Dear Yvonne

I understand how busy your department is at present and have attempted to contact you several times by telephone. I had wanted to discuss this matter with you before putting it in writing, but given the difficulties with the telephone system I wanted to ask if you would be able to telephone me so we can discuss it further. My number is

.

I am writing to express some concerns and to request your review of the evidence regarding the inquest held for Mr Michael Yemm on Tuesday 2 February 2021.

You will be aware that a Regulation 28 report to prevent future deaths has been issued to Norfolk County Council. However, I note that Norfolk County Council was not asked to provide a report for the Coroner about our involvement with Mr Yemm, nor to contribute to the inquest in any way.

There are a number of points I would like to raise with you regarding this matter from the perspective of Norfolk County Council’s Adult Social Services Department, and to ask that you would re-examine the evidence using the information received by Adult Social Services from the Norfolk and Norwich University Hospital (NNUH).

You may be aware that in March 2020, the Department of Health and Social Care published guidance requiring hospitals and local authorities to work together to implement new Discharge to Assess (D2A) arrangements.

COVID-19 Discharge Service Requirements (March 2020, HM Government/NHS) Hospital Discharge Service: Policy and Operating Model (August 2020, HM Government/NHS)

D2A is a concept whereby patients are transferred from acute hospital at the point where they no longer require acute hospital care through one of three pathways; either

at home with support (pathway 1), in community based sub-acute bed with rehabilitation and reablement (pathway 2) or in a care home sub-acute bed with recovery and complex assessment (pathway 3). Thereafter any further health or social care assessments are delivered outside of the acute hospital environment. There is a focus on the hospital’s integrated discharge team who work with the ward to assess and define health care needs in order to identify which pathway it is most appropriate. At the point of discharge, care is fully funded by the NHS.

1) Mr Yemm was placed into a totally unsuitable and unsafe residential setting

On 24 May 2020, Adult Social Services was contacted by a member of the ward staff at Langley Ward, NNUH, advising that Mr Yemm required ‘Support following hospital discharge. Unplanned admission to NNUH. Short term 24 hour residential support required while delirium resolving.’ Mr Yemm had been placed on D2A pathway 2. Norfolk County Council is not able to place people in nursing home care without a nursing needs assessment carried out by a health professional. We were advised by health professionals that nursing care was not needed at this time and residential placement was sourced at Melton House, in line with the hospital’s assessment.

As you are aware this placement broke down and Mr Yemm was readmitted to NNUH on 26 July 2020 following a fall. On 4 August a referral was received by Adult Social Services advising that Mr Yemm was now on the Discharge to Assess pathway 3 and required enhanced nursing care. It was noted at this point that Mr Yemm’s delirium had resolved which raises a question about why a lower level of care had been requested by the hospital in May.

A total of 31 nursing homes were contacted but none considered that they would be able to meet Mr Yemm’s needs.

On 2 September 2020, on receipt of Mrs Yemm’s letter, the CCG agreed to fund a bed in a neurological unit. I suggest the need for a neurological specialist bed was evident prior to the initial discharge, as the behaviours were apparent at this point and an issue on the initial discharge.
2) Mrs Yemm wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply

A letter has been identified which Mrs Yemm shared with the community response team social worker. The community response team social worker shared this with her senior managers and at that point the meeting was called with the CCG on 2 September 2020.

Mrs Yemm’s letter was not escalated to as it was received by the community response team and as a consequence, the matter was escalated appropriately and led to action by the CCG for an appropriate placement to be sourced and funded.

This case highlights a known issue where people with highly agitated behavioural needs due to dementia or other health conditions, whose needs are outside of the ability of registered dementia nursing homes to care for the needs being displayed. This is evidenced in that 31 homes were contacted and yet no placement was available

because the nursing homes were unable to meet Mr Yemm’s level of need. Until the CCG agrees to fund a specialist neurological placement, adult social care is not able to source a placement with a higher level of care. It was not until Mrs Yemm complained that her husband’s needs were assessed for specialist provision by healthcare services.

I would be grateful if you would give this matter your attention and consider reviewing the evidence taking account of information shared by Norfolk County Council. It would be most helpful if you would be able to contact me by telephone to discuss this further.

Kind regards

Director of Community Social Work

Dear Ms Blake Response to Regulation 28 report Death of Michael Yemm

am writing in response to the above Regulation 28 report (Report) that received on 10 February
2021. hope that this letter and the accompanying documents will satisfy you and Mr Yemm's family that the matters of concern raised in the Report have been carefully considered by the Trust and appropriate action has been or is being taken. The Report raises three matters of concern The Trust's response in relation to each one is set out below. 1_ The care home placement Mr Yemm was admitted to the Trust on 24 2020 and discharged on 17 June 2020 to Melton House Care Home_ Mr Yemm was discharged on a D2A3 (Discharge to Access) pathway for short term community bed for the assessment of his long term needs_ was involved in the discharge planning arrangements. It was initially hoped Mr Yemm could be discharged home with package of care_ However his increased needs and falls risk meant a short term community bed was the most appropriate option: Irequested bed close to home A referral was raised on 10 June 2020 suggesting Residential/Nursing home The placement at Melton House was sourced by Social Services and confirmed on 15 June 2020. Mr Yemm was readmitted on 18 June 2020 from Melton House following a fall, Concerns were raised by Mr Yemm's Community Care Nurse about the suitability of Melton House due to a lack of adequate supervision: new D2A3 discharge referral was raised on 23 June 2020. The referral states: "Please assess for short term bed. Wife wishes to be involved in planning as feels Morton House [sic] was unsuitable. It was subsequently agreed that Mr Yemm could be discharged back to Melton House but with 1:1 supervision funding for 2 weeks_ This was to allow time for the needs May

assessment to be undertaken. Social Services has confirmed the 1:1 supervision was provided but is unable to provide any information about arrangements beyond the initial two week period_ Mr Yemm was readmitted again on 26 July 2020 Melton House following another fall and with urinary tract infection. Melton House informed the Trust it was unable to meet Mr Yemm's needs. A further D2A3 discharge referral was therefore made on 29 July 2020. The referral states that: "He is unable to return to Melton House as they are unable to manage his falls risks and unable to manage his diabetes, Unfortunately, Mr Yemm deteriorated and new fast track referral was completed on 16 September 2020_ This referral stated that: "patient was in residential care are no-longer able to meet his needs SO requires new placement". Sadly , however; Mr Yemm passed away in hospital 2_ The hospital discharge despite being told couldn't send him back; and just leaving him there The Report states that: "The hospital dropped Mr Yemm off back at the care home without any warning after being informed that could not have him back He was also discharged on insulin which the home could not administer as they do not have trained nursing staff It also states that: 'After his second admission the manager of the care home told the hospital that would not accept him back as his needs could not be met by them. Despite this without notifying the care home, Mr Yemm was dropped off by hospital transport and the home had no option but to keep him as he was left there. did manage to obtain extra help, but his care needs increased, and he was again admitted to hospital. Mr Yemm was started on insulin during the 2020 admission. A District Nurse referral was made on discharge as Mr Yemm was unable to manage his own injections On 17 June 2020 verbal handover"' was given to Melton House including confirmation that the District Nurse referral had been completed in respect of Mr Yemm's "insulin administration" After Mr Yemm's admission on 18 June 2020, the Manager of Melton House was informed during discussions between 24 and 26 June 2020, that Mr Yemm was on long insulin and that the District Nurse would administer his regular doses_ It was also confirmed that 1:1 supervision had been requested and approved by Social Services Both land Melton House agreed the discharge to Melton House on this basis_ Mr Yemm's discharge was delayed pending the return of his Covid-19 swab test results Bothi and Melton House were notified that the discharge had been moved to 27 June 2020 and transport was arranged for 12.00 hours The Trust does not have its own non-emergency transport facilities, and all such transport is arranged via ERS Medical.
3. The in-patient fall and care of dementia patients from they they they they They May acting

Mr Yemm's fall on 3 September 2020 has been the subject of a Serious Incident (SI) investigation. confirm that work has been undertaken in accordance with the actions recommended in the Sl Action Plan attached to the Sl Report (see attached) , The relevant teams have also been notified of your concerns SO can ensure these are covered by the work being carried cut The relevant issues identified in the Action Plan are referenced below, together with details of the associated actions that have been undertaken: The patient was not referred to the Dementia Specialist Team There are number of actions being taken to address this issue: Ward Manager_ has issued reminder (see attached email) to all ward staff requiring them to ensure they are familiarlup to date with the "Memory Matters page on the Trust intranet which contains a range of educational resources; and (ii) Dementia awareness and DOLS training, both of which can be accessed via the Trust's online training facility (ESR) 2 Ward Manager hhas met with and organised ward based education sessions with the Dementia Support Team (DST) (see attached emails) Some ward based sessions have already been delivered via the Clinical Educator and this is ongoing: Arrangements are also being made for ward staff to spend a with the DST . 3 Funding is being sought for the implementation of ward based Dementia Support Worker post: Regular support is being provided to the ward by the DST in the meantime The Falls Risk and Safety Sides assessments are not adequate and require review The Falls Risk and Safety Sides assessments are under review as part of an ongoing project: has been working with Deputy Chief Nurse on the project. NICE compliant Falls Risk assessment has been trialled and final draft has been put together (see attached). The assessments and the associated policy are currently at the final adjustmentlreview stage_ It will then be question of implementing the roll out of the documents_ These presently form part of a risk assessment booklet which means complete roll out is dependent on other risk assessment documents being reviewed. There is no final completion date at the moment: Alongside the change in risk assessments, it is planned that there will be an education package to support staff through the changes and to recognise the multifactorial elements of falls prevention: The patient had a prolonged stay in hospital due to delay in acquiring suitable placement The Sl findings have been shared with the complex discharge team_ confirm that in addition the following steps have been taken to ensure that learning is shared as a result of the Sl findings: they day

The Sl learning was shared at the Endocrinology Clinical Governance for January 2021 (see attached slides)- was also shared in the Team Medicine Newsletter for February 2021 (see attached) and with the Governance leads via Divisional Governance in January 2021 (Agenda attached):
2) A ward newsletter was sent to all staff (see attached)- hope that this information provides you with the assurances you require that the Trust has implemented changes in practice and in place training to ensure that the risk of future deaths from similar circumstances will not occur again: