Dear Mrs Galloway Re Jean Williams _ inquest concluded 9November 2020 write to you confirming receipt of your Regulation 28 Report to Prevent Future Deaths, dated 16 November 2020, in relation to the death of Jean Williams, who sadly passed away on 19 November 2017 would like to extend my sincere condolences to Mrs Willlams' family In your letter you explain that during the Inquest; the evidence revealed matters giving rise to concern and that In your opinion there IS a risk that future deaths will occur unless action IS taken We have taken your concerns extremely seriously and we have carefully considered the concerns applicable to Blackpool Teaching Hospitals For those concerns, we have taken the following actions
1) Lancashire County Council do not currently have in place policy that any concernslissues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust And
2) The Occupational Therapy Team at the Trust; who are now correctly trained to fit and assess a patient for the use of the Bed Lever; are not _ at present routinely fitting the bed levers at Thornton House: In fact; there been a miscommunication that Bed Levers are no longer to be used at Thornton House: Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient Chairman Chief Exccutive RESEARCH MATTERS AND SAVES LIVES TODAY"'S RESEARCH IS TOMORROW'S CARE Blackpool Teaching Hospitals Is Cenlre of Clinical and Research Excellence providing quality Up to date care We are actively Involved In underlaking research to Improve treatment of our palients member of the healthcare leam may discuss current clinical trial With you disabilty confident| EMPLOYER City The has

NHS Blackpool Teaching Hospitals NHS Foundation Trust Although these concerns are not necessarily directed at Blackpool Teaching Hospitals, we were very keen to support our colleagues from Lancashire County Council (LCC) in making services for patients safer and meeting was held between our Trust ad LCC on December 2020 to address the concerns raised. In summary, the following agreements were made a) Bed levers are permitted for use at Thornton House An individual risk assessment must be completed by the prescriber for each patient; In with Blackpool Teaching Hospital's cross- prescriber training b) The 'deliver and fit' model will no longer be used for the provision of bed levers at Thornton House Prescribers will request delivery only and the bed lever will be fitted by the prescriber and the 'check completed in the presence of the patient: Should a patient bring thelr own bed lever Into Thornton House, the therapy staff with complete a risk assessment to ensure It IS fit for purpose and safe for use, prior to the bed lever being utilised The intermediate care team have been made aware of the above decisions at the meeting on 2 December 2020 C) LCC have advised that following the Inquest; the Thornton House daily risk assessment was updated and now specifies that the bed lever should be removed if any concerns are identified within daily checks The individual Identifying the concern IS responsible for removing the bed lever from use and contacting the Intermediate Care Team, to request a review by the prescriber patient's care plan is then to be updated to reflect the removal of the bed lever and Identify any increased support required to meet the patient's needs_ In addition to completion of our Interal action plan, which was part of the evidence submission for the inquest; and in order to drive wider professional learning; the Trust's Interim Chief AHP has also shared the findings of this very sad event; and your overall conclusions_ with senior Allied Health Professions (AHP) Leads across the Lancashire and South Cumbria Integrated Care System, at the monthly AHP Council meeting This will encourage system learning amongst senior AHP colleagues from different trusts across the Lancashire and South Cumbria iIntegrated Care System, who will undoubtedly introduce learning and improvements in their respective trusts where appropriate to do s0. hope that the above responses provide you with the assurance that we have taken your concerns extremely seriously and that we have taken appropriate actions to address your concerns, in order to prevent a similar event from occurring

Dear Ms Galloway,

Jean Williams – Inquest 3rd Nov – 9th Nov 2020

Further to your Regulation 28 report of 16th Nov 2020, I write with confirmation of actions taken by Lancashire County Council (LCC).

The safety of service users is of the utmost importance for LCC. We take your finding that there were matters giving rise to concern and your opinion that there was a risk that future deaths may occur extremely seriously.

A meeting was held between relevant staff members at LCC and Blackpool Teaching Hospitals (BTH) on 2nd December 2020, both parties agreeing the need to work together to address the concerns. The Council confirms the following actions in addressing your concerns:-.

a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).

The Occupational Therapist is responsible for the assessment of need for a bed lever which is undertaken with input from individual service users and considering their individual needs. The therapist will complete a prescription to the retailer on a deliver only basis. Only a trained member of the Occupational Therapy team can fit the bed lever and only with the service user present, to ensure it is relevant to their individual need. Risk assessments are undertaken at this time by both Occupational Therapy staff and LCC staff and support plans are updated to reflect the use of the bed lever.

Following the installation of the bed lever LCC staff check it is correctly positioned twice each day. Should it have significantly moved position the bed lever is removed until a time when a trained member of the Occupational Therapy team can refit it.

This process is detailed in the updated LCC document titled OP103 Bed Rails and Bed Levers Policy and Procedure, which governs the process and to which staff are trained. LCC staff will also ensure that new bed lever deliveries are not fitted until a trained member of the Occupational Therapy team is able to fit them.

Neither Mobility 2000 nor any other retailer will fit any bed levers.

These new arrangements were implemented week commencing 7th December 2020.

b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.

Following the hearing immediate action was taken to give guidance to staff on the escalation process. Our 'Bed Rail and Bed Lever Policy and Procedure' was already in place but that has now been updated, as referred to above, to make clear how concerns should be escalated and which staff/colleagues are to be made aware. This updated document is live as of 08 January 2021 and a further review will take place in April 2021 to ensure it is clear to all staff and has been appropriately implemented.

c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.

The miscommunication that suggested that bed levers are not used at Thornton House has been rectified and an agreement between LCC and BTH has been reached that bed levers can be used when appropriate to the resident's needs. As outlined at (a) above, further agreement was made that bed levers would be prescribed on a 'deliver only' basis and only fitted by a trained member of the Occupational Therapy team.

Further to the points raised, with regard to the incident at Thornton House, LCC have implemented the updated policies at all 16 LCC operated older peoples residential homes. I trust the information and confirmation of action detailed in this letter give you the assurances required that suitable action has taken place to rectify your concerns.

RESPONSE FROM MOBILITY 2000 LTD - JEAN WILLIAMS INQUEST

With regard to the fitting of bed levers in the absence of the patient this is likely to be because, on occasion, the equipment needs to be in place prior to the release of a patient from hospital. As the prescriptions are issued by LCC we will await their instruction of any changes to the current system. Our staff have always fitted the strap when installing the bed levers and they will continue to do so. We do occasionally purchase bed levers without a strap as some of our retail customers prefer them and they are still passed by the medical devices agency; however, these are not, and will not, be supplied via the tces system as the specification does not allow it. We have recently carried out further training with our staff on how to fit the levers and straps according to the manufacturer's instructions. Further action taken is to make sure a hard copy of the manufacturer's instructions is supplied with every bed lever. We await instructions from LCC with any change of policy regarding the timing of fitting the bed levers, since the incident involving Jean Williams. Finally, it should be noted that even in cases where Mobility 2000 Ltd have installed a bed lever we have no control of what happens to it once we have left the property. We know from past experience that the levers are often taken off beds for a number of reasons and subsequently replaced by someone other than ourselves.