Dear Madam

Re: Regulation 28 Report to Prevent Future Deaths – Margaret Rodgers

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 February 2025 concerning the death of Margaret Rodgers. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Margaret's family and loved ones. Surrey & Sussex Healthcare NHS Trust are keen to assure the family and the Coroner that the concerns raised about Margaret's care and the circumstances surrounding her death have been listened to and reflected upon.

The first concern raised was as follows: 'NICE and the National Wound Care Strategy guidance is that patients admitted to hospital have a pressure ulcer risk assessment within 6 hours of admission. This means that the first assessment will often need to be undertaken in the Emergency Department (ED). The court heard that the work to ensure that the ED completes such assessments is ongoing and not yet embedded and that there are practical difficulties, for example when ED patients were located on corridors.'

The Trust has considered this concern carefully and we enclose a copy of our Emergency Department action plan, with reference to the pertinent points below. This action plan has been in place since May 2024 and was implemented to assist with extended patient stays in the Emergency Department (ED) in a post-covid environment.

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1) Purpose T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) training

Purpose T is a nationally used tool to identify patients who are at high risk of developing pressure damage. Once a patient is identified as high risk, Purpose T prompts a set of assessments which need to be carried out by the nurse caring for the patient, including history of pressure damage/ulcers, nutritional intake, diabetes, perfusion, moisture damage and sensory perception. It also prompts nurses to consider whether the patient has capacity if they refuse to be assessed, and acting in the patient’s best interests if they are unable to consent to examinations and assessments.

Purpose T is a more in depth tool to use with greater consideration of a patient’s individual risk factors than, for example, the Waterlow score.

2) Cerner prompts and ClinOps

Any patient tasks/assessments that have not been completed are flagged as outstanding and create a pop-up reminder for anyone accessing the patient’s records on Cerner. For example, if the Purpose T assessment has not been completed then Cerner will prompt the nurse that it needs to be carried out when they access the records.

In addition to individual reminders, an overview of every ward and patient is available on the Ward View Nursing Production Board on ClinOps, which is overseen by Matrons and ward managers. This is a projection board which shows every patient who is breaching for any reason and is mainly utilised by managers to have oversight of the whole ward/department. The board highlights outstanding tasks for each patient, which are seen as an overview bar flagged red.

Matrons monitor the Ward View Nursing Production Board to ensure “every day is a green day”, whereby the expectation is that by the end of a nursing shift all tasks/action for the nurse’s patients should be green (i.e. completed). When commencing a new shift and taking over care of patients from another member of staff, the same list will form the nurses to do list for that patient.

It is important to note that patients receiving “corridor care” are always allocated to a nurse. The allocation is to the same ratio of staff to patients as it is if the patient was in the main Emergency Department. Similarly, the projection board will flag to management any outstanding tasks or assessments for corridor care patients in the same way would if the patient was located elsewhere in the hospital.

3) Train the trainer programme and a targeted teaching approach

All new ED staff receive training on pressure damage and pressure care as part of their mandatory training when they commence work at the Trust. However, it is recognised that nursing staff cannot be removed from ED to attend training sessions as easily as they could be on inpatient wards. When Purpose T was first introduced an intensified training programme was included in ED which allowed nursing staff to be trained alongside their day to day work. This

An Associated University Hospital of Brighton and Sussex Medical School

targeted approach included having a Practice Development Nurse on the shop floor in ED for two weeks to assist staff as they carried out their assessments and familiarised themselves with the new system. Train the trainer allows for clinical staff to be trained in certain competencies and to then train their colleagues utilising their new skills, and has been completed for bands 3-
7.

In addition, Purpose T also has a guidance section to assist in completing the assessments.

All ED staff have completed Purpose T training, including those employed via agency.

4) Nurse Quality Rounds These are designated rounds at 2 hourly intervals involving the band 7 nurse in charge, Matron and PDN (all three are not required for the round). They do an eyeball assessment on every patient, including those receiving corridor care, with the aim of supporting staff to ensure tasks and assessments are completed. The purpose of the round is to provide an additional level of safety netting as they may pick up something that a less experienced nurse might miss. Junior staff can also ask questions and seek guidance on any assessment their patient needs which they are unclear about.

The Practice Development Nurses in ED are supernumerary (do not have their own caseload of patients). They monitor and provide support to nursing staff to complete assessments that are outstanding. PDNs will also look at accuracy of any assessments undertaken.

The expectation is either the Matron or PDN will oversee that all patients are assessed as required and they receive their medication.

5) Planned audits to monitor progress relating to compliance in the ED

At present the systems referred to above are only available as a live version and so we aren’t able to audit compliance currently. We are working with the Trust’s informatics team to build a report whereby compliance can be monitored and audited.

The second concern was as follows: 'The court also heard that in December 2023 to January 2024, the period of Mrs Rodgers admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs. The Trust is undertaking a review of the staffing template for the ward, but that work is not complete and not yet incorporated into the budget.'

1) NHS England mandates evidence-based decision making for safe and effective staffing across all NHS organisations. All Trusts are required to conduct a biannual review of their ward establishments using the Safer Nursing Care Tool. At SASH, we have been carrying out this review on all wards for the past 18 months. While the results of the review and any necessary

An Associated University Hospital of Brighton and Sussex Medical School

staffing increases have not yet been reflected in the ward budgets, Nutfield Ward has addressed this by incorporating additional shifts into the roster template and utilising temporary staffing.

2) Staffing levels on Nutfield ward are 5 qualified nurses and 3 non-qualified staff during the day, and 3 qualified and 3 non-qualified at night. We have already increased the night rota to have an extra nursing assistant than the template allows and this was recognised through the need for acuity, and we allow this as a cost pressure to maintain patient safety. The matrons assess the acuity on wards on a daily basis and will use clinical decision making to ensure that wards are safe, if there are any concerns they will escalate to senior management and additional staff will be requested for that shift if necessary. We are also able to move staff to work on different wards if acuity requires it.

The Trust holds twice daily safer staffing huddles, attended by the Head of Nursing or a matron representative. During these meetings, each division reports staffing levels, mitigation actions taken, and any remaining gaps. The staffing situation is reviewed using the Safe Care Live system to identify potential cross-divisional moves or the need for temporary staffing. If these options are insufficient, corporate nursing teams are deployed to provide clinical support. The meeting also reviews staffing for the next day and on Fridays the weekend staffing is also considered. If staffing issues cannot be resolved, they are escalated to the Chief Nurse for further action.

The Trust would like to thank you again for bringing these issues to our attention and should you require any further clarifications, please do not hesitate to contact us via our legal services department.