Dear Ms Skerrett Mr_Jonathan Yates deceased am in reply to the letter dated 23 April 2019 from your Officer enclosing the Regulation 28 Report to prevent future deaths Thank you for agreeing to an extension of time to respond: The Trust has noted your outstanding concern as described in paragraph 5 of your Report_ namely, 'how the nutritional status of a patient, particularly when nil by mouth, is communicated effectively to staff caring for a patient during an admission: Assessment and management of nutritional status is a central element of caring for sick patients The Trust has an Adult Patient Nutrition policy to ensure that all patients receive appropriate and timely nutrition support during their admission: The policy sets nutrition quality standards, gives guidance on nutrition screening and the identification of patients at risk of malnutrition. However , the concern in this case arises from the failure on one occasion to use signage to safely and effectively communicate Mr Yates' nutritional status to the clinical team, rather than the assessment and management of his nutritional needs_ Effective communication of nutritional status is a fundamental element of clinical practice , and taught as part of professional training programmes. Within the Trust, communication of the nutritional needs of a patient is achieved through written records, verbal communication and the use of physical measures, and these follow the patient through their journey from admission to discharge. If the patient enters the Trust through the Emergency Department (ED) , the medical and nursing assessments will consider and record the nutritional needs of the patient at that early presentation, and how are to be delivered, These may be preliminary decisions, Katy writing they

intended to be reviewed later by the receiving medical teams if the patient is admitted to a ward. For Mr Yates; it was recorded that his PEG feeding device was broken, needed repair, and that he may be at risk of malnutrition until this was functional. Nutritional decisions made at this stage are available in the main ED medical record: Specific comments or instructions for the patient can also be noted in the ED handover document; used when admitted the patient to a ward, and for transferring information to the receiving clinical staff. When the patient moves from ED onto a ward; the written handover is accompanied by a verbal handover; between one qualified staff member to another. If a patient is subject to an internal move from one ward to another, specific internal handover document is available and this again is accompanied by a verbal handover between qualified staff For any move between clinical areas, the medical records will accompany the patient and can be referred to in handover discussions_ When a patient is admitted to a ward, nursing admission procedure is carried out before the patient is clerked (medically reviewed) by the doctor. If this is an internal move , the handover to the new will include details of the nutritional status for the patient as a specific handover item: If this is a new admission for the patient; the Gloucester Patient Profile (GPP) document will be used by the nurses to capture the condition and status of the patient on presentation to that ward. This includes an opportunity for a specific detailed nutritional review and includes scoring tool which screens for the risk of malnutrition. For new and internal transfer patients, the information passed to the receiving ward will form part of the whole ward handover information which is delivered to all ward staff, three times per day, at the beginning of each of the three shifts (early, late and night shifts) . During these handovers, any changes to nutritional status will be discussed, as will the maintenance of existing nutritional care programmes_ Further detailed handovers are often conducted in allocated ward areas (ie or single side rooms) between the outgoing staff member for that shift; and the incoming colleague for the next shift: On the admission of a surgical patient; the patient is assumed to be NBM until this is confirmed or changed by a doctor. Any patient who is nil by mouth (NBM) should be part of a robust safety handover On arrival on Ward Sb from ED, Mr Yates was known to be NBM, and the doctor was aware of this. In addition, a member of the nursing staff consulted a doctor about Mr Yates' continuing NBM status later that day, and this was confirmed. As a practice development; and to increase the quality of handovers, the Trust has recently introduced pilot of the 'safety huddle' concept on selected wards The aim of this daily event is enable an effective dissemination of patient safety information to the whole ward team; in a structured conversation. This looks in particular at patient needs in terms of falls risks, social work requirements, communication with relatives together with identification of the sickest patients and other immediate priorities such as nutritional status In the context of this case, 'huddles' will review and remind staff of the nutritional status of all patients, with attention to patients that have a prescribed change to their oral intake eg if again key ward bays,

patient has been NBM awaiting surgery which is later cancelled, or until a doctor confirms that the reason for being NBM before an investigation is no longer necessary: Physical measures are available in clinical areas to communicate nutritional needs visually, in the form of signs and markers. These are used to identify patients who have specific nutritional regimes, including being NBM or who may be taking fluids only, or different dietary preparations. The signs are placed close to the patient; usually above the head of the bed, on the door of a side room, or both locations. Mr Yates had such a sign in his bed space whilst in a bay, but when he was relocated to a side room, unfortunately, this was not moved with him. On review of the professional processes by which nutritional status is managed; the Trust is satisfied that appropriate systems are available and in use to safely manage the nutritional care of patients. Regrettably, in Mr Yates' case, human factors intervened in his care: The staff member who moved Mr Yates from one bed location to another omitted to move the NBM sign and replace in the usual position at the head of the bed or on the door; as was heard in evidence at the inquest: hope this information is helpful: Please do not hesitate to contact me if you require further information