Dear Sir,

RE: Regulation 28 Response for Sophia Ayuk

This is a formal response to your Regulation 28 report dated 20 January 2023 where you set out concerns relating to the care of Sophia Ayuk whilst under East London NHS Foundation Trust’s (the Trust’s) care.

I understand that at the inquest into Ms Ayuk’s death you heard evidence from the Trust’s Serious Incident (SI) review author outlining the learning that has taken place as a consequence of her death. However, you remained concerned about the risk of future deaths in relation to the following two areas:

1) At no time during the two periods of Ms Ayuk’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of Trust policy; and

2) Instructions given to monitor and record Ms Ayuk’s fluid and food intake were not adequately followed. I wish to assure you and the family of Ms Ayuk that the Trust has reviewed the issues highlighted by the Regulation 28 report and has planned or undertaken the actions outlined below.

VTE Assessment

I understand that you heard oral evidence at inquest that the Trust proposed the following actions to ensure that VTE risk assessments are undertaken in accordance with the Trust’s policy and best clinical practice:

1) A full review of the Trust’s VTE policy;

2) A VTE Screening and Assessment Clinical Alert was disseminated across the Trust;

3) Changes were made to the new doctors’ induction and junior doctors handbook to include information on VTE assessments;

4) Anti-psychotic medication has been added as a consideration on the Trust’s VTE assessment tool;

5) The Trust’s monthly two day physical health training programme now includes a session on VTE risk; and

6) A yellow card warning was raised with the manufacturers of the anti-psychotic, Zaponex through the Medicines Health Regulations Authority (MHRA) to alert to two patients who have both passed away from pulmonary embolism whilst on Zaponex.

7) The Trust has been trialling Power BI (a data analytics tool) in order to monitor compliance with VTE risk assessments.

Since the inquest took place the following further actions have been undertaken with the expectation that they will improve VTE risk assessment compliance:
1) An Advanced Clinical Practitioner (ACP) has started in the role of Consultant Nurse in Physical Health at NCfMH. She reviews physical health on the in-patient wards. If she has concerns about the physical health of in-patients, including around VTE assessments, she addresses them with staff during daily, morning safety huddles.

2) The Trust’s electronic medical records system (RiO) was updated to include a pop- up reminder to seek a VTE risk assessment if someone’s presentation changes every time nurses update the Observations and Measurements Form.

Since this further work, the Trust’s power BI and doctors task list results have shown that NCfMH’s compliance with VTE assessments has improved significantly.

Food and Fluid Intake Monitoring

I understand that you also heard oral evidence at inquest about the Trust’s plan to improve fluid and food intake monitoring on in-patient wards. The associated actions were as follows:

1) The Trust implemented a new nutrition policy that highlights the importance of food and fluid monitoring for in-patients;

2) The Trust recruited specialist staff to advise on service user nutrition:

a. A Band 7 Specialist Dietician was hired to provide (Trust-wide) nutritional guidance.

b. A Band 5 Dietician post has been approved specifically (Trust-wide) on nutrition. The role is currently being recruited internationally; and

c. The new ACP, Consultant Nurse in Physical Health at NCfMH (as above) will review all aspects of service user physical health including nutrition.

3) The Trust introduced a series of training measures in relation to nutrition on in- patient wards:

a. The Trust’s monthly two day physical health training programme now includes a session on food and fluid charts;

b. A new learning module on nutrition screening is now live on the Learning Academy; and

c. A newly launched nutrition and dietetics page can be found on the Trust intranet with advice and resources for in-patient ward teams.

4) A dietician referral system has been introduced to provide advice and guidance on complex cases.

5) There are on-going plans to add the St Andrews Nutrition Screening Instrument (SANSI) nutrition and malnutrition screening form to RIO.

Since you expressed your concerns in the Regulation 28 report. NCfMH has undertaken the following additional steps to address the issue of staff compliance with food and fluid chart completion:

1) Daily food/fluid chart checks are done by senior nurses to ensure completion.

2) Matrons now do weekly night checks that include review of food/fluid charts.

3) A new template for decision making for commencing/terminating food and fluid chart monitoring has been developed and is in use. I hope I have provided reassurance to you and the family of Ms Ayuk about the learning that has taken place as a consequence of her sad death.