Dear Miss Robinson Regulation 28-Report Linda Heath To address concerns regarding the lack of referrals to the district nursing team and other issues raised, the following measures have been discussed with the practice team and implemented to prevent future occurrences: Utilisation of Task Functionality in TPP SystmOne: Previously, some staff did not utilise this feature: All staff; including clinicians and administrative personnel, must now adopt and use the task functionality within the SystmOne clinical software_ This feature enables clearer, more structured communication clinicians to the administration team: Tasks are shared in a monitored inbox, ensuring they are actioned throughout the day: This method provides a reliable and transparent system for handling patient-related tasks, and tasks remain within the patient record for future reference: Training: Additional training and updates have been provided to all staff regarding the importance of good record-keeping: This includes understanding the significance of accurate and detailed documentation in the patient record. We have recently recruited a Data Quality and IT Officer to oversee and ensure that data is of a high standard through audits and training where applicable. These measures will enhance communication within the practice and the wider team within primary and secondary care. We will also continue to work with other organisations, including the local trust, to find ways to improve patient care pathways: Your sincerely Partner Partners: from

Dear Miss Robinson Inquest into the death of Ms Linda Heath Following the above Inquest; assurance was requested from CHCP in regard to the following matters (1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary. (2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care no referral was made post discharge by the GP surgery. (3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition. (4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers. Part of my role as the Executive Nurse is to ensure that CHCP adopt robust and comprehensive approach to taking action following recommendations formulated by our independent investigators. am extremely saddened by Ms Heath's death and the circumstances surrounding this_ appreciate the concern and upset which this has no doubt caused her family and sincerely hope that the actions we have taken will ensure, as far as is possible, patient safety. City Health Care Partnership (CHCP) is unable to provide any feedback in relation to the above concerns, as there was no referral made to CHCP Community Nursing by Hull University Teaching Hospital (HUTH) or St Andrew's Surgery Hull: CHCP has 24-hour Care Co- Ordination Hub, which manages all referrals into CHCP . chcp City Way

Excellence Compassion . Expertise Referrals can be made by any Health Care Professional (HCP): Patients relatives and carers can also make referrals for certain interventions. Pressure ulcerlwound care is an intervention that enables self-referral and non-HCP referrals The patient had previously received wound care from CHCP Community Nursing in 2018; it is unclear from the patient's electronic care record or information provided if safety netting was provided to the patient or their family by HUTH staff, that community nursing was required following discharge from hospital, or if the patientlfamily was provided with information by HUTH staff regarding contacting the CHCP Care Co-Ordination Hub if the community nurse did not attend Referrals to CHCP can be made via various routes Telephone via this telephone line is staffed through-out the 24-hour period, every day,so callers will always speak to a call advisor: Email via NHS e-Referral Service (e-RS) which includes copies of the referral criteria and available services_ Internally CHCP services can send SystmOne to SystmOne referrals, (SystmOne is CHCP main Electronic Care Record (ECR) system): CHCP is currently exploring options to enable external SystmOne users to also send SystmOne to SystmOne referrals. CHCP regularly shares updates in relation to the referral criteria, services offered and how to refer with GPs and other HCP organisations including Secondary Care, and GPs and HCP organisations also have access to the Directory of Services (DoS) via WWW directoryofservices nhsuk & NHS Service Finder via WWW servicefindernhs uk Referral criteria and how to refer can also be found on CHCP web page WWW chcpcic orguk Advice and support for the public can also be found on the following sites WWW eastridingofyorkshireccgnhs uk WWW hullccg_orq WWWnhs_uk WWW I1Lnhs Uk Bi-monthly Triangulation meetings between CHCP and HUTH Tissue Viability Nurses (TVN) are in place to discuss/hand over care for pressure ulcer and complex wound care patients. CHCP and HUTH Electronic Care Record (ECR) systems cannot communicate with each other, therefore with the help of CHCP SystmOne team CHCP TVN has been able to create a proforma that sits within SystmOne which is completed by CHCP TVN and sent electronically via email to HUTH TVN to the Triangulation meetings for discussion. chcp prior

Excellence Compassion Expertise HUTH TVN complete the same proforma and email it tol who place it in the SystmOne notes and task the TVN to inform that the proforma is there for discussion at the next Triangulation meeting: The proforma provides details of the patient and the wound type and progress to date along with any concerns. This enables the relevant Healthcare provider to investigate and feedback to the relevant team regarding wound concernslplans, which ensures that any patient with complex wound needs, who is transferring wound care between CHCP and HUTH will be discussed at the bi-monthly Triangulation meetings to ensure a cO-ordinated approach to tissue viability management: For patients where a discharge or admission is planned or imminent in between the bi-monthly Triangulation meetings, the CHCP TVN will contact the HUTH TVN (and vice versa) either by email or phone to discuss, both parties document any communication within their own ECR: This patient's proforma would have been sent to CHCP TVN to communicate the discharge date and CHCP community nursing would have continued to provide wound care following discharge from hospital_ The preferable solution to transferring care between CHCP and HUTH would be a digital solution between the two ECRs. CHCP TVNs are currently attending a time limited Task and Finish Group established by HUTH in relation to exploring discharge planning for patients with complex wounds/pressure ulcers and seek a digital solution: This Task and Finish Group is in addition to the Triangulation meetings. do hope this letter responds to your concerns.

Dear Ms Robinson,

Inquest – Linda Heath Deceased – Response to Regulation 28 Report to prevent future deaths

The Trust is in receipt of the Regulation 28 Report issued by yourself at the conclusion of the inquest you held regarding the death of Linda Heath who died in March 2022. This is the response of Hull University Teaching Hospitals NHS Trust.

It was understood by the Trust following the Inquest that there was an agreement that an update would be provided by the Trust on the measures already being taken which relate to the concerns raised by the Coroner. Therefore please can we request clarification as to whether the Coroner requires any further update beyond those provided in this response? If a response is also being sought from the national organisations listed at point 1, please could any responses provided be shared with the Trust?

Matters of concern at paragraph 5 of the Report are noted, and the Trust responds as it did at the Inquest in relation to points 1 and 4. Points 2 and 3 relate to primary care.

The first matter of concern relates to the immediate discharge summary not including relevant or sufficient information about the required treatment in the community or a nursing summary of care needs. This issue was canvassed extensively during the course of the inquest process. The Trust indicated that it would keep the Court advised as to progress to address issues which arise from the fact that a referral to district nursing upon Linda Heath’s discharge in February 2022 was not made. The problem here is the failure to make the referral, not the failure to refer to this issue in the immediate discharge summary as it

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

would not be for primary care to make the referral. The Trust has concentrated its efforts in seeking to address the core problem and reduce the risk of referrals to community services being missed, as happened here, at the point of discharge from hospital.

The Trust confirms that it has developed a pro forma to be utilised by nursing staff in relation to each and every discharge of an in-patient. This pro forma will be used when nurses are planning for a patient’s discharge, and it will identify and highlight a number of matters that need to be considered and addressed at the point of discharge. The pro forma is still being finalised, this work is expected to conclude within the next two weeks – because it is an electronic system, the Trust’s digital team has been involved in updating it. That said a number of wards are already using the document in paper form but this will be rolled out across the Trust very shortly. The pro forma will have a specific prompt to nursing staff to remind them to consider whether a referral to community nursing is required, and the form will also require them to insert details of to whom the referral has been made. Therefore in an equivalent case to that of Linda’s now this form would be completed by a nurse as plans for discharge are being made: the prompt on the form would remind staff of the need to consider whether a referral needs to be made to community nursing, and the form requires staff to complete information as to whom the referral has been made. This should serve to reduce the risk that necessary referrals that need to be made upon a patient’s discharge are overlooked.

In relation to the immediate discharge summary this is a document completed by medical staff, and is intended to be a summary of the medical care. There are ongoing discussions about the level of information that should be included within the form, as it is important it does not become too lengthy, but the Trust is of the view that in order to prevent the problem that occurred in Linda’s case, the issue to be addressed is ensuring that appropriate referrals are made in the first place, by the Trust at the point of discharge. In Linda’s case if the discharge summary had noted the need for community nursing referral it is true that it is possible the GP could have followed this up, but in fairness it would not be the GP’s responsibility to do that. In Linda’s case she proactively sought input from her GP and their involvement was discussed at the Inquest.

The other issue of concern relevant to the Trust’s involvement (point 4) related to an over-reliance upon private hygiene care packages with insufficient enquiry into the parameters of care provided by the private domiciliary carers. At the point of discharge, patients who are in receipt of care packages at home need

United by Compassion: Driving for Excellence.

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

to have them reinstated. Staff are being reminded of the need to consider whether the packages may require revision and re-assessment, as a result of whatever has brought the patient into hospital, and if such is required an appropriate referral usually to Social Services will be made.

It is also worth noting that the Trust has seen the response prepared by CHCP in relation to the Regulation 28 report and, in particular, note their comments regarding the triangulation meetings taking place in relation to complex Tissue Viability Nursing (TVN) cases. The Trust confirms that the system is working well in terms of improving liaison and communication between Acute Hospital TVN teams and the CHCP Community District Nursing Team in Hull that provide community nursing services. Plans and discussions are under way to establish similar processes for community providers in other parts of the Trust’s geographical area including North & Northeast Lincolnshire.

We trust this responds to the matters raised within the prevention of future deaths report.

Dear HM Coroner (Mrs Sally Robinson, Assistant Coroner) Regulation 28 Report following the inquest into the death of Mrs Heath 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 Heath. (‘the Regulation 28 Report’). In the Regulation 28 Preventing Future Deaths report HM Coroner raised the following concerns: CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary. (2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery. (3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition. (4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers.

Hull University Teaching Hospitals NHS Trust NHS trust’s do not report deaths to CQC, and we first became aware of the death of Mrs Heath on 10 May 2024 from your prevention of Future Death Report where we were a named responder. Following receipt of this report CQC held a management review meeting and agreed to request the inquest medical evidence bundle. In addition, we asked Hull University Teaching Hospitals NHS Trust to provide evidence of any action they had taken to date following the tragic death of Mrs Heath. We reviewed all the information obtained by the CQC and concluded there were no grounds to suspect a criminal offence. 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) CQC hold monthly engagement meetings with the trust to ensure that the fundamental standards of quality and safety are being met. At this meeting we review the trust’s progress on their post inspection action plan and ensure improvements made are sustainable and embedded. Since Mrs Heath’s death in March 2022 the trust have completed a number of actions relating to the management of pressure ulcers to eliminate the risk of this happening again.
• Mandatory training compliance levels for tissue viability for registered and non-registered nursing and midwifery teams are reported monthly to the safer skin committee. Tissue viability training now includes national e-learning modules, trust e-learning training videos in recognising and treating of moisture associated skin damage and chronic wound assessments.

• Audits for tissue viability and ward assurance are reported monthly to the safer skin committee who monitor any recommendations actions required and check compliance against an evidence based framework.

• Introduction of a senior nurse to regularly review patients who have moderate to high risk pressure sores. They ensure all members of the multidisciplinary team are involved in the patient care as needed. Referrals can be made to the tissue viability teams as well as plastic surgery. They are responsible for arranging onward referrals to district nursing teams and arranging appropriate equipment prior to discharge.

• Updated standard operating procedures for digital wound photography to include photographs of wounds on admission, when transferred to a clinical areas to identify improvements / deterioration of wound appearance.

• Monthly meetings with community health care partnership (CHCP) to work in partnership to improve communication for discharges and transfers of care across both healthcare providers.
• Clinical areas now display monthly posters for the number of days they have been “pressure ulcer free”.

• Updated standing operating procedures for ordering equipment such as dynamic mattresses.

• Updated patient information leaflet “preventing pressure ulcers – working together with patients and carers to prevent pressure ulcers”. St Andrew’s surgery at Elliott Chappell Health Centre CQC inspected St Andrew’s surgery at Elliott Chappell Health Centre in November
2017. The report was published in January 2018 and it was rated as good. A copy of the report can be found on our website - Elliott Chappell Health Centre NewApproachComprehensive Report (GPPractices Location Oct 2017)_INS2- 3890813910 (cqc.org.uk) City Health Care Partnership CQC inspected Community health services for adults in November 2016 and rated it as good. In June 2022 we carried out a focussed inspection based upon the quality of management of wound care within the Hull and East Riding community nursing service. The inspection did not look at other services provided by City Health Care Partnership or other areas of the community nursing service. This inspection was not rated, which meant the existing rating of good remains in place. CQC did not identify any required enforcement action during this inspection. A copy of the report can be found on our website - Core Service - Community health services for adults - (28/11/2022) INS2-12629169601 (cqc.org.uk) A national professional advisor and senior specialist for Primary and Community Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical records and practice response to the integrated care board who would cover the oversight of this GP practice. The findings will be shared with the operations team for Primary and Community Care to consider alongside other information held by CQC. This will inform our regulatory response. During the inspection process we routinely review correspondence, tasks and referrals. We will use the regulation 28 report to remind colleagues of the importance of this process. There will be ongoing monitoring of this provider via our monitoring and inspection process.

In addition to our inspection activity, CQC continually monitors all the information we hold about services for any themes and trends. We review intelligence data from a range of sources. For example, for trust’s we look at incidents reported to National Reporting and Learning System (NRLS) and Strategic Executive Information Systems (StEIS). This will now include incidents reported to the “Learn from Patient Safety Events” system (LPSIR). We also receive information from local authority safeguarding teams and attend meetings safeguarding meetings. We also engage with other regulators (such as the Environmental Health Agency or local Clinical Commissioning Groups) and Fire and Rescue Services or the Police. CQC receive information directly from patients or relatives of people who use services. This is extremely valuable to us as they are best placed to know whether they / their relative received safe, compassionate, and high-quality care. CQC also receive information from whistle-blowers (serving or former members of staff). If the CQC receives any information of concern about a service our aim is to respond as quickly as possible, assessing the risk using our new single assessment framework methodology and identifying the appropriate action to take. We will use our enforcement powers if regulations are not being met. CQC will discuss the concerns you have raised about Mrs Heath’s death at our next engagement meeting with the Hull University Teaching Hospitals NHS Trust. If we are not assured that improvements have been made, we will make an appropriate regulatory response. CQC’s next inspection of these services are 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

Linda Heath – NMC response to Regulation 28 Prevention of Future Deaths Report

Thank you for sending your Regulation 28 Prevention of Future Deaths Report (PFD) in connection with the death of Linda Heath for us to review in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I write on behalf of the Nursing and Midwifery Council (NMC) to confirm the action we are taking in response to the concerns raised.

Firstly, I am very sorry to hear about the circumstances of Linda’s death and I would like to offer my sincere condolences to her family for their loss. We take the concerns you have raised with us very seriously.

We have used the information in the PFD to reflect on the action we can take to address the concerns you have identified and to make sure they do not occur again where we have the power to do so. We set out below the action we have taken to ensure that the professionals on our register are fit to practise safely and professionally and that the public is protected in line with our role.

Additionally, I would like to apologise for the delay in acknowledging and responding to your report. We are taking steps to identify why the report did not reach the correct team in time for us to respond in accordance with the statutory deadline and will make appropriate improvements to prevent this from happening in future.

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Your concerns

I note that your investigation concluded that Linda died at Hull Royal Infirmary from sepsis caused by an infected sacral sore, also known as a pressure sore. Linda had been discharged in February 2022 with a grade 2/healing sore. A combination of management issues by healthcare professionals, including her not being referred for district nursing care, led to a worsening of her condition. Along with Linda’s pre- existing co-morbidities this led to an admission to Hull Royal Infirmary on 5 March
2022. Despite surgical treatment the situation worsened. Tissue viability nursing was not reinstituted post-operatively. Difficulties in care with nutrition and hospital acquired infections unfortunately led to Linda’s death on 31 March 2022.

You have raised the following concerns in the PFD report:

1. The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary.

2. Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery.

3. No trigger appears to exist whereby General Practitioners conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition.

4. An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers.

Our role

The NMC is the independent regulator of more than 808,000 nurses and midwives in the UK and nursing associates in England. We’re here to protect the public by upholding high professional nursing and midwifery standards, which the public has a right to expect. We maintain the integrity of the register of those eligible to practise and we investigate concerns about individual professionals.

Our Code of Conduct contains the professional standards that registered nurses, midwives and nursing associates must uphold. We will investigate alleged breaches of the Code when we become aware of them under our fitness to practise process.

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We have two clear aims for fitness to practise:

a. a professional culture that values equality, diversity and inclusion, and prioritises openness and learning in the interests of public safety, and

b. nurses, midwives and nursing associates who are fit to practise safely and professionally.

In appropriate circumstances we enforce the standards set out in the Code through fitness to practise proceedings. Fitness to practise proceedings can result in a range of outcomes, ranging from the provision of advice to the registrant by the NMC to removal from the register.

Our response to the concerns raised

The concerns that you have raised indicate that a nurse or nursing associate’s skills, knowledge, education or behaviour may have fallen below the standards needed to deliver safe and effective care.

Your report has been shared with our fitness to practise department, who will screen the case in accordance with our fitness to practise process. We screen cases to make sure that we’re the right organisation to address the concerns and it’s serious enough that regulatory action needs to be taken. It’s important to note that more often than not, employers can deal with most cases without the need for regulatory action.

In line with our screening process, we will now take steps to:

• confirm whether the concerns you have raised relate to a professional or professionals on our register;
• establish if there is evidence of a serious concern that could require us to take regulatory action to protect the public;
• confirm if there is clear evidence to show that a nurse, midwife or nursing associate is currently fit to practise.

If concerns are identified that relate to someone on our register, our screening team will carry out an initial risk assessment in relation to each concern. If they identify particular risks, such as a risk of harm to the public, the case may be referred to an interim order hearing. Interim order cases may include cases of serious lack of competence or poor clinical practice. An interim order has the effect of restricting the nurse or nursing associate’s practice with immediate effect.

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To help with our screening enquiries, we contacted your office on 23 August 2024, 5 September 2024 and 16 September 2024 to obtain further information. We have sought disclosure of the Serious Incident report to help us with our enquiries and are waiting for a response.

Finally, we recognise the impact that FtP proceedings can have on families, which is why we have a Public Support Service (PSS) to help support people through the process and understand how the investigation process works. Through it, our public support officers can answer individual questions or provide one-to-one meetings and help explain the different decisions that could be made. If we do proceed with an investigation our PSS team will reach out to Linda’s family to offer support. More information about our PSS can be found here NMC public support service - The Nursing and Midwifery Council.

Conclusion

We are taking steps to investigate the concerns raised to identify whether we need to take regulatory action in relation to a professional or professionals on our register. We are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future.

Once again, I offer my heartfelt condolences to Linda’s family. If you have any further questions concerning this case or the steps we are taking, please do not hesitate to contact us.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Linda Heath who died on 31 March 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 09 March 2024 concerning the death of Linda Heath on 31 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Linda’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Linda’s care have been listened to and reflected upon. 

I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused Linda’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

Your Report raises some concerns that would be more appropriately answered by the providers involved in Linda’s care, who I note you have also addressed your Report to. My response to you focuses on those areas that fall within the remit of NHS England’s national policy and programmes, although my regional colleagues have engaged with the Humber and North Yorkshire Health and Care Partnership on the concerns raised, as this is system in which the providers involved in Linda’s care operate.

We are advised by the GP Surgery involved (St Andrew’s Surgery in Hull) that they have implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, to ensure that tasks are more closely monitored and actioned throughout the day, and arranging additional training on what to record in the patient record.

City Health Care Partnership (CHCP) have also advised that referrals can be made to them via various routes, and that while their Electronic Care Records cannot currently communicate with those of Hull University Teaching Hospitals NHS Trust (HUTH), there is a proforma in place to record the details of the patient, wound type, history and concerns. Bi-monthly meetings take place between CHCP and HUTH Tissue Viability Nurses to discuss and hand over care for pressure sores, ulcers and complex wound care patients. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

29/07/2024

NHS England’s Primary Care Directorate have reviewed your Report and have advised that Linda’s care highlights the importance of follow-up or referrals being arranged by hospitals on discharge of patients, and the clear communication of any concerns or actions required to the GP team post-discharge. It is stated within the GP Contract that GPs should respond to a patient’s concerns ‘when they are ill or believe themselves to be ill.’ We would refer you to the providers for further information and any learning taken, including on HUTH’s discharge policies.

Nationally, there are several programmes of work underway to improve access to and the sharing of patient information between providers, both NHS and private. These include the National Care Records Service and Shared Care Records.

I would also like to provide further assurances on the 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 events, such as the sad death of Linda, are shared across the NHS at both a national and regional level and helps us to 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.