Dear Senior Coroner Hassell,

Re: Regulation 28 Prevention of Future Deaths (PFD)

I am writing to respond to the Regulation 28 Prevention of Future Deaths (PFD) report for Ms Cecilia Edwards on behalf of the District Nursing service at Whittington Health NHS Trust.

Matter of Concern 1 - On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse. However, no such referral was made, either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co- ordinator until 22 September 2020.

Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.

In addition, Whittington District Nursing service is working towards the digitalisation of clinical notes, and the streamlining of documentation to mitigate the risk of key information being missed.

At the time of the incident there were three different places where patient information was documented; the home notes (on paper kept in the home), eCommunity (the service’s nurse visits allocation software) and RiO (the electronic patient record keeping system used by most community services in the Trust.) Since January 2021, a new version of eCommunity has been introduced which removes the capability to record clinical notes. Additionally, the service will be moving toward single documentation of the clinical patient information on the community electronic records from September of this year. Therefore, removing the risk of documenting the same information in multiple places this includes patient assessments and care plans.

HM Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP

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Matter of Concern 2 - 60% of the district nurses who visited Cecilia Edwards were agency nurses. This is obviously undesirable in itself, although I recognise that it may be very difficult to address. That notwithstanding, the district nurse team manager giving evidence in court agreed with Ms Edwards’ niece (herself a former district nurse and health visitor, and her auntie’s longstanding advocate) that clear protocols would raise standards, make mistakes less likely and bring the agency staff in as part of the organisation. Ultimately this would improve patient care.

Due to the COVID-19 pandemic acute period (Late February – April 2020), there were significant staffing shortages across the District Nursing service. During this time Whittington Health benefited from having regular temporary staff (bank and agency) which enabled the service to continue providing care to patients who were housebound. The Trust recognises however, that when using agency staff, it is critical that there is continuity of care.

Through the improvements to the patient documentation there is a key strand of work in relation to improving continuity of care for all patients and ensuring that allocation of staff to patients includes this and that staff recognise the importance of getting to know their patients and families. This roll- out of the digitalisation patient records and visits allocation programme has involved all staff, permanent and temporary.

In addition, the daily handover process has been revised to ensure that all teams across the service have allocated time to attend, including temporary staff. Handover also now includes a specific item for pressure ulcer management. The District Nursing Leads (senior nurses) are monitoring handover on a regular basis to ensure the changes are embedded.

Work is also ongoing to recruit to the District Nursing service, both for substantive roles and on the Bank, both locally and internationally. The Trust actively works with agency staff who are regular workers to consider joining the organisation as permanent employees and they are offered several flexible options to meet their personal circumstances. Vacancies are monitored through the Trust divisional reporting structure and at the Trust workforce committee.

Matter of Concern 3 - The district nurses who visited Cecilia Edwards needed the assistance of the two carers to turn her and attend to all her nursing needs, but sometimes when they visited there were no carers present and so the nursing care given was incomplete. The carers attended at set hours four times a day, and so it seems that the onus was on the nursing team to arrange the twice weekly visits appropriately. Sometimes, individual nurses would ring individual carers to make arrangements, but there was no organisational system to ensure that nurse and carer visits coincided as a matter of routine.

There are robust arrangements established with local social care agencies and the District Nursing service. However, in this case there was a private carer arrangement, funded and organised by the family. This requires an individualised approach by the service to co-ordinate the care with families to meet specific requirements of the patient. The service has reviewed how it works with families in these circumstances and going forward there will be a discussion with the family and the nurse caring for the patient on this. The plan of care and working together will be agreed with the family and service and will be clearly documented in the electronic patient record care plan.

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This will be monitored on a regular basis by the senior nurses and included in future case note audits and caseload reviews.

I hope this information provides you with assurance of the actions the Trust has taken and continues to take to ensure that the Regulation is met.

Please do not hesitate to contact me if you would like any further information.