SPRINGANK NURSING HOME COLLEGE ROAD BARRY RESPONSE TO REGULATION 28 REQUIREMENT MADE BY CHRISTOPHER JOHN WOOLEY FOLLOWING THE CORONER INVESTIGATION INTO THE DEATH OF SANDRA WORDINGHAM RESPONDENT'S NAME & POSITION My name and am the Managing Director of Springbank Care Home Limited, and the Responsible Individual for Springbank Nursing Home: REASON FOR RESPONSE Thave received the Regulation 28 report prepared by Christopher John Wooley, Assistant Coroner for the Coroner for Cardiff and the Vale of Glamorgan following the investigation into the death of Sandra Wordingham who was a resident at Springbank Nursing Home, requiring a response prior to the 11th February 2014, Following the investigation the Coroner expressed specific concerns in that; Sandra Wordingham was to bed in Springbank Nursing Home in an unconscious state by nursing staff who suspected that she had suffered an epileptic fit, when she had actually suffered a primary intra-cerebral haemorrhage, was unconscious state throughout the night and that no medical attention was sought for her Whilst Sandra Wordingham suffered a profound insult which could not have been altered, had she suffered gradual onset stroke, early medical attention would have saved her life_ Residents in a unconscious state who are treated in the future in the same way as Sandra Wordingham may be at risk of unnecessary death or injury The Regulation 28 Report has required an Action Plan to prevent the unnecessary injury or deaths to residents who are found to be unconscious Operations Manager (who was also the Acting Manager at the time) and Iwho is now the Manager at Springbank have assisted me by looking at the following: If the core skills and knowledge to care for an unconscious person can be reasonably expected from a professional nurse trained in a University National Health Service setting and registered with the Nursing & Midwifery Council If the core skills and knowledge to care for an unconscious person are expected to be within the scope f a professional nurse and be a reasonable part of the professional nurse's periodic declaration to remain registered with the Nursing & Midwifery Council If it is a reasonable for the Employer to expect that a professional nurse trained in a University National Health Service setting and registered with the Nursing & Midwifery Council should work within the limits and scope of their training, knowledge, experience and working within the Nursing & Midwifery Council Code. How performance deficits in professional nurse's knowledge is identified and what education & training is/should be provided to them. When considering points 1_ 2 and 3 above it is reasonable to expect that the care of an unconscious person should be well within the capability of a professional nurse trained in a University National Health Service setting and registered with the Nursing & Midwifery Council 1 | Pa g e put

Time & Payment for Education & Training In my capacity as the Responsible Individual for Springbank Nursing Home continue to provide the necessary funding and time required for staff to train retrain and am cognisant of the Company's duty-of-care to ensure that staff are trained to provide care for our residents: When considering point 4 above it is reasonable to expect the Company to provide ongoing training for all of its staff, and the Company does provide 30 paid hours annual training for members of staff: Tvpes of Training There is a growing list of mandatory training that is required by the Local Authority(s) and University Health Board(s) in addition to list of other mandatory core training: Training Needs Training needs are identified in 2 ways: Managers Department Heads meet with Employees to identify education and training needs to support enhance clinical performance. All registered nurses have an obligation to inform their manager of any matters that may affect their performance and identify specific education and training needs Incident 19.3Opm 22.07.13 until 07.30am 23.07.13 The nurses on duty from 19.3Opm 22.07.13 until 07.30am 23.07.13 were RGN RGN The Company's Reasonable Expectation of the care of Sandra Wordingham by RGN and Beryl Hartland RGN It is considered reasonable for the Company to expect that a5 qualified professional nurses; both of whom were trained in a University National Health Service setting, and both registered with the Nursing & Midwifery Council, should have worked within the limits and scope of their training, knowledge, experience, and to the Nursing & Midwifery Council Code: The Company considers it reasonable to believe and expect that as both and are qualified professional nurses, who were trained in a University National Health Service setting and registered with the Nursing & Midwifery Council, had been trained to a level whereby the should have recognised Sandra Wordingham's altered state of consciousness and irrespective of possible clinical reasons, should have assessed and treated Sandra Wordingham appropriately, and that they should have summoned medical assistance in a timely manner. 2 | P a g e

The company took immediate & secondary actions to ensure the safety of current residents living in Springbank Nursing_Home Responses Action Taken Persons Date By Responsible Initial actions taken who was a nurse on the night of 23rd July to ensure the safety 22nd July was interviewed and suspended from duty Operations 2013 of residents Manager & Acting Manager at Springbank Nursing Home Secondary Actions who was a nurse on on the night of
23.07.13 taken to ensure the 22nd July was interviewed and, at a later Operations safety of residents suspended from Manager & (Following Acting Manager investigation by at Springbank South Wales Police Nursing Home & Safeguarding) The company required to attend
31.12.13 disciplinary procedures for gross misconduct: She was Responsible dismissed from her position as a qualified nurse and a Individual for copy of the hearing notes and outcome was provided to Springbank the Nursing & Midwifery Council Nursing Home The company required] to attend This will disciplinary procedures for gross misconduct: The Responsible be process is ongoing: When this is concluded a copy of Individual for concluded the hearing notes and the decision outcome will be Springbank as soon as forwarded to the Nursing & Midwifery Council Nursing Home possible REGULATION 28 ACTION PLAN Item Action Taken Persons Date By Responsible Improved First Aid & All staff to attend training with specific training element Planned Life Support for the immediate care of the unconscious person Operations for March Training Manager
2014. Springbank Manager Ensuring Nursing Following training and instruction nurses will have an Planned Staff Competency assessment of their competency to; Operations for March recognise consciousness levels Manager 2014 as undertake appropriate life support and neurological Springbank part of 15t observations Aid record & document life support and neurological Training 3 | Pa g @e duty point duty

observations Aid record & document life support and neurological Training observations be aware of a DNNAR arrangement with the agreement of the resident relative, and signed by the resident's Manager GP not to actively seek emergency assistance when the resident may be dying: assure their line-manager that will comply with training & guidance Adherence to All nurses have been provided with a copy of the NMC 576 Nursing & Midwifery code Operations February Council Codes All nurses have been reminded to practice within their Manager 2014 levels of training, competency; knowledge and Springbank & experience 11 AIl nurses have been reminded of their obligation for February public protection 2014 All nurses have been reminded of their obligation to Manager maintain their knowledge and skills through PREP Summoning AIl staff have been instructed to summon emergency Emergency services to attend to all unconscious residents as Operations February Assistance quickly as possible Manager 2014 Where a valid DNNAR is in place the nurse MUST follow Springbank the GP's instruction(s) 11 If Emergency Service Staff attend they must be shown February the valid DNNAR 2014 Where there is doubt about the level or recovery of Manager consciousness nurses MUST err on and summon the Emergency Services A protocol has been produced and made available to all staff working at Springbank Nursing Home Knowledge of The risk assessments and care plans will contain Care Plan probable reasons accurate and specific information about the possible or Operations Audits for and causes for probable causes and reasons why a specific resident Manager Epilepsy residents who may may become unconsciousness Springbank and become unconscious Risk Assessment and Care Plan for epilepsy must Diabetes due to epilepsy (and contain details of the type of fits that the person may are other illnesses) have (e.g. grand mal, petite mal, partial incomplete available seizures and whether the person has a prolonged Manager to tackle post-seizure recovery period) this_ Providing & Sharing protocol for managing the unconscious person has 6th Information about been provided for all occasional staff" and is included Operations February the management of in the Agency Nurse Induction form Manager 2014 unconscious people The Nurse Agencies will be informed and a copy of the Springbank with Bank and protocol will be provided to their head offices Agency Nurses working occasional shifts Manager Pa g e they safety etc, The

In the event of The member of staff will be required to explain their Immediate failure to summon action/ inaction Operations & Ongoing timely medical The member of staff will be reported to the Manager assistance Safeguarding Team: This may lead to a criminal Springbank investigation and prosecution The member of staff will be suspended from and disciplined. This may lead to dismissal and referral to the Nursing & Midwifery Council Manager Name: Signature Date lehyyzly Position: Responsible Individual, Springbank Nursing Home 5 | P a g e duty