Dear Mr-Winter Regulation 28 Report to Prevent Future Deaths Mr James Trevor Vinson write further to your correspondence dated 9 August 2017 regarding your concerns identified during the inquest into Mr James Vinson's death. enclose with this letter an action plan which confirms: a) the actions that will be taken by the Trust in response to your concerns; b) the target dates for completion of those actions; and c) the Officers with responsibility for progress of the actions As you will note from the enclosed action plan, the Trust is currently developing an Enhanced Care Standard Operating Procedure (SOP) to assess vulnerable adult in-patients' observation and care requirements. The SOP incorporates an Enhanced Care Risk Assessment Tool and defined criteria for heightened levels of observation. The purpose of this SOP is to ensure our staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within the stated criteria One of the witnesses in her evidence at Mr Vinson's inquest made reference to the draft SOP , however, you have expressed concerns regarding the lack of clarity around its implementation. would like to advise you that we are currently piloting the draft SOP on number of wards within the Trust; including the Acute Stroke Unit where Mr Vinson suffered his fall. As per the action plan, the target date for ratification and Trust-wide roll-out of the SOP is January 2018. We are also reviewing our Prevention and Management of Hospital-Based Falls Policy: The Falls Policy and the Enhanced Care SOP will be closely linked, so we have appointed the same Leads for both documents_ The target date for completion of this review is November 2017 . Neurophysiology Department Sunderland Eye Infirmary 8 Day Case Unit Chairman: John N Anderson QA CBE In association with the Universities of Newcastle, Sunderland and Northumbria

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Progress of the actions detailed within the action plan will be overseen by our Executive Director of Nursing and Patient Experience who keep me briefed and report to the Trust's Clinical Governance Steering Group. On completion, this will be escalated to the Trust's Governance Committee which is a sub-Committee of the Trust Board as well as to the Trust Executive Committee_ trust this information provides assurance to you that the Trust has taken appropriate action to mitigate any future patient safety issues with regards to falls risk assessment and management: would also like to take this opportunity to offer my sincere condolences to Mr Vinson's family on behalf of myself and the Trust;