Dear ir Pollaro , Rep Regulation 28: Report to Prevent Future Deaths following Inquest into the death of Ranjan Raman Mistry (Deceased) Write furlher t0 Yourttelter dated 4. March 2018 enclosing @ Regulation 28 Repor issued at Ihe conclusion ot the inquest 'ouchinig upon Gealh of Ranjan Ranan} Mistry which tcok plac? on 2 J February 2016. 4m, of course, very sorry Inat you had cause [0 issue thit report: hope to be able (0 edaress Your corcerns, a8 set out in Seclion 6 of your satisfaction, il} this letter_ have addressed (he areas %f concern, repori lo your numberirig} in sectior 5 Of your reporl &s (ollows adcpting Iha sanie You staied: The eviaence shoved that there Was no Or no sufficient, assessment of hor Falis Risk Tnc records infiicale that there was a Ialls assessment Inderiaken for Mistry This was updaled and reviewed several iimes curing her admission The Trust acknowledges Ihe Cororr'$ obserVations Ihat the assessmant was not €ufficienily comperad and inc Falls assessment tool shouid havc been updaled and reviewed afer Mrs found wus to have been on Ihe floor following uniitnessed events on tha 409/15 and the 17/09/15. Thg Trust h28 inileted orie tO une trairing and suppori Ior Ine menipers of statf IvO' ed ard I: currently underiaking 4 Feview Gl Ihe documentalion as a resull of the Coroner'8 comrents. This piece cf work willi also allgn {0 actions and Improvemen; plans we nave Ir Everyone Matiers Youi The Mrs Mistry

place as pari Of thc Trust wide' Palient Safely Work siream and following the Trusis participatian In tha Nalional Falls Audit 'ecommendations The Trusi is also (ocusing on falis prevenlion ard falls assessment In the Working witn our comrunity Dariners, Service Users and supporting agcncleseto Cook &/ improving Ilie' Quality &nd lifestyle o Tameside residents and icenlifying and asses; Inose palients who may be of perlicular risk In reiation :0 lalts and ing ensure patrway contiruly This involves ensuringe(ha? inforationma a9recing Gwawe commanity serviccs and ottier healthcare arid sociai gcrvices provide by Ine GP' and the patiell s everall pictuire an integrated view of Ve win 3i50 De looking at tnc wider picture In respect of earlier diagnosis cf ard identiticalion ol Jalients at (gher risk of a bony irjury Irom "'groisisintenstedoorasid reablement anc' Ihe' Denefit nf exercise anG mobilily trcrapy meaning that arid carers ara' Ic53 dependeni on intensive services and less likely to pecple arid thej hospital and fo have to mnobilise arid bc cared for in Warinar need admission t0 environments; Tho Neurological observationg charts were aither novcr cornpleted or had been Iost #om tle notes The Trust has & Falls in place which clearly inciudes & flowcharl ihict relatcs (o rcquiromcnt to assess the patient fcllowing a T3ll or suispected fali. Tne Falls ne tlowchart indicales that neuralogical observatiors would only be appropriate Nherc dnd injury was iridicated 01 suspected The Trust acknowedges that i (ha a head involving Mirs Mistry on ihe 17/02/2016 & head injury COgCs noa be ruled owitriested everit the tlowchart indicetcs Ihe takirg 0i neurologic:n orsorvationot Unwueessod {alltinaweii verbalis ng Ihat shc had banged her head) ' Towever stail did nol {all and 'vals There i5 nu evidence 0 Guggesitfat ease Cnwreveadaneerd {08/ fommeacoecucdshan; inference to Ihis would be conjecture This Indicates (hai the rec the records ufioeitake uiremenl for staff .0] nourological observations &s cited on the llowchart nceds (o be reinfarsed and gacticos monitored i0 erisur= roDusl implementaton of the policy standarcis Mn view 0f lhis, thie flowchart has been reissued to ail area: and Metrons and Ward Managers have been asked t0 ensure Ihal whlere Ihere IS an unwvilnossed tal and the paticrit is nol able to verify wheiher Or not (hey have injurad ineir head or There iS doubt &s to this, reurological observalions Shoulai be laken in line with the any shouid be chartcd arid recorded in Ihe medlical records anc these Therc was Glear eviclonce Ihat (hie Medical stalf were not reading ror even looking the nursing notos, and (ro nurses werc similarly noi looking a1 tne medical entres 8t} The decision to use tre records of & patienl is a clinical decision for individual clirical Oi continuous ba5is The Trust is not Uniquc in Ihat nursing and riedical stalf skaf their abservations &nd intoractions separate y in Ihe palier ; medical records; Threcara matter of praclicality Irom} the users viewpoini arid allows; Ine medical &nd access arg Update tneir records at the same time houfneindering each nursen?sta3iso allows Ihc staff (o contemporaneous records and to access Ihe most ciner but also rall within lheir main areaidiscipline cf practice without having to "ertces arrrasi otich disciplines entrics < owever Ihe Trust acknowicdges tha Coronera oofreevatroosgsaothes traditional aporoach t0 records kceping in practice can somelinies Icad to thal nis viAW of {he patient s averall care anid inconsistercy in knowledge Of recert fragmented interveritions if Everyon MJlter, icam de; Policy Policy Any policy find

"nose mcuical and rursing staff do not have methods &' keeping upclated witn Ihe slatvs ard conailion 0 Ilie: palient, Tc ensure thal staff maintain an overviev of the patieni from mecical and nursing perspective (he Trust has introduced Board rounds when multiisciplinary (eams including discharge cas mananer; Teet i0 discuss anu Arree (he aporoach t0 the managemeni of Ihe patierl, thesc arc held on Inc Waras daily and augment information provided at shilt handover. Nursir g stall allend Ward Rounas with medical staff to ensure (hat [hey are aware 0l the patient plan and that they Can ensure that palents and relatives &re upaatod Aditionally the mullidisciplinary teani wll hold formal and informal MDT meeuings Where pationt nave comulex needs The Trusl also has ar clecironic patjent sysiem arid information such as test rosults and Icttors, appoinlments and O.her informaticn can be accessed b' anpropriale slaff and used alorigside the harowritlen notes. A5 happening Nationally the Trusk iS towaras a paner light system of mediczi recoras which should support & more accessible and seamless approzch l0 mcdicail records Lhe hand over sheets for cach shift were being shredded ty Ine nurses &8 so0r1 as {nc Shitt wils completed Whiist I I3 apprcclated Inait ihese cannof be placed (n the record of an individual patient fr reusoris of conlidentiality, there IS no reason why cculd not be iiled On the wards #no retaincd for say 14 days which woula allow further reference t0 b8 made {2 them. should this be deemod necessary or helpfui. The Coroner $ observalions are noied and the Trusi a knowiedges that the Trust does not kecn an erchived Copy Df hiandcver shecte, lhks is for many reasurs incitcing cuniidentiality and to ensure that sheet being referred (0 is an UP Ia date one And noi one from previous date. However following ihe ` Coroner's observelioris Ite Trust recognises that therc is no reason WnY handovcr shcets which are e ectronically produced; coula not ba electroriically archived to provide a record of wha: information Wo pevig communicaled at handover al a point in iime . This wouid as {he Cororer observes prcvide recerd shiould it be necessary to reter to them. As a resull Ine Trust will be consiering introducing 3 sysiern OT archiving at Ward and Departmerital level to support ihe availabulily of ihese al & futurc Gate_ Although an "Incident Refort" was Garric } out in this case, the delatls available to Ihe Coroners GOurl wverc sketchy and inadequate. The Trust has 2 starcard in place which details the expactalions regarding processes (or reporting 0f and managerienl Of incidents within tne Trust The lype , proces s for and ievel of incident invesligation is proportionale lo the impact anG level 0f narm suslawned by the Palient For an event where Ine Daatient IS {oura on the floor followng a unwithessed evert which wes ascerlairiad at the une tG have !esulted in no harm (a occurrod In Mrs s case} the investigation is undertaken is Corcise and Iucal dha tha imporiant aspert of ifie interventions are fo review the !alls risk assessmant and to try to reduce (he risK' Ofa Jell occurring again t0 either Inat individual pateni or t0 other palents withn the hospifai environrenl The Trust hes initiated & Quidance Uacumenl which i5 available orline (or staff involved in 3 concise and Io62l Ialls "vestigation and as previously mentioned is currently undertaking 3 revicw of the (ocumentatior 3s resuit ol irje Cororier's comment ana to actions from rccomimendaiions foliowing the Trust $ participation in {he National Falls Audit: eeryon Matters moving (ncy Uhe Mistry' = align

Trusl hs been recognised 95 havirig outslanding levels oi openness and transparcncy i Icarning Irori mislakes and has been ranked 8th out 0f 230 Trusts relalion t0 3 renori published in March 2016 by the Departmenl of Health; Ir) do take your concerns sericusly and hopc that heve addressed your Corcerns rcassured You %f all thal thc Trusi nas already undertaken and is currentiy and orcar (0 prevent the recurrerce Of & similer set Of cirt Imstances In the fulure, undereking: In Should vcu have anv furtner queslioris arising from {he corlenls of this letter, nol hesilate t contacl me. pleasd & Yours sinccrsly CUu Karen James Chief Executive CC Moritor ccc Tameside and Glossop CCS Evetyone Mattcrs The