Dear Assistant Coroner Hayes

Inquest touching upon the death of Mr Fred Malcolm Reynolds Trust Response to the Regulation 28 Report to Prevent Future Death

I write in response to the Regulation 28 Report dated 15th July 2021, sent to Kent and Medway NHS Social Care Partnership Trust (KMPT) following the conclusion of the inquest, touching on the very sad death of Mr Fred Reynolds on 30th October 2019.

In your report to the Trust, you raised the following matter of concern:

Specialist neurology advice was given to conduct neurological observations every two hours for 48 hours following head injury. These observations were commenced but not continued. It was not possible to understand why these observations has been discontinued and there was no entry made in the medical records.

We fully recognise the importance of continuing with any recommended treatment as advised by clinical experts from the acute trusts, and have endeavoured to establish why, in Mr Reynolds’s case, the neurological observations recommended were stopped. We have been unable so far to identify the decision point or decision maker This appears to be a matter where on this occasion an appropriate record for ceasing the neurological observations was not made, but we consider that the changes made since will mitigate the risk of this occurring again. We describe these below. Significant changes have been made and sustained since 2019 when Mr Reynolds sadly died, which now mitigate the risk of neurological observations being stopped without careful assessment and medical approval. Set out below is a description of the new and more robust systems we now have in place. The new systems and in particular, electronic monitoring have significantly reduced the risk of neurological observations being stopped without careful assessment and medical approval.

Sonia Hayes Assistant Coroner Mid Kent and Medway

1. Our Falls Policy, which is NICE compliant, provides guidance regarding neurological observations. It clearly sets out that neurological observations should be completed every thirty minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this becomes hourly observation for the next four hours, and then two-hourly after that, until medical review has occurred. Staff are sufficiently trained and compliance with this quality standard is monitored through our Falls Care Pathway and incident reporting. We have a well- established system for sharing lessons learnt through our quality governance meetings, and Mr Reynolds’s story has been presented there.
2. Neurological observations are part of every handover if clinically indicated, as set out in the Inpatient Handover Protocol which was introduced in protocol in December 2018, and on the patient status board/at a glance board. Shift handover processes are regularly reviewed, and are subject to quality checks through our programme of CLIQ Quality assurance audits, in order to ensure ongoing quality improvement.
3. All patients on our wards have a set of vital signs recorded via NEWS2, i.e. the National Early Warning Score 2 since an electronic observations project was rolled out across 2019. This is a system designed to standardise the assessment and response to acute illness. Any patient returning from a visit to A&E, or the general hospital, have their vital signs recorded on eObs, an electronic recording system, that will calculate National Early Warning Score (NEWS2). This encompasses a consciousness level assessment, and will identify the need for Glasgow Comma Scale (GCS) to be completed. Neurological observations utilising GCS are implemented when clinically indicated, or following a reduced consciousness score from NEWS2.
4. Within NEWS2, which was launched in 2019, there is a 5-point consciousness scale. This is the standard observation undertaken for all our inpatients, and is completed as a minimum. NEWS2 is monitored through CLIQ Quality assurance audits on a bi-monthly basis. Results of these audits are shared and discussed at ward, service and Trust level, including up to Sub- Board Quality Committee.
5. At the time of Mr Reynolds’s death, we had commenced a Trust wide programme of work to gradually implement electronic observations (eObs) using National Early Warning Score 2 (NEWS) across all our wards. eObs is an electronic recording system accessed through a tablet device. The physical observations results are linked to Rio, our health record system, and can be accessed virtually by clinicians. This electronic system was not available on Woodchurch ward at the time of Mr Reynolds’s treatment; it came into effect in March 2020. At the time of Mr Reynold’s treatment, a paper version of Modified Early Warning System (MEWS) including assessment of conscious level was in place. The new electronic NEWS2 system has significantly improved the way in which we undertake and monitor physical health observation for our patients. It has importantly also improved our ability to monitor and scrutinise compliance with our standards, at multiple levels across the Trust. This means that when observations indicated for a patient are not completed at the agreed time, an alert is issued as a reminder for staff. The NEWS2 system also indicates to staff the frequency required for ongoing monitoring, depending on the score. For senior clinicians such as Doctors, they can easily access the results remotely and act if there are abnormal readings. As part of the roll out of this new system, training was provided and completed by all members of staff, and there is ongoing training offered to new nursing and medical staff. Their competencies are assessed and signed off as part of this training, further demonstrating the steps we have taken to improve staff knowledge, skills, and confidence with undertaking neuro observations.

6. In addition to staff training, the use of digital technology, and the improved quality governance and assurance systems in place, we have also employed specialist Physical Health Nurses on each ward as part of our nursing skill mix. This ensures that we have staff with relevant technical expertise to teach, support and supervise provision of high-quality physical health care to our patients. This was not in place at the time of Mr Reynold’s treatment.
7. Our resuscitation service has further developed a Trust-wide “Train the Trainer” course for neurological observations and the Glasgow Coma Scale, and has delivered this to all physical health nurses. Since March 2021, all the physical health nurses across the Trust have been trained, and we now offer a short refresher training session for each team, and will continue to facilitate these sessions as required. This training is also available via iLearn (virtual learning platform) for all staff to access as needed.
8. Following Mr Reynolds’s death, the Older Adults Care Group developed and disseminated a learning bulletin to all staff, reiterating the need for neurological observations to be completed for any seen or unseen incident where a patient is presenting with a head injury, possible stroke symptoms or any medical emergency. It clearly reminded staff that observations should be completed using the Glasgow Coma Scale. We are sincerely sorry for the shortcomings in our care of Mr Reynolds and are committed to ensuring that the improvements we have made are sustained.

I hope that the detailed information provided offers you a level of assurance about both the seriousness with which we have received and responded to your concerns, and the significant improvements we have made since the sad passing of Mr Reynolds.

We are, as always, happy to provide further information or evidence if that would be helpful.