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Assistant Coroner for South Yorkshire (East District)

9 August 2018

Ref: Regulation 28 Letter relating to the Inquest of Mr Alfred William Meek Further to your Regulation 28 letter sent to the Chief Executive of Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest of Mr Alfred William Meek, I have been asked to provide the Trust response to your concerns. The first concern in your letter was regarding gaps in the reliability of daily reassessment and appropriate intervention. In response to this concern, I can confirm that our policies and documentation are designed to achieve an appropriate frequency of reassessment and appropriate interventions. The reliability of daily assessment and appropriate intervention can be seen through monitoring with regular audits. The total results for ward S12 are:

Patient records audited Overall compliance 25/6/18 14
97.1% 9/7/18 13
95.7% 16/7/18 15
96.5% 23/7/18 10
96.1%

The Trust Falls Specialist Practitioner has also undertaken audits across the Trust and these can be found appended to this letter. This shows a broadly high level of compliance in respect of assessments being undertaken at the appropriate frequency and action for supervision being taken. There are some areas for improvement on the implementation of the relevant actions to address a patients specific falls risk factor/s and de-escalation interventions, which is supported through the training provided, subsequently described in this letter. The second concern described in the letter was about the action taken following escalation. The investigation report found that the staff did not escalate any staffing needs, as they had not recognised the need for Mr Meek. This aspect relates to the reliability point above and there are systems in place through the Enhanced Supervision & Engagement Policy. The following steps set out the systematic approach that is in place to manage staffing resources optimisation:

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Initial management to provide appropriate supervision When a need for supervision is indicated then the nurse in charge of the ward would allocate resources to achieve this from the existing staff on the ward in the first instance. This may create a need for redistribution of work for the rest of the team, or if there is insufficient staffing to achieve this then the matron or a senior member of nursing staff should complete the enhanced care prescription assessment (Enclosure 1). Enhanced Care Prescription This tool verifies the assessments undertaken and validates that all of the appropriate interventions have been taken to reduce the risk for an individual patient. This would include a range of potential supporting interventions to help the patient be oriented and supported. The assessment tool also makes a recommendation for cohorted or 1:1 supervision above the planned staffing level. Staffing levels are planned according to the acuity of patients using the Safer Nursing Care Tool, which takes into account the need for supervision. The need may be within the expected staffing level, but where it is above normal staffing level then the Enhanced Care Prescription provides authorisation to permit additional staff. Access to additional temporary staff The Trust is resourced with finite financial support, but when there is a clinical need for additional resources, additional resources will be requested from the nursing bank, provided by NHS Professionals. The fill rate for NHS Professionals is at about 80% of the demand for Heath Care Assistants, who are the staff group booked for supervision needs. Staff who already work for the Trust are asked to undertake additional duties, prioritised on part time staff, but would include overtime when other options have not been successful. If there is no-one available despite these attempts, then staff may be redeployed to spread the risk and optimise patient safety and safe staffing levels across the hospital. A limitation remains in achieving short notice responses, exacerbated when there is sickness and absence that creates additional demands for temporary staffing. A report on the overall and ward level position for our actual staffing against the planned level is reported to a national staffing return and also reported through the Trust governance arrangements, including a report to the Board of Directors as part of the performance report each month. The Trust has a strategic approach and focus on preventing falls, with the development of policies, assessment tools and compliance to NICE guidance in respect of falls prevention. As a Trust we are committed to reducing inpatient falls and improving our learning from falls. To facilitate this we have developed a standard Trust action plan which meets the minimum standards we would expect to see after a fall resulting in moderate harm, severe harm or death. Tier 2 falls prevention and management education including falls documentation is provided to all frontline Trust staff within the Person Centred Care study day. To date 1029 Trust staff have received this training over 2 years, this is ongoing, bi-monthly training enabling up to 100 staff to attend at each session. The Trust action plan for Falls & Bone Health Management supports the falls ward accreditation to be implemented this year. This is similar to other accreditation initiatives already in place such as nutrition and infection control. The falls accreditation will provide proactive assurance of the work

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the wards are doing to improve quality proactively, rather than responding after an event has occurred. The accreditation will be monitored by the falls prevention practitioner to identify areas requiring additional support and training to ensure quality improvements are being made in all areas within the Trust and to further embed the education and documentation. To achieve accreditation:  75% of falls champions (one on each ward) to attend the quarterly training event. Records to be kept by the falls prevention practitioner.  50% of all ward staff to have attended the Person Centred Care study day. Records kept my training and development department.  90% of staff trained on the daily supervision and engagement assessment, enhanced care plan and safety side assessment. Ward Manager to keep register of staff signed off.  95% compliance with a monthly audit on 5 sets of notes each month, looking at compliance against the daily supervision and engagement assessment, enhanced care plan and safety side assessment The accreditation process feeds in to the Quality Assurance Tool, so all areas have a series of quality and performance processes, designed to improve the quality of care provided. I trust that this provides an assurance that there are systems in place to manage staffing to supervise patients and monitoring of the reliability of staff undertaking assessments. The Trust prioritises patient safety and provision of high quality care. The lapses in care in this case are accepted and action is being taken to improve. I would also like to offer my condolences to Mr Meek’s family following his death. Kind regards

Deputy Director of Nursing, Midwifery and Allied Health Professionals