PFD report

Myles Edward Scriven · Prevention of Future Deaths report

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Issued 14 Jul 2025•West Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
26

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to audit the impact and outcomes of learning disability and autism training and provision
  2. Failure to act on relevant electronic patient record entries across clinical colleagues
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionable
  3. Lack of required adjustments for patients with learning disabilities and autism
    Part of recurring concern: Failure to provide required reasonable adjustments for patients with disabilities
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

  1. Action

    Establish a Quality Assurance Group reporting to the Board subcommittee to oversee care standards and record-keeping compliance.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
  2. Action

    Pilot and roll out patient-centred bedside boards across all areas, with evaluation of their impact.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  3. Action

    Use standardised ward audits and direct engagement to verify standards, care-plan and passport use, and timely critical medication administration.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.

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 audit the impact and outcomes of learning disability and autism training and provision

Wider context from the report

“(brief summary of matters of concern) The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when? ”

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

Failure to act on relevant electronic patient record entries across clinical colleagues

Wider context from the report

“(brief summary of matters of concern) The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when? ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable.

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 required adjustments for patients with learning disabilities and autism

Wider context from the report

“(brief summary of matters of concern) The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when? ”

Is this part of a recurring concern?

Yes — Failure to provide required reasonable adjustments for patients with disabilities.

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 apply Mental Capacity Act principle 2 in clinical decision-making

Wider context from the report

“(brief summary of matters of concern) The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when? ”

Is this part of a recurring concern?

Yes — Failure to reliably apply Mental Capacity Act principles in care decisions.

Open source report

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 Quality Assurance Group reporting to the Board subcommittee to oversee care standards and record-keeping compliance.

Verbatim wording from the response

“The Chief Nurse will be chairing a new Quality Assurance Group from September 25 that will report directly into a sub committee of the board. This group will be responsible for oversight of compliance against expected standards of care for all patients including effective record keeping. Findings from the revised audit program will be fed into this group for action.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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

Pilot and roll out patient-centred bedside boards across all areas, with evaluation of their impact.

Verbatim wording from the response

“We have a Patient Centred Care Group that is a sub - group of the Patient Experience and Involvement Group. This group is led by an Associate Director of Nursing and is responsible for the development of evidence based practice in relation to the delivery of person centred care. We are currently piloting ‘behind the bed boards’ to replace existing boards. These boards describe what is important to patients and provide an opportunity for patients and families to capture key information, questions or concerns for their clinical team. The boards also act as a prompt for patients, relatives and our teams to capture important information in relation to reasonable adjustments or care needs. The boards will be rolled out across all areas by December 2025 with an associated plan to evaluate their impact.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 4 · response
Published 17 July 2025

Open published response

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 standardised ward audits and direct engagement to verify standards, care-plan and passport use, and timely critical medication administration.

Verbatim wording from the response

“Through a standardised audit process (incorporating the national 15 steps challenge of seeing care through patient and relative eyes) and direct ward engagement, nursing leaders verify compliance with legal and regulatory standards, ensure consistent use of care plans and hospital passports, and promote timely administration of critical medications for patients with a learning disability. This provides the opportunity to resolve any issues identified at the point of care with feedback given in real time to the team involved.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 5 · response
Published 17 July 2025

Open published response

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

Revise the learning-disability care plan and support implementation with training on completion expectations.

Verbatim wording from the response

“We have already identified through our enhanced audit program that changes are needed to the current learning disability care plan. ████████ is working with our Chief Nursing Information Officer and stakeholders across Bradford and Airedale, who share our clinical record system, to revise the content and approach to completion of this care plan. This will be supported through a training program that clearly describes expectations for completion. Once the care plan is live in our electronic patient record the results will be added to our quality assurance dashboard for oversight and action.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 4 · response
Published 17 July 2025

Open published response

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 a monthly audit of Mental Capacity Act application for patients with learning disabilities.

Verbatim wording from the response

“We are developing a monthly audit that will focus on application of the mental capacity act for patients with a learning disability that will be undertaken by our medical lead for learning disabilities and nurse consultant. This audit will be managed through existing governance structures but importantly will be used as an opportunity to recognise themes and trends and address practice at an individual level.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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

Undertake weekly detailed audits of learning-disability care, including involvement, senior review and specialist recommendations.

Verbatim wording from the response

“A more detailed audit is undertaken for patients with a learning disability on a weekly basis that provides an in-depth review of the care being delivered, focusing on patient, family and carer involvement and evidence of a senior review and implementation of any specialist recommendations. The findings from these audits will be discussed at the monthly Quality Assurance Group as well as the Learning Disabilities Group.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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

Revise quality-improvement governance so divisions set measurable priorities and representatives are accountable for delivery.

Verbatim wording from the response

“The approach to quality improvement has been revised to ensure that each division describes priorities with measurable actions that can be monitored in relation to impact and effectiveness. Representatives will be held to account for delivery of priorities through this group.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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

Enhance Learning Disabilities and Mental Capacity Act content in induction and preceptorship, and develop clinical bite-sized learning and briefings.

Verbatim wording from the response

“We are enhancing the Learning Disabilities and Mental Capacity Act training into Trust induction and preceptorship training for all staff groups and reviewing the existing training offer in Safeguarding and other training sessions that can should reference learning disability awareness. We recognise that this area requires ongoing focus and attention and are developing an approach to learning that will be delivered in the clinical setting such as bite sized learning and 7-minute briefings.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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 weekend senior nursing leadership reviews across both hospital sites to assure sustained improvement.

Verbatim wording from the response

“We recognise through this process that audits in real time are required to address issues and provide ongoing assurance that the care is delivered in line with local and national standards. As highlighted in Ms McKie’s evidence, senior nursing leadership reviews now take place every weekend across both Huddersfield and Calderdale hospital sites. These reviews provide assurance that sustained improvements are being made.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 5 · response
Published 17 July 2025

Open published response

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

Reinforce Mental Capacity Act principles 1 and 2 through training and monitor application through the revised audit programme.

Verbatim wording from the response

“Although we have a robust Mental Capacity Act policy that is aligned to national standards, we recognise that this needs strengthening in relation to the application of principles 1 and 2. This will be reinforced through training and monitored through the revised audit program which will focus on the 3 key principles in relation to this.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 5 · response
Published 17 July 2025

Open published response

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

Further develop the learning-disability dashboard to support patient identification, care prioritisation, audit compliance and oversight.

Verbatim wording from the response

“To support clinical oversight of patients with learning disabilities we are further developing the learning disability dashboard within KP+ (Qlik Sense) digital system. This is a data analytics/reporting tool which has the LD flag built into reporting fields which allows the Trust to identify patients with a learning disability so that clinical teams can use this data to allow prioritisation of care needs and oversight of care delivery.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 3 · response
Published 17 July 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. 1

    Adopt scenario-based learning and clinical supervision for Learning Disabilities champions.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
  2. 2

    Change the learning-from-deaths process for people with learning disabilities and provide Medical Director oversight through the clinical outcomes group.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.
  3. 3

    Establish a Lessons Learnt Forum to evidence shared learning across the organisation.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  4. 4

    Implement the national Oliver McGowan mandatory training programme for staff.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.
  5. 5

    Develop senior ward, department and community leads as accountable Learning Disabilities champions.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  6. 6

    Conduct a mid-programme audit of staff understanding and confidence in Oliver McGowan training, escalating persistent gaps nationally.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
  7. 7

    Strengthen Learning Disabilities Group leadership by appointing medical and senior nursing co-chairs.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.
  8. 8

    Provide the coroner and Senior Coroner with a progress update on learning and developments after six months.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
  9. 9

    Undertake a resource-scoping exercise to assess whether learning-disability expertise meets current demand.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  10. 10

    Deliver Oliver McGowan Part 2 training with structured evaluation and leadership oversight of priority places.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  11. 11

    Appoint a colleague with learning disabilities to the patient experience team to support lived-experience understanding, learning and bespoke training.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2025.
  12. 12

    Evaluate the multidisciplinary meeting’s impact and improve staff awareness of its referral criteria.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
  13. 13

    Progress Martha’s Rule across adult and children’s services to enable immediate escalation and clinical review of safety concerns.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  14. 14

    Build a digital library of patient stories to improve understanding of learning-disability patient experience and outcomes.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
  15. 15

    Review Learning Disabilities champion training to address issues identified through the case and audits.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.

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 scenario-based learning and clinical supervision for Learning Disabilities champions.

Verbatim wording from the response

“Scenario based approaches will also be adopted for our learning disabilities champions supported through robust clinical supervision.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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

Change the learning-from-deaths process for people with learning disabilities and provide Medical Director oversight through the clinical outcomes group.

Verbatim wording from the response

“An important action from this case has been the changes we have made to our learning from deaths process specifically for people with Learning Disabilities, this will have oversight from the Medical Director through the clinical outcomes group,”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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 Lessons Learnt Forum to evidence shared learning across the organisation.

Verbatim wording from the response

“As part of our response to the implementation of the Patient Safety Incident Response Framework we have developed a Lessons Learnt Forum. This group is becoming established with a focus on how we can evidence shared learning across the wider organisation.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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 national Oliver McGowan mandatory training programme for staff.

Verbatim wording from the response

“The Trust has implemented the national Oliver McGowan mandatory training programme which is over a three year cycle.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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 senior ward, department and community leads as accountable Learning Disabilities champions.

Verbatim wording from the response

“The organisation has a network of Learning Disabilities champions who receive enhanced training, education and supervision in relation to this agenda. Whilst we will continue to support existing individuals with an interest in this role, we will be developing all our senior ward, department and community leads to become champions as the accountable leaders in those areas. We are reviewing the training provided to this group to ensure that it addresses the key issues identified through this case as well as audit findings.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 3 · response
Published 17 July 2025

Open published response

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 a mid-programme audit of staff understanding and confidence in Oliver McGowan training, escalating persistent gaps nationally.

Verbatim wording from the response

“Part 2 (Tier 1) webinar and (Tier 2) face-to-face training is underway, with structured evaluation captured at the point of delivery. A mid-programme audit is planned to ensure staff understanding and confidence, with any persistent gaps escalated to the national oversight body. ████████ is supporting the identification of key individuals with responsibility for leadership and oversight of care delivery for priority places on this training.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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

Strengthen Learning Disabilities Group leadership by appointing medical and senior nursing co-chairs.

Verbatim wording from the response

“We have strengthened the medical leadership into this group and have welcomed ████████ as the medical lead for learning disabilities. ████████ is taking a key role in reinforcing messages with medical colleagues across the organisation and is supporting our renewed audit program. We have also appointed ████████ who is our Deputy Chief Nurse to work with the ████████ as the co-chair of this group to support senior nursing leadership and oversight.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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 the coroner and Senior Coroner with a progress update on learning and developments after six months.

Verbatim wording from the response

“As part of that commitment, we will provide you and the Senior Coroner with a further update in six months to share progress and developments.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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

Undertake a resource-scoping exercise to assess whether learning-disability expertise meets current demand.

Verbatim wording from the response

“Each clinical team has access to expert advice from our Learning Disabilities Consultant Nurse. We recognise that with a growing caseload it is not always possible for her to oversee every patients care which is why we are developing our expertise within the wider senior nursing team. We are undertaking a scoping exercise to understand whether our existing resource meets current needs and will be in a position to update on this review in the next 6 months.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 3 · response
Published 17 July 2025

Open published response

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

Deliver Oliver McGowan Part 2 training with structured evaluation and leadership oversight of priority places.

Verbatim wording from the response

“Part 2 (Tier 1) webinar and (Tier 2) face-to-face training is underway, with structured evaluation captured at the point of delivery. A mid-programme audit is planned to ensure staff understanding and confidence, with any persistent gaps escalated to the national oversight body. ████████ is supporting the identification of key individuals with responsibility for leadership and oversight of care delivery for priority places on this training.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 6 · response
Published 17 July 2025

Open published response

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

Appoint a colleague with learning disabilities to the patient experience team to support lived-experience understanding, learning and bespoke training.

Verbatim wording from the response

“████████ also attends the Patient Experience and Involvement Group to report on activities against our strategy. We have recently welcomed a colleague with Learning Disabilities into our patient experience team. This individual supports colleagues to understand the lived experience of people with Learning Disabilities and takes a lead role on many of our strategic ambitions, particularly in relation to learning and the delivery of bespoke training as well as Part 2 of the Oliver McGowan training. We are building a library of digital stories that will further support understanding in relation to patient experience and outcomes.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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

Evaluate the multidisciplinary meeting’s impact and improve staff awareness of its referral criteria.

Verbatim wording from the response

“All colleagues have access to our Multi Professional MDT meeting which meets on a weekly basis. The purpose of this meeting is to request expert support and advice in the management of any patient with complex needs. Further work will be undertaken to evaluate the impact of the MDTs inputs and ensure that all colleagues are aware of the referral criteria for this meeting.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 3 · response
Published 17 July 2025

Open published response

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

Progress Martha’s Rule across adult and children’s services to enable immediate escalation and clinical review of safety concerns.

Verbatim wording from the response

“As an early adopter of Martha’s Rule we are progressing this across adult and children’s services to ensure that patients families and carers are able to escalate safety concerns for an immediate review and response from a clinical team. The Trust is undertaking continuous evaluation and is part of the national and regional programme of work and research for this important initiative.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 4 · response
Published 17 July 2025

Open published response

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

Build a digital library of patient stories to improve understanding of learning-disability patient experience and outcomes.

Verbatim wording from the response

“████████ also attends the Patient Experience and Involvement Group to report on activities against our strategy. We have recently welcomed a colleague with Learning Disabilities into our patient experience team. This individual supports colleagues to understand the lived experience of people with Learning Disabilities and takes a lead role on many of our strategic ambitions, particularly in relation to learning and the delivery of bespoke training as well as Part 2 of the Oliver McGowan training. We are building a library of digital stories that will further support understanding in relation to patient experience and outcomes.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 2 · response
Published 17 July 2025

Open published response

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

Review Learning Disabilities champion training to address issues identified through the case and audits.

Verbatim wording from the response

“The organisation has a network of Learning Disabilities champions who receive enhanced training, education and supervision in relation to this agenda. Whilst we will continue to support existing individuals with an interest in this role, we will be developing all our senior ward, department and community leads to become champions as the accountable leaders in those areas. We are reviewing the training provided to this group to ensure that it addresses the key issues identified through this case as well as audit findings.”

Source location

Response from Calderdale and Huddersfield NHS Foundation Trust
Page 3 · response
Published 17 July 2025

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026