Dear Mr Irvine,

Thank you for your Regulation 28 report to prevent future deaths dated 5 October 2023 about the death of Ms. Iris Elaine Fordham. I am replying as Minister with responsibility for dementia.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms. Fordham’s death and I offer my sincere condolences to their family and loved ones. Please accept my sincere apologies for the significant delay in responding to this matter.

The report raises concerns that the hospital that admitted Ms Fordham failed to follow standard practices for a patient with dementia and at risk of falls.

In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission.

The Barts Health NHS Foundation Trust have confirmed that a Falls Risk Assessment was completed for Ms. Fordham but that this was missed by the investigator conducting the Serious Incident Review. However, an Enhanced Care Assessment and Care Plan, required for a patients with dementia and at risk of falls, was not completed for Ms. Fordham.

The Trust have agreed to implement the following actions to ensure robust implementation of standard practices for patients with dementia and/or at risk of falls and to improve incident investigation and divisional governance: a) all patients at risk of falls should have an up-to-date Enhanced Care Assessment which should be discussed at the multi-disciplinary meetings and of which the nurse in charge should be aware; b) the risk of fall ID band should be used for any patients with a history of falls or deemed to be at risk of a new fall;

c) all permanent members of staff to complete the 4 Harms and Slips, Trips and Falls Statutory and Mandatory Training; d) a Falls Risk Assessment and Care Plan and an Enhanced Care Assessment should be completed on all patients admitted with confusion or dementia, and those over the age of 65 within 6 hours of admission to ward or clinical area; e) education regarding the Falls Policy and Action Plan are currently being revisited with staff in ringfenced team time; f) a training plan for Falls Risk Assessment on the Computerised Records System (CRS) is to be rolled out and will be audited once the training plan has been completed; g) the information shared at multidisciplinary team meetings should include details of how and why the patient presented as well as the outcomes of Falls Risk Assessment and Enhanced Care Assessment to ensure that appropriate decisions about care are made; h) staff involved in Ms. Fordham’s care should be given feedback, so that they can reflect and improve the care that they provide their patients; i) the Trust will explore having the full Falls Risk Assessment mandated on the Computerised Record System; and j) findings and learnings from the review will be shared in Trust Mortalist and Morbidity meetings.

Further, the Trust is conducting a diagnostic assessment on essentials of care and associated patient risk assessments (including falls). The Care Quality Commission continues to have regular engagement with the Trust as part of their usual mornitoring powers. This includes continued monitoring of the agreed actions the Trust provided the CQC with regarding improving their serious incident investigation and divisional governances.

You may wish to refer to the Trust for an update on the status of the above listed actions.

In the community, as per the Care Act 2014 (legislation.gov.uk), where it appears that an adult may have needs for care and support, the local authority is required to carry out a needs assessment. To support local authorities in improving the care provision for patients discharged from hospital, £600m has been made available through the Discharge Fund for 2023/24. Further guidance on support and services available following a dementia diagnosis can be found on NHS.uk.

I hope this response is helpful. Thank you for bringing these concerns to my attention.