Dear Ms Mutch

Mrs Evelyn ROSS (deceased)

I am writing on behalf of Sir in response to your Regulation 28 Report sent to Manchester University NHS Trust (‘the Trust’) on 27 April 2020. Your report related to the death of Mrs Evelyn Ross at Trafford General Hospital on 23 September 2019 and whose Inquest was held on 13 March 2020. We would like to express our condolences to the family of Mrs Ross for their loss.

Trafford General Hospital is part of the Trust’s Wythenshawe, Trafford, Withington and Altrincham (WTWA) site.

I understand that you concluded that Mrs Ross died following complications from surgery contributed to by a fractured neck of femur and anticoagulation. After hearing the evidence at Inquest, you have raised the following matters of concern.

1. The Inquest was told that the ward in question had been short staffed for a number of months. As a result, there was a reliance on agency staff and less experienced staff. The Trust was now seeking to resolve the issue, but it was still not fully resolved. It reflected a wider issue of a national shortage of nurses.

2. The Inquest was told that whilst Mrs Ross was medically fit for discharge prior to 01 July she had not been discharged because of delays in arranging a suitable care package to support her in the community.

3. During the course of the Inquest the documentation relied on by the Trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.

4. The Inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross.

5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.

I have sought to address each of your matters of concern in turn below.

1. The Inquest was told that the ward in question had been short staffed for a number of months. As a result, there was a reliance on agency staff and less experienced staff. The Trust was now seeking to resolve the issue, but it was still not fully resolved. It reflected a wider issue of a national shortage of nurses.

Recruitment of nursing staff both registered and unregistered has in the past proven an ongoing challenge for a period of time at Trafford General Hospital however, some significant positive progress has been made in this regard.

Since April 2019, a number of International Recruitment (IR) Registered Nurses have been recruited to wards at Trafford General Hospital in addition to successful domestic recruitment to Registered Nursing posts across Trafford General Hospital. A substantive appointment was made for a new Ward Manager that joined the team in January 2020, in addition four experienced Band 6 Registered Nurses have been appointed to Ward 6 specifically. A Band 3 Patient Flow Coordinator role has also been developed and successfully appointed to on Ward 6.

The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine nurse staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and January 2020. The outcome of this data collection was utilised to inform the establishment review process, which was completed for Ward 6 in March 2020. Further workforce redesign is being progressed collaboratively with Therapy Leads for Ward 6, to reflect the requirements of the rehabilitation service at Trafford General Hospital. Roles for Nursing Associates, Trainee Nursing Associates and Aspirant Nurses are currently being utilised and incorporated into the wider workforce planning across Trafford General Hospital services.

In March 2020, ward establishments at Trafford General Hospital were reviewed, this was completed for Ward 6. The outcome confirmed the requirement for additional Nursing Assistants, which has gone through an approval process and these posts are currently being actively recruited to. Ward 6 is currently fully recruited to the required nursing establishment for Registered Nurses and has no vacancies. The Senior Nursing Leadership team at Trafford General Hospital continuously monitor staffing levels, and redeploy staff as required to ensure safe staffing levels are maintained.

Prior to Mrs Ross’ admission, in April 2019 a new Head of Nursing commenced at Trafford General Hospital, who has undertaken and completed a review of the nursing leadership structure. These include changes to areas of responsibility and line management, and further appointments made to the post of Lead Nurse in addition to four Matron posts. To further strengthen the Senior Nursing Leadership team at Trafford General Hospital, a Matron for Quality Improvement and Patient Safety has been appointed on a 12-month secondment. This has established a new experienced Senior Nursing Leadership team at Trafford General Hospital, supporting a robust professional governance structure, providing clear lines of assurance and accountability directly to the WTWA Director of Nursing.

Induction for new recruits is provided on the Trafford General Hospital site, and the Head of Nursing now supports this with the welcome and introduction session. This provides an additional opportunity for staff to engage with Senior Nurses who give feedback and provide ongoing support.

Ward Managers’ roles have been realigned to allow for increased clinical time (15 hours’ management time and 22.5 hours’ clinical time per week) and therefore also provide more visible clinical professional leadership for ward teams, patients and visitors.

As detailed in the witness evidence of Matron , due to deployment of NHS Professionals temporary staff at Trafford General Hospital to supplement substantive staff levels, a local induction has been developed for each clinical area. This is to ensure that staff who are unfamiliar with the ward are given an overview of the expectations, their roles and responsibilities.

A review of the skill mix and roles and a Training Needs Analysis for the Out of Hours team has also been undertaken. This is to ensure that the clinical contribution is maximised, and the correct level of professional leadership is provided to teams at Trafford General Hospital in the out of hours period.

The Matrons, Lead Nurse and Bed Managers meet three times a day to plan deployment of staff and highlight any concerns that require escalation across the site to support the ward nursing teams. Senior nursing colleagues have reiterated to all nursing staff the clear process of escalation of any concerns, if they require any additional support from the Senior Nursing Leadership team.

Extensive work has been undertaken at Trafford General Hospital under the new leadership team in respect of recruitment of substantive staff; and notable improvement in staffing levels have been made. Unfortunately, nurse recruitment and workforce supply continue to be an issue of national concern across the NHS. The Trust however continues to focus efforts on ensuring the recruitment and retention of staff in accordance with patients’ clinical need.

2. The Inquest was told that whilst Mrs Ross was medically fit for discharge prior to 01 July she had not been discharged because of delays in arranging a suitable care package to support her in the community.

As detailed in the evidence you heard at Inquest, whilst Mrs Ross has been deemed medically fit for discharge, she required a review by the Mental Health Liaison Service Rapid Assessment Interface and Discharge (RAID) team, and a package of care to enable discharge from hospital to take place. I understand that on 24 June 2019 Mrs Ross was referred to Ascot House, a service provided by Trafford Council, which is an intermediate care community assessment centre for older adults that also provides rehabilitation. Mrs Ross was however declined admission by Ascot House due to additional care needs. The necessary notification (Section 5) was submitted by the Trust to Social Services on 01 July 2019, as the indicator that Mrs Ross was medically fit for discharge from hospital to the relevant Social Services provision; to trigger the response from Social Services to ensure services were set up and in place to allow for discharge from hospital.

In line with usual practice in secondary care, patient discharges from hospital are in some cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions by other bodies such as Local Authorities; for instance assessments in respect of any ongoing package of care required in the community, as well as other bodies in the Social Care sector. It is the Trust’s responsibility to undertake such liaison where applicable to ensure arrangements are in place so that the Trust can effect a safe patient discharge to the community. Given the Trust’s dependence on other parties in respect of this, delays can occur, and this is unfortunately an NHS-wide issue not unique to our Trust. Safe discharge requires teamwork across many people and organisations.

In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local ‘Discharge Policy for Adult Inpatients (excluding Children and Maternity)’, implemented May 2019, a copy of which is enclosed (Appendix 1). At the Trust’s WTWA site this policy is overseen by the Integrated Discharge team. The policy is applicable to all Trust staff who are involved in the assessment, planning and monitoring of patient discharges. It also applies to staff from other health/social care organisations involved in the discharge

process. The purpose of the policy is to support a well-organisation, safe and timely discharge for all adult patients.

The discharge policy acknowledges that the planning of patient discharge should be a process and not an isolated event, and hospital discharge plans should be established at the earliest opportunity in order to ‘identify factors that may impact on efficient discharge’ (DH 2010). To ensure a safe hospital discharge to an appropriate setting, the Trust discharge policy requires that a discharge plan should be well-defined, comprehensive and agreed by the patient or their carer. The discharge policy also requires effective communication at every stage of the discharge process between the Multidisciplinary Teams (MDT) and the patient or carer/s, identifying factors that may impact on their discharge and ensuring that each review and update has been discussed and conveyed to all associated parties. Therefore, where discharge is on hold, for instance pending In- reach Psychiatric or Social Services assessment of the patient; the patient, their carers where relevant and families are kept informed at each and every appropriate stage.

Weekly length of stay meetings are held with the MDT where all patients planned for discharge are reviewed. This is documented in the Electronic Patient Record (EPR) to aid effective communication between professionals, patients and their families. MDT daily board rounds are held in each ward, to review patients’ estimated date of discharge and to ensure that the ‘SAFER’ standards are applied. The SAFER patient flow requirements re that senior reviews are undertaken for all patients before midday by a clinician able to make management and discharge decisions, all patients will have an expected date of discharge and clinical criteria for discharge set by assuming ideal recovery and assuming no unnecessary waiting. The flow of patients is to commence at the earliest opportunity, early discharge is effected where possible, appropriate and safe, and there is a systematic MDT review of patients with extended lengths of stay (over seven days), with a clear objective of promptly discharging patients where they are medically fit for discharge and discharge from hospital can be safely effected.

As stated above, a Patient Flow Coordinator role has been developed and successfully appointed to Ward 6 at Trafford General Hospital. In addition, the Hospital Discharge Service is available and responsible for supporting wards in the discharge process of patients, and their input is routinely sought for instance in respect of patients who require special considerations or who may have complex support needs on discharge. The discharge service will assist the ward staff to plan and identify the supporting needs of the patient for discharge.

The Trust discharge policy requires that timely referrals are made to other specialist teams or services as necessary to formulate comprehensive diagnostic, treatment and discharge plans. The Ward Manager is responsible for ensuring that an effective discharge planning process operates on the ward and is required to attend the length of stay meetings to discuss any discharge issues. The Ward Manager is also required in accordance with the policy to inform the Ward Matron of any issues which are impacting on the effective discharge of patients from their ward.

Whilst some patient discharges are classed as ‘simple discharges’, some cases given the nature of issues involved may be classed as ‘complex discharges’, in line with the policy. The nature of the discharge will have a bearing on the process of discharge planning. Complex discharges are defined as patients who will be discharged either home, to intermediate care, or to a nursing or residential care home, and/or who have complex ongoing health and social care needs, which require detailed assessment, planning, and delivery by the MDT and multi-agency working; these are patients whose length of stay in hospital is more difficult to predict.

In respect of the specific reviews awaited in Mrs Ross’ case, given that as highlighted above both In-reach Liaison team review was mandated and an assessment/rehabilitation

centre placement was declined by the Local Authority; in order for the clinical team to progress her discharge, as I am sure you will appreciate, there was a limitation on further actions the Trust was able to take to address this issue, due to its dependence on actions by In-reach, Social Care and other bodies.

Mrs Ross’ discharge was complex, and I am assured that all meetings and reviews for discharge could be safely effected.

The Trust’s discharge policy highlights the need to minimise unnecessary delays in the discharge process and ensure length of stay is determined by clinical need. Unfortunately, in Mrs Ross’ case, whilst discharge plans were being arranged, her clinical condition changed such that she was no longer deemed medically fit for discharge and required a prolonged hospital admission to tend to her acute care needs.

3. During the course of the Inquest the documentation relied on by the Trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.

I am sorry to learn that you consider the Trust’s clinical notes lacked in detail and apologise if the evidence you heard was not able to reflect the progression of Mrs Ross’ condition and the clinical decision-making around this. I confirm these concerns have been raised with the relevant members of the clinical team involved in Mrs Ross’ care and the Inquest.

The Nursing and Midwifery Council’s ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associations’ (2018) and the General Medical Council’s ‘Good Medical Practice’ (2013) set out the expected professional standards and responsibilities around clinical record keeping. Suffice to say, all Trust clinical staff are of course required to adhere to these fundamental tenets.

Additionally, the Trust has its own local policy in respect of clinical documentation and record-keeping, which sets out the core clinical standards required for record keeping along with best practice guidelines relating to paper and electronic records.

The Trust’s health records management policy also emphasises that health records are essential for delivering quality and safety of care and highlights the legal obligations and responsibilities of individual staff members to comply with the requirements of health records legislation.

Training is provided to all clinical staff in respect of documentation in clinical records. As part of the mandatory induction of all staff, Trust training is provided in respect of Information Governance, which covers accurate and clear record keeping. This is also covered in the mandatory training updates which all staff are required to undertake every two years. All staff also receive a local induction in their own area of work which comprehensively covers all areas of documentation and records keeping relevant to the individual staff member’s role. The Trust retains records of all staff training undertaken Trust-wide, including mandatory training.

Ward 6 Nurses have now completed extensive competency-based assessments relating to all aspects of nursing care, and standards of documentation have been reviewed and signed off by a Senior Nurse.

The monitoring of performance in maintaining professional standards in respect of good clinical record keeping is undertaken by way of regular audits of clinical records. At Trafford General Hospital ward-specific documentation audits are undertaken monthly by the senior team on the ward and periodical/spot-check audits are completed by the Matron for Quality Improvement and Patient Experience, to provide a real time understanding of compliance. Any areas of non-compliance identified via audit are discussed with staff proactively to

promote shared learning and address any omissions in the required standard of care around clinical documentation.

As of April 2020, the Matron for Quality Improvement and Patient Experience’s compliance audit for falls risk assessment completion and falls care plan implementation was 90%. Hot Topic Sessions covering falls risk reduction and management have been launched in June 2020. So far this month across Trafford General Hospital 30 members of staff, including six members of staff from Ward 6, have attended the training, with several further sessions to take place this month to capture further staff.

4. The Inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross.

As detailed in the nursing witness evidence you heard at the Inquest, Mrs Ross was identified as presenting as a falls risk, and the ward staff discussed with Mrs Ross’ daughter and son on 31 May 2019 the decision to move her to a bay tagged area so that she was visible at all times. during the weekly risk assessment updates however, whilst it was noted that Mrs Ross was still deemed to be a falls risk, reviews of the care plan were not completed every 24 hours as required. Mrs Ross however did continue to receive regular observations, she was nursed in a cohort bay, and she was mobile with a zimmer frame and the assistance of one person. Falls risk reduction measures were in place in accordance with falls care plan actions.

When a nursing review of Mrs Ross’ care was undertaken prior to the Inquest, it was identified that the individualised additional interventions section of the falls care plan were not reviewed every 24 hours. It was noted however that at the time there was a discrepancy in the Trust falls policy which did not specifically refer to a requirement to undertake this, and document this review every 24 hours. Subsequently, the Falls Specialist Nurse was made aware of the discrepancy in the falls policy. This amendment to the policy has been incorporated with further updates to the policy (to reduce the need for multiple policy revisions being shared with staff intermittently, and to provide one comprehensive update). These changes are due to be ratified by the Trust’s Professional Board following which the updates will be presented to the Manchester Falls Collaboration and disseminated across the Trust.

As part of the Monthly Matron Review proforma, a sample of patient assessments are audited to monitor the ongoing completion of Falls Risk Assessments. Results of these audits are highlighted at the Monthly Matron Confirm and Challenge meetings with Ward Managers.

Training is provided to all clinical staff in respect of falls management. The current compliance rate for Ward 6 staff for falls e-learning training is 83%. This compliance rate will increase once staff members who are currently absent due to sick leave return to work and are able to complete the training.

Prior to Mrs Ross’ admission, the Trust had recently, in April 2019, implemented a new Trust-wide updated Falls Management Policy and I enclose a copy of this for your information (Appendix 2). I am very sorry to hear that there was evidence that aspects of the falls policy were not adhered to in Mrs Ross’ case.

I confirm that a clinical walk round was completed at Trafford General Hospital prior to the implementation of the new policy. This included the Specialist Falls Nurse and a Matron attending each of the clinical areas and wards, promoting the new documentation. The Specialist Falls Nurse and Clinical Educator completed further sessions delivering the revised paperwork and launching the policy. The implementation of the new policy was also published in the Trust-wide communications news brief. It was disseminated at Ward Manager meetings and Ward Managers were tasked with cascading the policy and new

paperwork to staff at the daily safety huddles. From May 2019, falls education sessions were held at Trafford General Hospital, enabling staff to ask questions about the new policy and paperwork and talk through the new algorithm. Face to face training and support has continued in addition to the provision of interactive e-learning training around falls, mandatory for all clinical staff and required to be completed every three years.

Trust-wide audit work is undertaken to ensure compliance with policies such as that in respect of falls management in order to measure the effectiveness of the new policy. There is also a programme of annual Ward Accreditation in place, which includes review of standards of documentation, including completion of falls risk assessments and adherence to the policy.

Specifically, in relation to falls risk assessments, the updated falls policy includes a new risk assessment tool, which was launched at Trafford General Hospital in April 2019. There are weekly audits of falls risk assessments in ‘hot spot’ areas, which assess completion and accuracy. Audits are ongoing and subject to scrutiny by the Trust’s Leadership team.

In April 2019, Trafford General Hospital launched a new electronic patient record system called Chameleon, onto which all inpatient risk assessments including falls assessments are entered.

In addition to the updated policy prior to Mrs Ross’ admission, in March 2019 the Trust established a multidisciplinary Task and Finish Group dedicated to addressing the issue of inpatient falls at Trafford General Hospital. This initiative was led by the Head of Nursing for the WTWA Division of Medicine. The team developed an overarching Action Plan for Trafford General Hospital as well as a specific Action Plan for Ward 6. The Task and Finish Group met fortnightly to guide, progress and document the actions taken. The Group comprised the site Head of Nursing, Lead Nurse, Matrons, Ward Managers, Physiotherapist, a governance manager and clinicians. The Task and Finish Group oversaw the implementation of actions identified in the Action Plans and this work has been incorporated into the work streams of the WTWA Falls Task and Finish Group. Each individual Ward Manager has been provided with a checklist to support falls risk reduction, as well as falls reduction and management prompts.

In order to strengthen its governance, accountability and assurance framework, in January 2020 the Trust established a Quality and Patient Safety Group at Trafford General Hospital to lead the development and implementation of an overarching quality improvement and transformation programme. The Group is chaired by the WTWA Deputy Chief Executive/Director of Finance in order to oversee the delivery of Trafford General Hospital’s Quality Improvement and Transformation Programme and Quality and Patient Safety objectives. The Group reports directly to the WTWA Quality and Patient Safety committee, in addition to the Hospital Management Board. The Group has patient safety and quality improvement objectives, aiming to have a measurable impact by way of positive outcomes for patients, carers and their families. The Group’s progress is monitored and measured against agreed key performance indicators. The single overarching quality and patient safety improvement plan developed for Trafford General Hospital includes actions relevant to all wards and departments, as well as specific actions relevant to individual areas. Key lines of responsibility have been identified to ensure progress. The Group has resumed meetings monthly from June 2020, after usual business was paused by necessity due to the Trust’s emergency response to the COVID-19 pandemic.

In addition, a Quality and Patient Experience Matron post has been seconded to Trafford General Hospital for 12 months, in order to prioritise and monitor patient feedback, incident themes, training and supporting the implementation of ward-specific Improving Quality Programme (IQP) projects. The Matron has for instance overseen the development of the above-referenced Training Needs Analysis document specific to staff on Ward 6 at Trafford General Hospital, to identify and prioritise ongoing staff training and development. IQP

projects are identified throughout the year as part of the Trust’s commitment to continuous improvement.

The Manchester Falls Collaborative has an overarching work programme, underpinned by hospital-level falls work plans. The WTWA site has a Falls Work Plan in place for the period 2019-2022, which Trafford General Hospital is monitored via the monthly Quality and Patient Safety Committee.

Falls resulting in patient harm are presented to the monthly Falls Accountability meeting. Thematic analysis is considered in order to establish learning arising out of patient incidents in respect of falls and to implement preventative measures to improve patient safety.

In addition to thematic analysis of falls resulting in patient harr across the WTWA site, the Trafford General Hospital Senior Nursing team hold weekly Harm-Free Care meetings where each Ward Manager presents their ward’s patient falls from the previous week. This process provides assurance that all falls, including falls resulting in no harm, are investigated and managed appropriately. For the WTWA site, the majority of all falls have been found to have been unavoidable from January – April 2020. If a fall is found to have been avoidable, actions and lesson learning are discussed at ward level with all staff. The outcome of the Harm-Free Care meeting is recorded onto the Trust’s Ulysses risk management system for ongoing monitoring of compliance with required clinical standards.

Work is underway with the WTWA Falls Specialist Nurse, Matron for Quality Improvement and Patient Experience at Trafford General Hospital and the Practice-based Educator team to implement an additional condensed training package at Trafford General Hospital, using the ‘Hot Topic’ awareness scheme for falls in June 2020. This supplementary training commenced on 16 May 2020 at the Wythenshawe Hospital site and comprises discussion of Trust falls policy and risk assessments, background information on falls such as prevalence and the human cost of falls, risk factors in relation to falls, practical falls risk reduction measures, and post-fall care including an in-depth run through of the post-fall algorithm, completing a post-fall action record and incident reporting. It is intended that this additional training package will be rolled out at Trafford General Hospital following on from work already embedded by the Matron for Quality Improvement and Patient Experience.

A number of initiatives are already in place at Trafford General Hospital to ensure oversight of falls across the hospital including Matrons/Lead Nurse completing their enhanced care reviews three times per week as per policy, live documentation audits, relaunching the Bay Tagging initiative on hot spot areas and firmly challenging staff who do not adhere to policy, quality improvement projects in relation to intentional rounding and increased daily senior nursing on clinical areas to ensure correct adherence to Enhanced Observations of Care Policy and proper use of falls sensor equipment.

In addition to these assurance processes, senior nursing teams across WTWA are being asked to relaunch both the Staff Competency Checklist for the Risk Reduction and Management of Inpatient Falls, and the Falls Risk Reduction and Management Prompts, to ensure staff feels comfortable and confident in falls risk assessment and care planning; and that additional training needs are highlighted appropriately. This process also allows for staff managing individuals involved in falls incidents to consider their competency level and ensure guided reflection is appropriately provided.

The Trust’s WTWA site continues to progress with the harmonisation and streamlining of all falls management processes and procedures. The Trust is committed to providing har free care for patients identified to be at risk of falling. The Trust leads the multi-agency Manchester Falls Collaborative, which enables learning and evidence-based best practice to be shared and is committed to ensuring delivery of its falls work programmes.

5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.

The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily at the morning Board Rounds and all patients are discussed and followed up to Consultant level as needed. If clinical concerns are raised in respect of an individual patient’s case, a member of the Senior Medical team (Consultant or Registrar) will review the patient.

In respect of review of specific patients, as detailed in the Consultant witness evidence that you heard at the Inquest, Consultant reviews of individual patients take place at twice- weekly MDT meetings, which are led by the Consultant in Care of the Elderly. At each MDT meeting, half the patients on the ward are discussed under their named Consultant. In addition to this, any unwell patients or concerns of the clinical team regarding any ward patient are discussed i.e. irrespective of whether the MDT is being led by the patient’s named Consultant.

The junior doctors and clinicians who undertake the daily patient assessments/reviews are aware of the requirement to escalate to Consultant level in respect of specific clinical factors or potential areas of concern. Consultants are contactable by telephone in the event that junior doctors on the ward have any concerns about patients. In the absence of one of the two leading Consultants for Ward 6, the other Consultant provides cover for patients. If a Consultant is not available on-site due to other commitments, such as clinical commitments at one of the Trust’s other hospitals, the on-call team as well as the Consultant of the week is immediately available to review any unwell patient.

Having undertaken a comprehensive review of the entries in Mrs Ross’ clinical notes, the Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case there were in fact regular Consultant reviews, in line with required standards, and there was no issue in respect of junior doctor escalation, which as documented in the clinical notes took place as required. I apologise if the evidence you heard at the Inquest did not accurately convey this.

We hope that the above provides you and Mrs Ross’ family with assurance in respect of the matters of concern you had raised. The Trust is committed to ensuring patient safety is our priority. If you require any further information, please do not hesitate to contact us.

Dear Ms Mutch,

Thank you for your letter of 27 April 2020 to Matt Hancock about the death of Evelyn Ross. I am replying as Minister with responsibility for patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Ross’s death and I extend my sincere condolences to Mrs Ross’s family and loved ones on their loss. It is important that we take the learnings from Mrs Ross’s death so that people continue to receive the highest quality care from the NHS.

Your report raises several matters of concern relating to the care received by Mrs Ross while at the Trafford General Hospital. I am advised that the Manchester University NHS Foundation Trust has provided a detailed response in relation to these concerns. I understand this includes information about the improvement in nurse staffing levels; the Trust’s hospital discharge, falls management and clinical record policies; and arrangements for the review of patients by consultants in the Care of the Elderly.

My response will focus on the actions being taken at a national level that are relevant to the concerns you have raised about the nursing workforce, falls prevention and delayed transfers of care.

Individual NHS Trusts are responsible for the number and type of staff they employ and they must ensure that there are sufficient staff and that those staff are trained and competent to carry out their duties. This applies equally to the usage of agency staff, which is a local decision for individual employers.

At a national level, it is acknowledged that whilst the deployment of a flexible workforce is an important element of efficiently running the NHS, recruitment agencies are expensive, and it is crucial that we continue to reduce unnecessary expenditure on agency staff in the NHS. In 2015, the then Secretary of State, Jeremy Hunt, announced the introduction of several measures to reduce agency spend, including price caps, procurement frameworks and expenditure ceilings.

We recognise that to fully eliminate unnecessary agency spending, the Department and the NHS need to support trusts in developing a viable alternative source of flexible staffing in the form of in-house Staff Banks. Having reduced the rate of agency spending, we are now entering a new phase of work, focusing on the creation and improvement of staff banks, wherein existing NHS staff, who choose to work flexibly, can do so through an NHS owned bank, as opposed to a privately-owned agency. In the context of staff shortages in the NHS, in-house staff banks, and especially collaborative banks, create a larger pool of flexible staff, ensuring better quality and continuity of care, and reducing unnecessary agency spending by avoiding expensive commission.

In terms of the health and care workforce overall, Health Education England (HEE) provides leadership for the education and training system at a national level. HEE ensures that the workforce has the right skills, behaviours and training, and is available in the right numbers.

The NHS published the Interim People Plan1 in June 2019 that sets out the long-term vision and immediate actions to meet the challenges of workforce supply, reform, culture and leadership. Publication of the final NHS People Plan has been deferred so that the NHS is able to devote its full operational effort to the COVID-19 response. However, when published, the final NHS People Plan will set out further actions to secure the NHS staff we need in the future.

Ensuring the NHS has the staff it needs, especially our nursing staff who are the absolute bedrock of the NHS and care system is, and will remain, a priority for the Government. We are making progress on this and at a national level we have seen an increase of 19,398 (6.9per cent) since March 2010 in the number of nurses and health visitors to March 2020

However, we of course accept we need to do more and that is why on 18 December 2019, the Government announced a commitment to deliver 50,000 more nurses in our NHS by
2025. We will do this through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS.

This Government has already taken steps to deliver this commitment through our recently announced financial support package for eligible students. Eligible pre-registration nursing, midwifery and most allied health professional students on courses at English universities from September 2020 will benefit from grants of at least £5,000 per academic year. There will be up to £3,000 additional funding for some students to help with childcare costs or who choose to study in regions or specialisms struggling to recruit, including with priority given to shortage groups that are key to delivering the NHS Long Term Plan2. None of this funding will have to be paid back.

In relation to the delay experienced by Mrs Ross who, you explain in your report, was clinically ready to leave hospital but could not until care arrangements were in place, we are clear that no one should stay in hospital longer than necessary. Doing so removes

1 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf

2 https://www.longtermplan.nhs.uk/

people’s dignity, reduces their quality of life, leads to poorer health and care outcomes and is more expensive for the taxpayer. For older people in particular, longer stays in hospital can lead to worse health outcomes and can increase their long-term care needs. We know that for people aged 80 years and over, ten days in a hospital bed equates to ten years of muscle wasting.

Despite the NHS being busier than ever before, with hospital admissions rising by 18 per cent from 2009/10, the majority of patients are discharged quickly. The average length of stay has fallen from 5.6 days in 2009/10 to 5.0 days in 2018/19. The NHS and social care services have been working hard to reduce delays and free up beds and since February 2017, 1,798 beds per day have been freed up nationally by reducing NHS and social care delays.

It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. Discharge arrangements from hospital should start before a patient is ready for discharge and the hospital should involve local social services at the earliest opportunity to plan post- discharge care and avoid delays.

The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.

During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.

Finally, with regard to falls prevention, the National Institute for Health and Care Excellence (NICE) has published a clinical guideline on Falls in older people: assessing risk and prevention (CG1613) that includes guidance on preventing falls in older people during a hospital stay. The guideline says:

1.2.2.1 Ensure that aspects of the inpatient environment (including flooring, lighting, furniture and fittings such as hand holds) that could affect patients' risk of falling are systematically identified and addressed

3 https://www.nice.org.uk/guidance/cg161

This recommendation would apply to wards, toilets and other parts of the hospital. The guideline recommends that for patients at risk of falling in hospital, an assessment of the patient’s individual risk factors should be conducted and where necessary, appropriate intervention put in place. NHS trusts are expected to take account of NICE guidelines when planning care.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

NADINE DORRIES