Dear Ms Saunders,

GIG NHS Bwrdd lechyd Prifysgol Aneurin Bevan University Health Board

Date:08 October 2024 I am writing to provide you with the Health Board's response to the Regulation 28: Report to Prevent Future Deaths, following the inquest into the death of Mrs Kay Simmonds. As requested, the information presented below is intended to describe the action taken / being taken to mitigate the risk of future deaths.
1. Action that will be taken to introduce an electronic observation and NEWS recording system within the Emergency Department (ED) at the Grange University Hospital (GUH) The ongoing concerns regarding the manual recording of observations within the Emergency Department at the Grange University Hospital is acknowledged. You will be aware that other clinical areas within the Health Board use an electronic system called CareFlow to electronically record observations to improve patient safety and outcomes. CareFlow Vitals is an electronic observation and decision support system designed to improve patient safety and outcomes. It monitors and analyses patient vital signs to identify deteriorating conditions and provides risk scores to trigger escalation pathways. CareFlow vitals can also generate alerts if there are signs of sepsis and calculate early warning scores based on specific algorithms. Implementing this solution in ED will enhance patient care, provide a complete electronic record through integration with Symphony, improve efficiency and reduce the need for paper and human error. Bwrdd lechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ tts. 01633 436 700 f Bwrdd I echydPrifysgol X. BIPAneurinBevan Rydym yn aoesawu gohebiaeth yn BYrataa9 a aYadwa yn Pala, yn Gymraeg heb °ad] Bwrdd lechyd Prilysgol Aneurin Bevan yw ems taveillvedol Bwrdd lederd Lied Prilysgal Aneurin Bevan. 1\1 1 Clinigol Clinical Aneurin Bevan University Health Board Headquarters, St Cadoc's Hospital Lodge Road, Caerleon, Newport NP18 3XQ
1.01633 436 700 f AneurinBevanHealthBoatd X AneurinBevanUHB We welcome correspondence in Welsh and we WS respond in Wash without delay. Anowin Bevan University Health Board is the operational name n Aneurin Bevan University Local Health Board

Bwrdd lechyd Prifysgol Aneurin Bevan University Health Board

Currently, observations are recorded in CareFlow in other clinical areas but in ED staff use paper observation charts to record the observations and do not input the observations into a handheld device. NEWS scores are then manually scored, which can occasionally lead to human errors. To monitor compliance across the nursing documentation the ED undertakes daily One Patient One Day audits reviewing all the documentation of a patient. The department also undertakes NEWS audits to monitor compliance and ensure appropriate actions are taken. The Senior Nurse also undertakes Dignity and Essential Care Inspections (DECI) monthly which encompasses a review of nursing documentation across a number of patients. Patients' attendance to the ED are recorded on an electronic patient management system that supports tracking and clinical workflow called Symphony. Symphony currently does not interface with CareFlow meaning the ED is unable to use CareFlow. Patients admitted to assessment units and ward areas are admitted onto the Health Board's Clinical Workstation which does interface with CareFlow. The ED has previously investigated the viability of introducing CareFlow within the department to align with the rest of the Health Board, but due to the functionality of the electronic patient management system used within the ED, this has not been possible. The Urgent Care Division has met with the Health Board's digital team on 29 August 2024 to discuss the requirement and urgency to introduce CareFlow within the ED, this is now a priority for the Division. Following the meeting, a member of the digital team attended the ED on 17 September 2024, to map the current processes and requirements and following this visit the digital team are developing an options appraisal to determine how the recording of electronic observations can be recorded within the ED. The options appraisal will be available by mid-October and will look at the safest, quickest and most cost-effective way to implement e-observations in ED and will include any additional licencing and integration costs. The Bwrdd lechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ
4..01633 436 700 f BwrddlechydPrIfysgol BiHAneurinBevan Rydym yn croesawu gohebirugh yn Gymmeg a byddwn yn ymateb yn Gyrnmeg heb oedi. Bwrdd lechyd Pdlysgol Aroma, Bevan yw ems gweithredol Bwrdd ledwd Ued Prifysgol Aneurin Bevan. Clinigol Clinical Aneurin Bevan University Health Board Headquarters, St Cadoc's Hospital Lodge Road, Caerleon, Newport NP18 3XO,
t. 01633 436 700 f AneurineevanHeattnacard X AneurinBevanUHB We welcome cortespondence in Welsh and we wit respond in Welsh without delay. Aneurin Bevan Univensty Health Board W the operational none al Aneurin Beall University Local Health Board.

Bwrdd lechyd Prifysgol Aneurin Bevan University Health Board Digital team have made contact with the system suppliers and have received quotes for this work and have also prepared a capital bid and are seeking prioritisation of funding. We would like to reassure you that the Digital team are committed to delivering this project. They have reviewed resources internally, prioritising this over other workload and once they have an approved way forward, will be able to produce a timeline for implementation. I trust that this information reassures you with regard to the matters raised, however, if you require any further information or assurance, please do not hesitate to contact me.