Dear Ms Hayes I write further to the inquest into the death of Isabella McCreadie and the PFD Report you have written expressing your concerns about risks of future deaths. I will take each of your concerns in turn and hope to provide you with reassurance about the Trust’s investigation into each of your concerns.
1. In evidence I was advised during Mrs McCreadie's stay in hospital her dietetic needs were not addressed as there was insufficient staffing in the dietitian department. I asked the hospital when giving evidence if these issues had been addressed and was advised that there were still ongoing. I am concerned that if appropriate staffing levels are not put in place, patient's needs will not be met.

A review is currently being undertaken to look at demand and capacity for the whole of the therapy’s directorate including the dietetics team and a staffing proposal paper is being compiled. The Trust seeks to reassure you that resources in the dietetics team are being used as effectively as possible to ensure patient’s needs are appropriately met and bank work is being offered where appropriate. Earlier this year, some resource was moved from the Wexham Park Hospital dietetics team to Frimley Park Hospital to meet the higher demand in the acute team at Frimley Park Hospital. The Trust has engaged with a national benchmarking programme which is being managed by the British Dietetic Association who feel that the current national safe staffing guidance for dietetics needs to be updated. This is based on the fact that 55% of respondents to the British Dietetic Association questionnaire felt there was unsafe staffing within their dietetics team. We feel that this illustrates that resourcing for dietetics is a national issue. Data has been input into the national benchmarking programme and the results should be shared with us soon.

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Where referrals to dietetics cannot be actioned immediately due to higher risk patients requiring their input, nursing staff are provided with safety netting advice from the dietetics team. Nursing staff are advised of the following first line nutrition support measures that should be put in place for patients at medium or high risk of malnutrition: “Please ensure that MUST (Malnutrition Universal Screening Tool) care plans have been implemented (“Malnutrition – high risk” for MUST 2 or more, and “Malnutrition - medium risk” for MUST of 1) Patients at medium or high risk of malnutrition (MUST 1 or more) who are able to drink level 2 fluids or thinner at FPH, should:
- be offered the first line oral nutritional supplements (Fortisip Compact Protein) twice daily, between meals
- have a fortified menu (if able to have a normal diet)
- Complete weekly weight and MUST screening
- Document food and hydration intake (ensure the Nutrition section on the Daily Cares/Safety flow sheet is used to document dietary intake). Type yes in the box for “Patient flagged at risk of malnutrition” then the relevant boxes will appear to document dietary intake.
- Patient to be encouraged to eat snacks and to drink between meals (biscuits and milky drinks, consider finger food if appropriate)
- Red or yellow tray put in place and provide assistance at mealtimes if required
- Check any symptoms affecting food intake are adequately controlled e.g. nausea, vomiting
- Liaise with clinical team to ensure correct drug treatment e.g. anti-emetics, laxatives
- Check that any psychological factors affecting food intake have been highlighted to the relevant teams e.g. dementia team
- Ensure the patient is on the most appropriate menu for their clinical situation” In this case, despite the fact that the dietitian could not complete a full review for the patient within the expected 3-4 working days, the dietitian who triaged the referral also implemented the first line oral nutritional supplements (Fortisip Compact Protein) on Epic, and therefore the nutrition support intervention the patient required was not delayed. The Trust has included nutrition improvements as one of its quality priorities for 2024/25 as part of its Quality Account. This will be monitored closely and supported in the Trust. In April 2024 the Head of Dietetics, Speech and Language Therapy and Podiatry at Frimley Health NHS Foundation Trust, who chairs the Fundamental and Better Care council for the Trust commenced a quality improvement project focusing on interventions at a ward level to prevent malnutrition in our patients. This is due to be completed by March 2025. One of the key aims of this improvement project is to ensure patients at risk of malnutrition are being given first-line oral nutritional supplements. The possible solutions to be trialled are:
- optimising the process in the Trust’s electronic patient record (Epic) to ensure the ordering of oral nutritional supplements is clear, efficient and effective;
- ensuring the wording on the best practice advisory box on Epic is clear when a patient scores medium or high risk of malnutrition;

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- introduction and roll out of updated online training to ward nurses to enable them to be able to order first-line oral nutritional supplements without having to ask for a counter- signature;
- providing tip sheets, posters and face-to-face training to ensure staff on wards are aware of who should be ordering oral nutritional supplements and how to order them;
- education for patients and relatives about the importance of oral nutritional supplements if a patient is at risk of malnutrition;
- include key messages about oral nutritional supplements in the quarterly key nutrition messages from the nutrition steering group;
- ensuring oral nutritional supplements are visible on the medication administration record; These improvements will be reported and monitored at the Nutrition Steering Group in the Trust and ultimately by the Quality Assurance Committee.

2. During evidence I was advised that a training need had been identified for staff regarding pressure sores following the passing of Mrs McCreadie. I have been advised in submissions by the hospital that they intend to address this training need by identifying eLearning staff can complete. Given in evidence it was identified that: a) some staff do not know how to support and or handle patients who are in pain and refuse to be repositioned; and b) the staff are unaware of the techniques needed to be used to reposition patients who have multiple injuries, I do not consider that these can be adequately addressed by eLearning.

Improvement of the management of pressure ulcers is also one of the Trust Quality priorities identified in January 2024. An improvement plan is under way which will be closely monitored and reported on at various committees.

Currently, nursing staff and healthcare support workers receive manual handling training in person on induction which provides training on how to reposition patients. This training is 4 hours on induction for any nurse or healthcare support worker with prior healthcare experience and 6 hours for anyone without prior clinical experience. Refresher training is provided online every 3 years.

As part of both the induction and refresher training, nursing staff and healthcare support workers are trained in how to reposition complex patients with multiple complex injuries. Staff are also trained to support patients with the assistance of another staff member whenever there are issues such as a patient being in extreme pain or where they are resisting repositioning.

In the coming months the Trust will be introducing a new skin assessment tool (PurposeT). This tool is prescriptive with regards to actions that should be taken once a patient’s pressure areas have been assessed. This is as a result of a new National Wound Care Strategy initiative. There will be training to all nursing staff on how to use this skin assessment tool.

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Where patients are refusing repositioning due to pain, all nursing staff and healthcare support workers are aware that analgesia should be offered as prescribed. If no analgesia is prescribed, they will seek support and guidance from the relevant specialist team (this may be the Pain team, the speciality Dr, on-call Dr, or Night nurse practitioner).

Every ward has a manual handling champion nurse and healthcare assistant who links in with our manual handling trainers and are provided with extra training in order that they can support staff with any manual handling concerns which may arise on their ward. Over the next year we will be providing regular face to face education sessions for all staff, regarding pressure ulcer prevention. This will be supported by the lead Tissue Viability Nurse, Practice development and wound care specialists.

The Trust also now has access to a new specialist mattress called a “Dolphin” which can be used in conjunction with a tilting bed frame, designed to manage patients who find repositioning extremely painful. The ward staff receive training from the company who supply the equipment and the use of the mattress is monitored by the company with weekly visits from the supplier’s clinical adviser. There is also access to an electronic help line which can be used for any issues which arise. Staff request the dolphin mattress for patients via the Trust’s tissue viability nurse. This ensures that these patients, who are at risk of pressure injuries due to the fact they find repositioning painful, are also receiving input from the tissue viability team.

3. During the doctor’s evidence, at inquest, an issue was highlighted regarding ordering of fortsips on the hospital computer system, a dietary supplement. An order had been made to be started on 10th May to 3rd June twice daily. This was not processed. I was advised in evidence by the hospital that the doctor could be shown how to release it. However, there is no evidence as to how this error could be identified if it should reoccur and a clinician was not aware that the order for fortsips was not released on the system.

Fortisip Compact Protein is a fortified nutritional supplement and as an Advisory Committee on Borderline Substances (ACBS) approved product it does not need to be prescribed and as such does not need to be released on the Trust’s electronic patient record (Epic) before it can be given. Fortisip Compact Protein can be given to a patient by a dietitian, doctor or nurse who has undergone relevant online training compiled by the dietetics team. First-line oral nutritional supplements should be given to any patient who is scored at 1 or above on the Malnutrition Universal Screening Tool (MUST) and for whom the supplement is clinically safe.

We have reviewed Mrs McCreadie’s chart and can confirm that the Fortisip Compact Protein was ordered by a dietitian on 10 May 2023 at 08:48 and this was auto-released. Mrs McCreadie received the first Fortisip Compact Protein at 09:00 on 10 May 2023. We can see however that there were issues with Mrs McCreadie receiving further Fortisip Compact Protein supplements during her stay as recommended by the dietitians who triaged Mrs McCreadie’s referral on 10th May 2023.

As a result of this PFD report we have become aware that there is a need for greater education to all staff about the Trust’s Adult Oral and Enteral Nutrition Guidelines, and the administration of oral nutritional supplements.

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The Trust Guideline states that: ‘Patients who are deemed to be at medium or high risk of malnutrition should have appropriate first-line oral nutrition support measures initiated at ward- level. Unless the patient has issues with swallowing, food allergies or is at risk of refeeding syndrome, the management guidance detailed on page two of the Malnutrition Universal Screening tool at the back of the Patient Assessment Booklet should be implemented at ward level. This includes….”Provide two Fortisip Compact Protein (FPH)”

This document is in the process of being updated to reflect the process changes due to the implementation of Epic rather than using paper nursing documentation.

The Trust are investigating whether it is possible to clarify the wording on the best practice advisory box in Epic to remind nursing staff of this guideline whenever a Malnutrition Universal Screening Tool (MUST) score of 1 or above is inserted into Epic.

This advisory box would clearly set out that:

- All patients with a MUST score of 1 or more should be given first line nutritional supplements twice a day and this should be recorded in their clinical record.

The advisory box will also remind nursing staff that first line nutritional supplements are not medication which needs to be prescribed and can be given to a patient by any nurse who has undergone the relevant training. The training is required due to safety and allergy contradictions.

A small percentage of the Trust’s nursing staff have already undergone this training which means they can place orders for Fortisip Compact Protein for patients without requiring a counter signatory and there is a plan to roll out this training to more nursing staff on a rolling basis as part of the quality improvement project.

Ward F6 have taken this issue extremely seriously and they have 100% compliance with the training for MUST (malnutrition screening tool). The nurses on ward F6 have also been identified as a priority to receive training to place orders for nutritional supplements.

4. At the time of the inquest, I was informed during Mrs McCreadie's stay a number of staff were agency staff. I note that the hospital now have more permanent staff in place on the ward than when Mrs McCreadie was on the ward. I remain concerned that agency staff who may still need to be called to assist on the ward may not have sufficient training on the computer system used for recording medical care provided before they are required to do so whilst working on the ward. At the inquest there was evidence that insufficient training had been given and therefore there were inconsistencies in recording of treatment given or needed. I understand permanent staff receive 9 hours of training, whereas agency staff may receive only up to 1 hour of training.

Since October 2023 agency staff have been required to complete one hour of online training and 4 hours classroom based Epic training in person before they can work a shift at the Trust.

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There is also an assessment at the end of this training to check the user has understood the training. The Trust has significantly reduced its reliance on agency staff over the last year. In May 2024 our use of temporary registered nursing staff was down to 10.27%, with only 2.15% of this being provided by agency staffing. The remainder of the temporary registered nursing staff has been provided by staff employed with the Trust under a bank contract. I would also like to reassure you that under the Trust’s temporary staffing policy we have made it very clear that anyone working on the wards from an agency will be supervised by a substantive member of staff. This substantive staff member will be available to assist with any queries the agency worker may have about recording on a patient’s electronic patient record. We have also made ‘My Learning Hub’, (the Trust’s electronic training platform) available to all agency staff for any ongoing training which they may require. I do hope the above provides reassurance as to the Trust’s ongoing commitment to patient safety and continuous service improvement. Please do let me know if any further information would be of assistance.