Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ethel Doreen Reed who died on 2nd March 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th February 2024 concerning the death of Ethel Doreen Reed on 2nd March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ethel’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Ethel’s care have been listened to and reflected upon.

In your Report you raised the concern that H130 at Hull Royal Infirmary had no established permanent staff and was placed under significant pressures. You raised that other wards opened during winter pressures may have the same issues, using agency staff without a fixed team in place and with a lack of visible leadership, posing risk to patients.

While staffing is the responsibility of individual Trusts, growing the healthcare workforce is one of NHS England’s chief priorities and we were pleased to achieve the government target of having 50,000 more nurses working in the NHS by November last year than in 2019. Nurse, Allied Healthcare Professionals, and wider health and care vacancies remain a pressing concern which we are addressing through the delivery of the NHS Long Term Workforce Plan, offering flexible routes into the professions including apprenticeships and working with employers to support retention of the current workforce. Winter remains a challenging period for NHS organisations, amidst significant existing pressures. Recovery plans, such as those for urgent and emergency care (UEC) and primary care, together with broader strategic and operational plans have also provided a firm basis to support NHS organisations to prepare for challenging winter periods. In July 2023, NHS England wrote to Integrated Care Boards (ICBs) and Trusts setting out the national approach to 2023/24 winter planning and delivering operational resilience. This set out four areas of focus for health systems:
1. Continuing delivery of the UEC Recovery Plan and ensuring that high-impact interventions are in place. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2 April 2024

2. Completing operational and surge planning to prepare for different winter scenarios.
3. ICBs to ensure effective system working across all parts of the system, including acute trusts and community care, elective care, children and young people, mental health, primary, community, intermediate and social care and the Voluntary, Community and Social Enterprise sector.
4. Supporting the workforce and their wellbeing to deliver over winter. NHS England has engaged with Humber and North Yorkshire (ICB) on the concerns raised around the care delivered to Ethel. Following an internal multi-disciplinary inspection of the ward, we are advised that Hull Royal Infirmary has made improvements, taken learning from patient experience, and addressed recommendations. They have confirmed that there is now an established team on Ward H130 including leadership, nursing and medical teams. Hull University Teaching Hospitals NHS Trust has provided assurance that learning from the opening of H130 has been undertaken and informed a planned methodology for opening additional capacity on an urgent basis safely. The Trust is now over-recruited against its nursing staff and can use this resource as required, reducing the need for bank and agency staff. We would refer you to the Trust for further information.

Your Report also raised a concern around the Lorenzo electronic patient record keeping system not auto-populating the identification of the author of any changes made in the immediate discharge letter after it has been finalised. NHS England no longer have a contract with Dedalus (Lorenzo system) and therefore the relationship sits directly with the Trust(s) and supplier.

We are advised that the Trust have informed the supplier of this issue, and they are working on a solution which displays the identification of the author of the Immediate Discharge Summary (IDS) relating to the amendment. The system currently provides a full audit trail of access and amendments to the system, the solution would either display all amendments or force the author of the amendment to be displayed when the form is finalised and distributed. In the meantime, communications have been sent to staff to reinforce the process that needs to be followed when completing IDS’s for patients using the Trust’s Electronic Patient Record (EPR) on Lorenzo. We understand that the Trust’s Digital Team are also in the process of exploring further system functionality that may improve the current process and help to mitigate further issues.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear HM Coroner (Mrs Sally Robinson, Assistant Coroner)

Regulation 28 Report following the inquest into the death of Mrs Reed We provide the formal response of the Care Quality Commission (CQC) to the Regulation 28 Preventing Future Deaths report made by HM Coroner (Mrs Sally Robinson, Assistant Coroner) following the inquest into the death of Mrs Reed. (‘the Regulation 28 Report’). In the Regulation 28 Preventing Future Deaths report HM Coroner raised the following concerns: (1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could, but they reported that the ward was chaotic, and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward. Mrs Reed was dehydrated, and family reported that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patents, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff. (2) An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised.

This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths. The trust’s last comprehensive inspection was in November 2022 and the report was published in March 2023. CQC rated the trust as “Requires Improvement.” A copy of the report can be found on our website - Trust - RWA Hull University Teaching Hospitals NHS Trust (23/03/2023) INS2-13905362001 (cqc.org.uk) The trust subsequently provided CQC with a copy of their post inspection action plan detailing the immediate action taken in response to the concerns raised at inspection. The trust provided details of the longer-term actions required to ensure the improvements made would become sustained and embedded. CQC has had regular monthly engagement with the trust, reviews evidence and closely monitors their progress against all action plans to ensure sustained improvement. CQC first became aware of the death of Mrs Reed’s death on 8 March 2023. Holy Name Community Rehabilitation Centre submitted a statutory notification to report Mrs Reed’s death as an expected death on 1 March 2023. The notification stated Mrs Reed had been referred for a level 4 rehabilitation bed on the 26 February 2023 following a therapy assessment. Staff identified Mrs Reed’s health was deteriorating naturally and she was put on an end of life pathway. Mrs Reed and her family were aware that palliative care had commenced, and staff offered support and comfort. CQC had no concerns regarding this expected death based on the information received on this notification. Following receipt of the preventing future deaths report CQC held a management review meeting on 20 February 2024. CQC agreed to request and review the inquest medical evidence bundle in line with CQC specific incident guidance. In addition, CQC asked Hull University Teaching Hospitals NHS Trust to provide evidence of any action they had taken to date following the tragic death of Mrs Reed by Thursday 7 March
2024. CQC noted the information supplied at the inquest that H130 ward had only been open for 2 weeks when Mrs Reed was admitted in January 2023. The ward had been opened due to the significant pressures and demands on the trust. The trust began its “Discharge to Assess” (D2A) transformation programme in January 2023, bringing together care partners across Hull and the East Riding of Yorkshire to reshape and improve discharge processes and care planning. In June 2023, the trust permanently opened two “no criteria to reside wards” H130 East and H130 West on the 13th floor at Hull Royal Infirmary as part of its “Discharge to assessment” model. This model is staffed by a multidisciplinary team which includes therapists, nurses, medics, social workers, and pharmacists. Once patients are assessed as medically fit, they are transferred to these wards to have an assessment with a plan for a same day discharge. The discharge team has been relocated to be close to these wards.

Since the last inspection, the trust made improvements to their staffing on medicine wards. All associated post inspection action plans for staffing have been completed. CQC regularly monitors staffing in terms of fill rates (planned vs actual), reduction in the number of vacancies, improved turnover rates and improved sickness rates. CQC continues to monitor staffing levels to ensure these actions are fully implemented, embedded, and sustained. The trust submitted further assurance around the current staffing levels for the 13th floor which includes wards H130 East and E130 West. There is now an established team including leadership, nursing, and medical teams. A funding request has been submitted to the board for a permanent third registered nurse as this additional post has demonstrated improved performance in relation to medicines management and quality of patient care. A non-clinical coordinator role has also been introduced to support these wards. The trust is now over-recruited against its nursing staff which reduces the need for bank and agency staff. CQC have not been informed of any further staffing concerns from medical care wards but will continue to monitor the trust if they are any further wards opened at short notice. The trust conducted their own internal multidisciplinary inspection to ensure the new “discharge to assess” model for H130 East and E130 West was embedded. The trust provided assurance that lessons have been learnt and improvements have been made from when the wards was first opened in January 2023. CQC regularly monitors the access and flow of patients in and out of medical care wards. There has been measured improvements with a reduction in patient moves, improved length of stay, reduction in delayed discharges and improved patient pathways. All associated post inspection action plans have been completed. The trust now has clear escalation pathways to review patients who deteriorate and transfer them to an acute medical ward if considered appropriate. Staff on these wards are fully aware of this model and also have clear escalation and communication channels with medical teams. The trust submitted additional assurance that personal care is provided on these wards. There is now a cohort of volunteer staff and activity champions to support patients and relatives. Patients also have visits from therapy dogs. The trust were exploring how to make patients feel more comfortable and had requested funding for televisions and radios. The trust have also established a “relative” clinic to ensure good communication with families. In addition, staff are being supported to complete appropriate care training. The trust has made improvements with communication with patients and their families. The ward sisters are present on wards; H130 East and E130 West on a daily basis. They have set up a “relatives clinic” which provides dedicated time for patients or relatives to meet with ward sisters and ask questions, seek advice, or raise concerns. The wards promote positive feedback using the Friends and Family Test (FFT) and display feedback, results and any action taken. There are clear contact details available for PAL’s, complaints, and the ward matron.

Following the Lorenzo System related incident the trust sent out communications to reinforce the process that needs to be followed when completing Immediate Discharge Summaries (IDS) for patients using the Trust’s Electronic Patient Record (EPR) on Lorenzo. The trust’s digital team are also in the process of exploring further system functionality that may improve the current process and help to mitigate further issues. In the meantime, the trust’s digital team will continue to work with the clinical teams to reinforce and embed current processes and provide support or additional training as needed. In addition to our inspection activity, inspectors regularly monitor the National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), reviewing a Trust’s National Patient Safety Incident Reports and Serious Incident investigations data. Currently these data sources are going through a significant transformation, as NHS England implements the new Learn from Patient Safety Events system, which limits CQC’s ability to carry out further national analysis until this has been completed. CQC will continue to monitor information we receive about the service. Where CQC identifies that regulations are not being met, we will use our enforcement powers to require improvements to be made. CQC will also check the provider’s compliance with the regulations on our next inspection of the service using our new single assessment framework methodology in accordance with the CQC regulatory remit. CQC will highlight any repeated or new breaches of regulation and ask the trust to make necessary improvements. CQC’s next inspection of the service is not yet confirmed, however we have adopted a more risk based approach to inspections should CQC receive negative intelligence or have further concerns about the service we would carry out responsive inspections. CQC hope that this response addresses your concerns.

Dear Ms Robinson,

Re: Death of Ethel Doreen Reed – Response to Regulation 28 Report to Prevent Future Deaths

I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the 8th February 2024, issued as a result of the concluded inquest into the death of Ms Ethel Doreen Reed.

I would like to take this opportunity to express my sincerest condolences to the family of Ms Reed for their loss.

During the course of the inquest, the evidence revealed matters giving rise to concern. These are as follows:

1. H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.

Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and

United by Compassion: Driving for Excellence.

Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust

therefore no way of patents, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.

2. An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised. This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths.

Please find below the response from the Trust and the detail of the actions being taken in relation to each concern.

Concern 1 - Ward H130 and future winter pressure wards

At the time of the deceased’s admission to ward H130 in January 2023, the ward had been opened as a temporary winter ward to manage the capacity issues across the organisation and had been open for two weeks.

The Trust recognises that there are a number of patients who cannot be discharged due to lack of care home or home care capacity, which has placed different capacity pressures on the organisation since the winter of 2023. It is recognised that this is both a local and national situation.

In June 2023, in response to these capacity issues, the Trust took the action to use the 13th floor and open ‘No Criteria to Reside Wards’ on the 13th floor (H130 East and H130 West) at Hull Royal Infirmary on a longer term footing.

When patients are assessed as medically ready, they will transfer to the 13th floor for ‘Discharge to Assess assessment’; this includes all partners (therapists, nurses, medics, social workers, pharmacist, intermediate care workers, trusted assessors, progress to discharge assistants, housekeepers and

United by Compassion: Driving for Excellence.

Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust

hygienists) working in an MDT approach to assess and discharge patients on the same day (wherever possible).

The Trust acknowledges that this new model was embedding into practice in the summer of 2023 and did require improvement. Since the ward opened, the Trust has taken the opportunity to make the required improvements, learn from patient experience and address recommendations following an internal multi- disciplinary inspection to the 13th floor. This visit was led by the Director of Quality Governance and had attendance from the Chairman and a Non-Executive Director for Hull University Teaching Hospitals NHS Trust, Practice Development Matron, Compliance Team as well as Health and Safety and external representation from Kingston upon Hull Healthwatch. An improvement plan for the 13th floor has been in place since October 2023, with progress against delivery of the plan. The improvement plan is attached at Appendix A for information.

The Trust can confirm that there is now a very well established team on the 13th floor, including leadership, nursing and medical teams. The Ward Sisters are present on the wards on a daily basis with clear signposting for patients, relatives and carers if they need it. The Ward Sisters have set up ‘relative clinics’, which provides dedicated time for patients or relatives to meet the Ward Sisters to ask questions, seek advice or raise concerns. The wards promote patient feedback via Friends and Family Test (FFT) and displays feedback, results and actions taken by the areas. The wards also have volunteer presence, activity champions and visits from the therapy dogs.

The Trust has made great strides in improving the care, treatment and experience for patients transferred to the 13th floor as a No Criteria to Reside base and recognises that, at times, additional capacity during winter pressures or increased times of demand on the service it will need to opened. The Trust can provide assurance that learning from opening of the 13th floor has been undertaken and informed a planned methodology for opening additional capacity on an urgent basis, safely. The Trust is now over-recruited against its nursing staff and is able to lean on that resource as required, reducing the need for bank and agency staff.

Concern 2 - Immediate Discharge Summary letter

The Trust have met with Daedalus, the supplier of the Lorenzo system, to discuss potential solutions to the concerns raised by the Coroner in the system, which is utilised by a number of providers nationally.

United by Compassion: Driving for Excellence.

Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust

We have not yet been able to identify a single remedy to the issue raised around the identification of all authors making changes to the Immediate Discharge Summary (IDS). The primary barrier to a simple solution to this issue is that there are often non-clinical staff involved in the management of the IDS before it is finalised.

However, we have completed an internal review of the current process and consulted with other Lorenzo users. The outcome of these discussions is that the Trust is now looking to change the current process of completing the IDS as detailed below:

The Trust currently have in excess of 60 different IDS templates created as clinical notes in the Lorenzo system. A review of the data items within these documents shows approximately 40 data items consistent across most of the templates and 46 variable data items. Templates have been created at the request of departments or users to accommodate variable data required between departments, clinicians or procedures and treatments. We now believe that this level of variability would be more appropriately managed using the clinical data capture (CDC) forms in Lorenzo and not in the IDS. This change would allow mandatory data to be captured for all, and the variables to be added as and when required. This in turn can create a final clinical note at discharge that is reflective of the individualised care received by the patient.

This piece of work will require resources of Project Management, Change Management, CDC Form Developer, System Support and Information and reporting. There will also be significant stakeholder engagement required including the pharmacy team. Due to this and other similar concerns raised recently, it has been recommended that this piece of work be given a priority 1 and resources allocated as soon as they become available. The timescales for deployment will depend on the approach, but would likely begin with those areas with a significant number of IDS templates set up currently.

We are in the process of our internal Digital Information and Systems approving this change and then will begin the work to make this change.

I hope that this letter provides both you and Ms Reed’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report.

United by Compassion: Driving for Excellence.

Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust