-disability improvement-standard audits and action their findings.
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NHS Humber Health Partnership Raise Trust DATIX reports for each Martha’s Rule escalation to monitor trends and identify process concerns.
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NHS Humber Health Partnership Disseminate Humber LeDeR learning briefings through internal groups, the mortality team and the Trust learning-disabilities intranet.
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NHS Humber Health Partnership Update and seek approval for the deteriorating-adult policy and NEWS2 escalation ladder, including family and carer concerns and defined response times.
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NHS Humber Health Partnership Establish a High Observation Bay in the Acute Medical Unit with increased nursing ratios for higher-acuity patients.
View source
NHS Humber Health Partnership Use a Task and Finish Group to align deterioration and sepsis education with the needs of medical, nursing and support staff.
View source
NHS Humber Health Partnership Roll out mandatory Oliver McGowan learning-disability and autism training, beginning with all Emergency Department staff.
View source
NHS Humber Health Partnership Complete Structured Judgement Reviews for all patients with identified learning disabilities who die while receiving Trust care.
View source
NHS Humber Health Partnership Mandate the eLearning pain-assessment module for all registered nurses across the Trust.
View source
NHS Humber Health Partnership Provide designated rapid-assessment capacity, escalation clinicians, safety nurses, sepsis champions and streaming-desk nursing cover for deteriorating patients.
View source
NHS Humber Health Partnership Introduce a standalone electronic pain-assessment section supporting alternative tools, including the Abbey and Visual Pain Assessment Tools.
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NHS Humber Health Partnership Resume monthly deteriorating-patient training ahead of the updated policy rollout.
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NHS Humber Health Partnership Introduce and use a standardised learning-disability health passport scanned into the electronic patient record for repeat attendances.
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NHS Humber Health Partnership Disseminate Abbey Pain Assessment Tool guidance through posters, pocket guides, intranet resources, QR codes and targeted staff training.
View source
NHS Humber Health Partnership Maintain a reasonable-adjustment admission pathway for people with learning disabilities across repeat attendances.
View source
NHS Humber Health Partnership Maintain electronic learning-disability flags and a virtual ward mechanism to identify admissions and provide specialist reasonable-adjustment support.
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NHS Humber Health Partnership Operate a Patient Engagement Workstream that gathers patient and family feedback for the improvement strategy, including sepsis and deteriorating-patient work.
View source
Care Quality Commission Check the provider’s regulatory compliance during the next inspection using the single assessment framework, highlight breaches and request necessary improvements.
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Care Quality Commission Attend the monthly Quality Improvement Group to review the trust’s action-plan progress and priority quality risks.
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Care Quality Commission Continue closely monitoring information received about the service.
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Care Quality Commission Continue monitoring progress against the trust’s action plans to ensure sustained improvement.
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NHS England Operate the LeDeR mortality review programme to review health and social care received by deceased people with learning disabilities and autistic people.
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NHS England Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.
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NHS England Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to follow clinical recommendations for 30-minute observations
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of internal investigation of serious incidents
Wider context from the report “(4) Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. The court heard evidence from independent experts who opined that it would be expected, following a death in these circumstances, for there to have been an internal review to consider improvements to include input from a specialist with a learning disability team.
” Is this part of a recurring concern? Yes — Inadequate safety incident investigations .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate NEWS2 scores above seven for specialist advice
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to accurately assess pain in people unable to communicate with words
Wider context from the report “(1) Pain is not accurately assessed in people who are unable to communicate with words. The court heard evidence that Mr Lodge at no point was provided pain relief, despite requests from the attending family member who was speaking on his behalf. An independent expert, a Consultant in Emergency Medicine, gave evidence that there was no evidence of reasonable adjustments in respect of assessing Mr Lodge’s pain to account for his baseline condition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department
Wider context from the report “(2) Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department. The treating physicians in evidence agreed that there should have been a high index of suspicion of pneumonia in Mr Lodge’s case and that it is one of the leading causes of death for people with learning disabilities. The court heard evidence that Mr Lodge did not have a chest examination carried out on him due to him not presenting any signs of respiratory distress. The independent expert gave evidence that a thorough examination should have been undertaken and that there was the opportunity to do so after the sedation medication was given.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Diamond Standard acute-care pathway for learning-disabled and autistic people across emergency, planned-admission and outpatient services.
Verbatim wording from the response “11. The Trust has completed this yearly audit and actioned findings. Learning from best practice saw the introduction of the Northeast and Cumbria Learning Disabilities Diamond Standard Acute Care Pathway in 2022/23 in the emergency department, planned admissions and outpatient attendances.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed learning-disability improvements across adult and children’s services and monitor training compliance.
Verbatim wording from the response “7. These improvements have been embedded and are in use across adults and children services alongside training compliance reviews.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate Weekly Patient Safety Summit meetings to discuss patient-safety concerns with senior clinical, nursing, care-group and governance leads.
Verbatim wording from the response “56. The Trust hold Weekly Patient Safety Summit (WPSS) meetings to discuss patient safety concerns. Senior Clinical and Nursing staff as well as Clinical and Governance Leads from the Care Groups all attend this meeting.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree, implement and monitor Trust improvement actions arising from LeDeR learning at the internal learning-disability steering group.
Verbatim wording from the response “60. Learning from the Humber LeDeR briefings that are directly related to the Trust are discussed, with subsequent improvement actions and implementation plans agreed and monitored at the Mental Health, Learning Disability & Autism Steering Group.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish partnership safety structures and escalation routes linking resuscitation, deterioration and sepsis groups to the Quality and Safety Committee.
Verbatim wording from the response “Hull University Teaching Hospitals NHS Trust (HUTH) along with North Lincolnshire and Goole NHS FT (NLAG) have recently joined forces to create NHS Humber Health Partnership which has brought a wealth of expertise together to create structure and improvements to patient safety. The creation of NHS Humber Health Partnership has created more structure than ever before. Various groups from HUTH such as the Resuscitation, Deteriorating Patients and Sepsis Steering Group and the NLAG Resuscitation Committee have come together to share their knowledge and experiences and created a route of escalation to the” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update sepsis policies and screening tools in response to NICE guidance, including digital versions, and collect daily screening and management data.
Verbatim wording from the response “51. In relation to Sepsis the Trust has carried out a substantial amount of work in the Acute Assessment Unit and the Emergency Department and data is collected on a daily basis relating to sepsis screening and the implementation of the correct management. Since the recent changes to NICE guidance the Trust have updated their policy and screening tools and created digital versions.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue auditing pain-assessment quality and analgesic provision, and plan conversion of the paper Abbey tool to an electronic version.
Verbatim wording from the response “32. Whilst it is too early to tell if this has resulted in a demonstrable improvement of clinician’s pain assessments, the Acute Pain and Digital Teams will continue to audit and monitor the progress and plan to convert the paper-based Abbey Pain Assessment Tool to an electronic version.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop multi-professional deteriorating-patient training for high-risk areas and seek Board approval through a business case.
Verbatim wording from the response “49. The aim of the Trust team is for the training to become mandatory and discussions are being held with the Trust in this regard. In 2024 the NUTS-S team began work on developing the training further with the aim of rolling out the training to multi professionals working in high risk areas and dealing with deteriorating patients and a business case has been presented to the Board for approval. The overall aim of the training is to improve patient safety.” Source location Response from Humber Health
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial and embed the nationally recognised patient wellness questionnaire to support Martha’s Rule escalation.
Verbatim wording from the response “43. The above policy update is also in line with ‘Martha’s Rule’, which is a major NHS England patient safety initiative providing patients and families with a way to seek an urgent review if their own or loved one’s condition deteriorates and they are concerned this is not being responded to. HUTH are not part of the NHS England Trust Pilot scheme which ends at the end of March 2024. However, the Trust have attended all of the NHS England conferences regarding Martha’s Rule and have adopted the nationally recognised patient wellness questionnaire which is being trialled within the Trust and which we are working hard to embed. The Trust have already seen some referral’s under Martha’s Rule to the Critical Care Outreach Team (CCOT).” Source location Response from Humber Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
Verbatim wording from the response “48. In addition to the monthly training outlined above the Nurses Training in Simulation and Sepsis team (NUT-S), have been running training sessions since 2022. The NUTS-S team was created off the back of the incident involving Mr Lodge which prompted the development of learning and the NUTS-S team have used Mr Lodge’s case as a simulated example within the training sessions. The training was developed by the Trust’s Deputy Director, Hull Institute of Learning and Simulation which began as a Pilot training session and was first delivered to the Nurses in the Acute Medicine Department and was later rolled out to include the Nursing Team within the Emergency Department and it is now Trust wide. The training covers different scenarios, however the structure and focus is always the same and includes a patient who shows signs of deterioration.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the Royal College of Emergency Medicine Learning Disabilities Toolkit in the Emergency Department.
Verbatim wording from the response “34. The Emergency Department has adopted the Royal College of Emergency Medicine Learning Disabilities Toolkit, following the conclusion of the inquest.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a dedicated Learning Disability Liaison Nurse role with specialist support, advice and safeguarding expertise for patients, carers and clinical staff.
Verbatim wording from the response “3. From May 2021 to date, Hull Clinical Commissioning Group has commissioned one full-time equivalent Learning Disability Liaison Nurse role, hosted by Humber Teaching Foundation Trust with an honorary contract within Hull University Teaching Hospitals NHS Trust. There are posters printed and displayed in the Emergency Department to make staff aware of this role and the poster includes contact details so the team are able to contact if support is required.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a Trust Standard Operating Procedure incorporating Martha’s Rule and direct escalation to the Critical Care Outreach Team.
Verbatim wording from the response “44. In addition to and alongside the above policy update a separate Trust Standard Operating Procedure (SOP) to incorporate Martha’s Rule will be introduced. The wording of the SOP will follow NHS England’s recommendations. It is anticipated that if concerns are raised and no action is taken or the action taken is deemed insufficient the patient could be escalated directly to the critical care team for assessment. Under Martha’s Rule the patient or their family will not require the treating Doctors opinion to contact the Critical Care Outreach team.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct annual safeguarding and learning-disability improvement-standard audits and action their findings.
Verbatim wording from the response “8. Fundamental Standards Safeguarding audits have been in place across the organisation since 2021. This audit reviews both service users feedback and clinicians’ knowledge of safeguarding. Compliance over 2022 and 2023 is seen in the table below.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise Trust DATIX reports for each Martha’s Rule escalation to monitor trends and identify process concerns.
Verbatim wording from the response “46. Each time there is an escalation under Martha’s Rule a Trust DATIX will be raised to monitor trends, gather evidence of clinical incidences and highlight issues and concerns in Trust processes.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate Humber LeDeR learning briefings through internal groups, the mortality team and the Trust learning-disabilities intranet.
Verbatim wording from the response “59. The Humber LeDeR Steering Group have developed learning briefings with good practice and areas for improvement presented from reviews that have occurred across the Humber region in both primary and secondary care. These briefings are shared at the internal Mental Health, Learning Disability & Autism Steering Group, internal End of Life Steering Group and with the Trusts mortality team manager. In addition, the briefings are made available on the Trust Learning Disabilities intranet website for staff to access.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and seek approval for the deteriorating-adult policy and NEWS2 escalation ladder, including family and carer concerns and defined response times.
Verbatim wording from the response “39. The Emergency Department follows the CP326: Recognition of the Deteriorating Adult Patient Policy. This is a Trust wide policy and is therefore also used outside of the Emergency Department.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a High Observation Bay in the Acute Medical Unit with increased nursing ratios for higher-acuity patients.
Verbatim wording from the response “57. In addition we have seen the introduction of the High Observation Bay (HOB) in AMU which is for higher acuity patients who are placed in the bay with a higher nursing ratio.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a Task and Finish Group to align deterioration and sepsis education with the needs of medical, nursing and support staff.
Verbatim wording from the response “50. A Task and Finish Group has also been set up to make sure education meets the needs of all staff groups including medical staff, nursing staff and Health Care Support Workers who come into contact with a deteriorating patient and also to cover learning outcomes relating to sepsis.” Source location Response from Humber Health
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out mandatory Oliver McGowan learning-disability and autism training, beginning with all Emergency Department staff.
Verbatim wording from the response “13. As a Trust we are now rolling out, as of January 2025 the Oliver McGowan mandatory training on Learning Disability and Autism. The training is named after Oliver McGowan, whose death shone a light on the need for health and social care staff to have better training. The Health and Care Act 2022 introduced a statutory requirement that regulated service providers must ensure their staff receive learning disability and autism training appropriate to their role. The Trust provide the Government's preferred and recommended training for health and social care staff.” Source location Response from Humber Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete Structured Judgement Reviews for all patients with identified learning disabilities who die while receiving Trust care.
Verbatim wording from the response “55. However, since Mr Lodge’s death, Trust process and procedure has developed and going forward a Structured Judgement Review (SJR) is completed for all patient’s with identified learning disabilities and who sadly pass away while receiving care and treatment at the Trust. The SJR will be completed by the Vulnerabilities and Enhanced Care. The SJR will be completed despite the outcome of the initial clinical review of the care and treatment provided and despite the outcome of the decision from LeDeR in terms of their investigation.” Source location Response from Humber Health
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate the eLearning pain-assessment module for all registered nurses across the Trust.
Verbatim wording from the response “22. There is an eLearning Pain Assessment module on HUTH’s training platform (HEY247). Up to December 2024 317 staff had completed this module, 36 of whom are based in the emergency department or acute assessment unit. On the 27 February 2025 it was agreed at the Learning and Organisational Steering Group meeting that the eLearning module for pain assessment will be mandated across the Trust for all registered Nurses.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide designated rapid-assessment capacity, escalation clinicians, safety nurses, sepsis champions and streaming-desk nursing cover for deteriorating patients.
Verbatim wording from the response “52. Over the last 18-24 months many changes have been implemented in the Emergency Department for incoming patients who need prompt treatment. The Emergency Department at present have 2 out of 8 bays within the initial assessment area which are earmarked for quick assessment and treatment. These are used, when capacity allows, for patients who are clinically unwell and may have a high NEWS. This allows for closer supervision and quick assessment of these patients.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a standalone electronic pain-assessment section supporting alternative tools, including the Abbey and Visual Pain Assessment Tools.
Verbatim wording from the response “27. In April 2024, Hull University Teaching Hospitals Acute Pain Team completed an audit to review progress regarding the assessment of pain. The results produced from the Emergency Department audit showed that pain was being assessed in 100% of cases. However the audit demonstrated awareness of the Abbey Pain Assessment tool remained low. This concern was escalated to the Chief Nurse, Corporate Patient Experience Committee. At the time there was no distinction in relation to which pain tool was being used and therefore further action was taken in November 2024 as indicated below in terms of changes on Nevercentre.” Source location Response from Humber Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resume monthly deteriorating-patient training ahead of the updated policy rollout.
Verbatim wording from the response “47. Training on the topic of deteriorating patients was provided to all staff until September 2024, however, the training had to be stalled due to unforeseen circumstances. The monthly training is due to resume in April 2025 in time for the updated policy roll out.” Source location Response from Humber Health
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and use a standardised learning-disability health passport scanned into the electronic patient record for repeat attendances.
Verbatim wording from the response “6. In June 2022 Hull University Teaching Hospitals collaborated with the ICB and partners to produce a standardised health passport for people with a learning disability which are brought in by the individual or carer and scanned into the electronic patient record programme, Lorenzo, in case of repeat attendances.” Source location Response from Humber Health
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate Abbey Pain Assessment Tool guidance through posters, pocket guides, intranet resources, QR codes and targeted staff training.
Verbatim wording from the response “25. In addition to the training provided, as outlined above, following the 2022 CQC inspection (published March 2023), the trust acknowledged that pain assessment was not consistently assessed for patients who were non-verbal and/or unable to use the visual pain assessment scale. In response the Acute Pain Team implemented an action plan to address the issues raised which included the following in addition to other action taken.” Source location Response from Humber Health
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a reasonable-adjustment admission pathway for people with learning disabilities across repeat attendances.
Verbatim wording from the response “2. In June 2020, the Safeguarding Adults team in consultation with the Community Learning Disabilities team established a reasonable adjustment admission pathway for David (digitally stored on Lorenzo) to ensure his needs were considered and where possible met for all repeat attendances at Hull University Teaching Hospitals.” Source location Response from Humber Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain electronic learning-disability flags and a virtual ward mechanism to identify admissions and provide specialist reasonable-adjustment support.
Verbatim wording from the response “9. In 2022, a virtual ward for learning disability and safeguarding was developed within the electronic nursing records. Once a learning disability diagnosis is recorded, an electronic flag for learning disabilities remains in place and is pulled through to future episodes of care within HUTH. This mechanism allows the adult safeguarding team and learning disability liaison nurse to identify patients quickly following their admission and then contact the wards (mon-fri) to provide specialist support and advice on reasonable adjustments and care.” Source location Response from Humber Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Patient Engagement Workstream that gathers patient and family feedback for the improvement strategy, including sepsis and deteriorating-patient work.
Verbatim wording from the response “Since the coming together of the two Trusts a number of key work streams have been created, some of which are addressed below, including education, Martha’s Rule, and patient engagement. NHS Humber Health Partnership believe that Patient engagement is vital. Feedback from patients and families is being obtained and the information gathered is being used to develop our improvement strategy which will feed in to our work around sepsis and deteriorating patients. The Partnership has seen the setup of the Patient Engagement Work stream which was a subsidiary group from the Resuscitation, Deteriorating Patient and Sepsis Steering Group.” Source location Response from Humber Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check the provider’s regulatory compliance during the next inspection using the single assessment framework, highlight breaches and request necessary improvements.
Verbatim wording from the response “CQC will also check the provider’s compliance with the regulations on our next inspection of the service using our new single assessment framework methodology in accordance with the CQC regulatory remit. CQC will highlight any repeated or new breaches of regulation and ask them to make necessary improvements.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Attend the monthly Quality Improvement Group to review the trust’s action-plan progress and priority quality risks.
Verbatim wording from the response “In addition to inspection activity the CQC attends a monthly Quality Improvement Group (QIG) chaired by NHS England, where the trust presents monthly updates against the CQC action plans and key priority areas. The purpose of the QIG is to support planning, coordination and facilitate the sustained delivery of actions to mitigate and address the quality risks within the trust.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue closely monitoring information received about the service.
Verbatim wording from the response “CQC will continue to closely monitor information we receive about the service. Where CQC identifies that regulations are not being met, we will use our enforcement powers to require improvements to be made.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring progress against the trust’s action plans to ensure sustained improvement.
Verbatim wording from the response “The trust was required to submit an action plan by the 8th of November 2022 to indicate actions taken and any further steps to be taken to mitigate immediate risks to patient safety as identified above. This action plan was submitted, and accepted, by CQC within the required timeframe.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the LeDeR mortality review programme to review health and social care received by deceased people with learning disabilities and autistic people.
Verbatim wording from the response “As referenced above, NHS England has a significant learning disability mortality review (LeDeR) programme which outlines a clear expectation that “Integrated Care Systems (ICSs) will be responsible for ensuring that LeDeR reviews are completed of the health and social care received by people with a learning disability and autistic people (aged four years and over) who have died, using the standardised review process”. A LeDeR review is currently in progress to look at the care delivered to David.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of David, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
Verbatim wording from the response “NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital. An aggregated score of above 7 is considered high clinical risk and should trigger an urgent or emergency response by a clinician or team with competence in the assessment and treatment of acutely ill patients, including recognising when the escalation of care to a critical care team is appropriate. The response team must also include staff with critical care skills, including airway management.” Source location Response from NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust did not declare a serious incident because harm was not deemed to have been caused by the Trust.
Verbatim wording from the response “53. Information of Davids death was provided by the emergency department to the Mental Capacity Act lead. No concerns were raised regarding omissions in care or treatment during the hours spent at Hull University Teaching Hospitals. A safeguarding concern was submitted to the relevant Local Authority for investigation due to the pathway of admission and prior knowledge of community safeguarding issues. Mr Lodge’s death was also reported to LeDeR who confirmed that a review of care would be completed at the conclusion of the inquest.” Source location Response from Humber Health
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PFD Monitor interpretation The Humber Steering Group manages the LeDeR action plan across the ICB, while Trust-related actions are monitored through the LeDeR Panel Review Group.
Verbatim wording from the response “58. Programme relevant to the Services. This includes the Learning Disabilities Mortality Review programme (LeDeR) of which NHS Humber Health Partnership is a member of the Humber Steering Group. Mr Lodge’s case was referred to LeDeR prior to the inquest and action was to be considered following the conclusion of the inquest. The Trust are aware that the LeDeR Panel Review Group are carrying out of full review of the care and treatment Mr Lodge received. The Panel Review Group meet every two weeks and the action plan ensuing from the review, which relates to the Trust will be monitored at the Panel Review meetings. The action plan across the ICB would be managed by the Humber Steering Group.” Source location Response from Humber Health
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Emergency Department has not identified evidence that basic examinations are omitted specifically for patients with learning disabilities.
Verbatim wording from the response “38. The Emergency Department has not identified any evidence to suggest that basic examinations are not being carried out specifically in patients with learning disabilities. Nevertheless the Emergency Department and the Trust continually reflect on how the care and treatment can be improved for patients with learning disabilities.” Source location Response from Humber Health
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Verbatim wording from the response “In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share” Source location Response from NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities and community agencies largely hold responsibility for supporting and safeguarding vulnerable adults and families.
Verbatim wording from the response “David was a vulnerable adult who was dependent on an elderly parent, with no other apparent social support. The welfare of vulnerable adults is largely the responsibility of local authorities and other community agencies, yet David and his father did not have contact with social care services for four days or more. A proactive system of support to David and his father could have alerted services to the perilous state that they were in. NHS England can emphasise to member agencies of Integrated Care Partnerships their important role in supporting and safeguarding vulnerable families.” Source location Response from NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Verbatim wording from the response “In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share” Source location Response from NHS England
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