Dear Dr Earland Robert JONES Deceased DOD: 01/04/2014 Thank you for your letter of 21 January 2015. fully agree with your report and recommendations_ The recommended actions are primarily the responsibility of the hospital trust: | enclose a copy of their Action Plan which have just received from Matron of South Molton Community Hospital and which believe satisfactorily addresses all your concerns and recommended actions_ will be sharing this Action Plan with all GP colleagues in my practice and will be having ongoing discussions with the Community Hospital management team to ensure that these actions become firmly embedded into practice Please do let me know if you have any further questions or concerns.

Dear Dr Earland Thank you for your letter dated 21st January 2015, which enclosed the Regulation 28 Report that you had prepared following the Inquest into the death of Mr Robert Alan Jones in addition to the CD recording of the Inquest and a copy of the Record of Inquest; Please find Northern Devon Healthcare NHS Trust's response to section six, 'action should be taken' , of the Regulation 28 Report. (1) Revise the Trust's falls policy to include the recommended frequency and duration of neurological observations based on NICE guidance for patients where head injury has occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of care. The Trust's falls policy (enclosed) has been revised to include information relating to the frequency and duration of neurological observations (in line with the relevant NICE guidelines) and published on the Trust's policy website _ The policy includes a post falls checklist (enclosed) which details how often and for how long neurological observations should be recorded. The Trust's bedside handover and safety briefing standard operating procedure clearly identifies information relating to patient falls (including their risk of falls) is a component in shift to shift communication, and must be included in handover. Bedside handovers are audited via observation and reports and actions provided to wards and teams where there are gaps in information being shared. Improvement is measured by re-audit: A link from the falls policy will be in to Bedside Handover of Safety Briefing Standard Operating Procedure & vice versa_ (2) Implement a system to ensure the Multi Disciplinary Team (MDT) is aware of the total number of falls. page of 2 the key put the

Northern Devon Healthcare NHS] NHS Trust Incorporating community services in Exeter; East and Mid Devon As per (1), this information is included in safety briefings, which are multi-disciplinary events Additionally, the Trust's post falls checklist allows staff to record multiple falls on the same document; ensuring that information relation to falls is held in a central place_ The trust is implementing a system that requires the post falls checklist to be filed with the patient's physiological observations neurological observations chart; which is reviewed by the Multi Disciplinary Team on a daily basis_ (3) Ensure delivery of targeted training on performing neurological observations for nursing staff at South Molton Community Hospital and as a general communication across the Trust: Targeted training on performing neurological observations for nursing staff is in place and all registered nurses completed this training by the end of February 2015. Additionally, training relating to reduced consciousness (AVPU Alert, to Voice, Pain Unconscious has been delivered to non-registered support staff: To support the actions detailed above, the Trust will issue a Patient Safety Alert; which will communicate the need for neurological observations when a head injury has occurred or cannot be ruled out, completion of the post falls checklist, to include the frequency and duration of observations to ensure post falls checklist is filed with the patient's observation chart for ease of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are disseminated across the whole Trust to clinical and managerial leads_ hope that this response provides you with assurance that the Trust has taken seriously the findings of the Regulation 28 Report; but please do not hesitate to contact me should you require further information: