Dear HM Coroner Landau Re: Inquest of Hazel Fleur Wiltshire I write in relation to the regulation 28 report to prevent future deaths dated 1st September 2021 in connection with the inquest of Hazel Fleur Wiltshire. We are very sorry that Mrs Wiltshire died in these circumstances at the Princess Royal University Hospital. We have apologised to her family for the failings in our care and we have offered them our sincere condolences. In your report you have identified the following concerns:
• The matron who gave evidence was not aware ofobtaining data on response times from the call bell system and had not introduced any other system to monitor response times.
• Staffing levels were inadequate due to higher dependency ofpatients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help.
• Although Mrs Wiltshire was at risk offalls, no risk assessments were completed on any ofthe three wards in which she stayed. This suggests a systemic problem across the hospita/ that requires remedial action. Thank you for highlighting these points and giving us an opportunity to respond and to update you on the improvements we have made to ensure that patients are consistently receiving high quality care at King's College Hospital. Response times from the call bell system The current call bell system at the PRUH is approximately 20 years old and is due for replacement. Unfortunately it does not automatically generate reports on response times. The replacement plans are now being progressed and we expect this to take place in 2022. A project group has been identified including nursing representation to ensure this is implemented in a way that most benefits our patients. The upgraded system will enable reporting of response times. I t I •1• , 111 I KING'S HEALTH PARTNERS An Academic Health Sciences Centre for London Pioneering better health for all

Prior to the implementation of the upgraded call bell system, we have re-introduced local Quality Audits led by the Matrons at the PRUH, alongside intentional quality rounding checks, which look specifically at documentation including. In November 2021 we are also launching Executive Quality walk-rounds across the hospital sites. We will also be including an audit of response time to call bells in our monthly ward audit cycle through the Perfect Ward app. The audit will include response times, checks to the call bell functionality prior to admission of a new patient and checks to see if call bells are within reach of patients whilst in bed. If any bells are found to faulty, they will be reported to Estates immediately and an incident report form will be competed. The Heads of Nursing and Director of Nursing will be completing these audits alongside the ward teams. The wards and care groups will monitor the audit results via the Perfect Ward reports and improvements made accordingly. These results will be monitored locally whilst also being shared at Nursing and Midwifery Board monthly as a standing agenda item. This information will then be cascaded to all nursing and midwifery staff as well as patient safety and experience colleagues in feeder committee meetings on a regular basis. Staffing and continence care Mrs Wiltshire's admission coincided with the height of the second COVID-19 wave when the PRUH site was at capacity. At the time of the admissions there were 273 patients in general and acute beds, 157 patients through the Emergency Department and 19 patients in the Intensive Care Unit (ICU). I would stress that we are not trying to excuse the failings in our care, but in recognising the impact of the pandemic on staffing, and the way in which care was delivered in extremis, is an important context when considering how to prevent future deaths in similar situations. Covid-19 patients were often higher dependency, meaning that more staff were required to care for them on acute wards. This was in the context of staffing challenges made worse by staff sickness and requirements for self-isolation. A review of staffing rates at the PRUH in January shows that the average fill rate for day staff was 86. 7% (the lowest rate recorded for day staffing at the PRUH site in the last 12 months) and the average fill rate for night shift staff was 91.6% (also the lowest rate recorded for night staffing at the PRUH site in the last 12 months). Although we experienced more stretched nurse to patient ratios during the pandemic as we were in extremis I want to provide assurance that daily staffing calls took place, led by senior nursing staff at the PRUH/SS, to mitigate risks and ensure ratios were as safe as possible. Throughout the waves of COVID-19 our recruitment and retention activity did continue although since wave 2 we have increased this work which is happening alongside HR colleagues across all sites to ensure we have robust plans to attract, develop and retain our current and future workforce. At the time of her fall in hospital Mrs Wiltshire was Covid-19 positive and therefore. was being cared for in a side room for infection, prevention and control reasons. In order to attend to her, the nursing team were required to don (put on) and doff (take off) personal protective equipment before entering and when leaving side rooms. Whilst it is not possible to be specific in Mrs Wiltshire's case (as there are no specific records of when the call bell was activated) this may have been a factor in delaying the team attending to her as quickly as they would have liked. With additional training during the waves of COVID-19 and increased familiarity of donning and doffing it is probable that this activity has now become a quicker task to complete. · The story which you have heard about another patient who was not supported with her continence needs is distressing and deeply regrettable. If you have further details about this case, then I would be grateful if you could share these details to enable us to apologise to the patient and their family, and to ensure we can investigate and learn from what happened. I t I•11 •H MKING'S HEALTH PARTNERS An Academic Health Sciences Centre for London Pioneering better health for all

We recognise that falls in hospital are often connected with patients using the bathroom or trying to get to the bathroom. We are working to ensure that our continence care is pro- active, e.g. patients assisted to the bathroom before they go to sleep and early in the morning. Our Practice Development, Clinical Safety and Bowel and Bladder Clinical Nurse Specialist T earns are currently working collaboratively to share learnings from poor practice, like you describe, in order to raise awareness and show case best practice. We are ensuring, in line with our Trust wide competency matrix and training needs analysis, that our senior nurses and practice development nurses have the appropriate skills and knowledge to provide gold standard continence care to all our patients and will role model this at all times. Continence care is also part of our rolling annual 'Topic of the Month' programme with the Practice Development Nurses who will deliver specific bite-size teaching co-produced with the Bowel and Bladder CNS Team. This will be audited the following month and fed back so we can follow a continuous cycle of improvement. Falls risk assessments The absence of a documented falls risk assessment for Mrs Wiltshire prior to her fall was not acceptable. In the Serious Incident investigation carried out by Trust it was identified that there had been at least 3 missed opportunities on different wards to complete the falls risk assessment. The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.} We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust} to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU} to move to a more automated approach using the current patients' electronic health records in the interim. The Practice Development Nurses are now supporting with falls training and promoting best practice across the PRUH wards. We also have named staff from each ward at the PRUH who will be the Falls Champions and are working closely with our Falls Practitioner Team. Falls refresher training sessions, delivered by the Falls team, have also been included as part of the annual clinical update (commenced in April 2021), which Band 5, 6 and 7PRUH nursing staff have been attending Feedback from these sessions has been very positive. In September 2021, the Trust ran a number of events to mark Falls Awareness Week which focussed on falls prevention. This occurred alongside Falls being the Topic of the Month for September 2021 which also included further training and bite-size teaching which is currently being evaluated and feedback shared with the teams. The PRUH are also doing some focussed work on falls prevention, led by the Site Director of Nursing, who chairs an operational falls meeting. This has focussed on collaborative working across professions to identify risks and common themes in relation to falls prevention with a clear action plan and deliverables from this working group. Since April 2021 the number of falls have reduced significantly, and work continues to further reduce the number of falls and lessen the impact on our patients. The Trust's Harm Free Care Forum, was reconvened following Wave 2 of the pandemic. This is a forum which champions falls prevention and helps to focus on the implementation of actions arising from trends and themes in falls incidents. The main purpose of the forum is to review recent incidents and share what went wrong, why and the learning from this to ensure we are creating a good safety culture in the Trust. I trust that this response provides you with an assurance that the Trust have taken this seriously and are actively working to ensure we mitigate the risks of falls to all patients in our I KING'S HEALTH PARTNERS An Academic Health Sciences Centre for London Pioneering better health for all

care. We do recognise the severe impact that a fall can have any patient, but particularly for our frail and elderly patients.