Dear Mrs Harding Re Mr Peter Blakeney King (deceased) Following the conclusion of the juest hearing into the death of Mr Peter Blakeney King on 20 September 2017 and your subsequent letter dated 20 November 2017 pursuant to paragraph 7 Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, write to infom you of the actions and considerations taken by East Kent Hospitals University NHS Foundation Trust: We note this Regulation 28 Report to prevent future deaths is one of three Inquests heard by the Central and South East Coroners in September 2017 and the matters of concem relate to the management of falls within the Trust Acknowledgment by the Senior Coroner of the improvements that have already been made by the Trust regarding timely and adequate falls risk assessments is gratefully received and this work continues as outlined in my response_ The rate of patient falls and patient falls resulting in harm to patients are patient safety measures which the Trust monitors monthly as part of our quality indicators. They also form part of the core patient safety component of the Board priorities for 2017/18. Reports are received monthly to Board of Directors and the Quality Committee on our performance against plan. We have set ourselves challenging stretch targets to achieve a8 our patient falls prevention programme is of a high priority_ The latest confimed results for October 2017 show the falls rate is
5.63 per 1,000 occupied bed which is below our target for year: The confimed falls national rate from the 2015 National Falls Audit was 6.6 per 1,000 occupied bed the Trust overall had a confinmed falls rate of 6.29 at the time of publication This shows the falls rate for the Trust overall Is better than the national rate_ Cu Inqe key the days, the days; We;

The National Falls Audit also reports a patient harm rate i.e. where the hamm to the patient; a8 a direct consequence of the fall is severe or death a8 with the patients concerned: The national rate In the 2015 report was 0.18 per 1000 occupied bed this was the rate for the Trust overall in this part of the National Falls Audit, This shows the rate of harm to be the same as the national rate_ The results of 2015 National Falls Audit showed that the Trust had improvements to make in all three of our bed-holding hospitals; this improvement programme has been a priority for the Trust. There are no published studies of falls risk prediction tools that predicted risk at greater than 70% sensitivity: The National Institute Health and Care Excellence (NICE) therefore concluded that all inpatients aged 65 and older 'should have their care managed as if are at risk of falling' on the basis that these patients 'often have newly acquired risk factors (such as acute illness, delirium, cardiovascular disease, impaired mobility, medication or syncope syndrome) and are exposed to unfamiliar surroundings, which puts them at increased risk of falling during their inpatient stay' The current falls policy and risk assessment tool reflect NICE guidance and we have focused on these areas specifically in order to action the factors that are known t0 reduce falls risk: We therefore reviewed our Falls Risk Assessment and Care Plan (FRACP) to be explicit about how incorporate this guidance. We also developed a quality improvement programme call "Fallstop" which to prevent patiente falls in our care. Round 2 of the National Falls Audit took place in May 2017 , after the three falls in question had occurred; the audit resulta were published on 22 November 2017 , two days after the Trust received the three Regulation 28 reports: Table 1 demonstrates current performance and the improvements seen across the three hospitals. Table 1 _ Comparative data from the 2016 and the 2017 National Falls Audit Site Delirium Continence BP % Medlcatlon Vislon % Call bell Mobllity % CP % % % aid % 2017 K8CH 100 100 24 95 88 78 92 QEQMH 100 93 40 100 100 95 86 WHH 92 93 38 94 92 93 100 2015 K8CH 60
65.2
88.2
91.7
86.7
84.6 92 QEQMH 65 50
66.7 88
70.6
76.9
88.5 WHH
37.9
45.5
45.8
36.4
18.2
55.6 The patient falle all occured on the frailty Ward at the William Harvey Hospital; this ward often has confused, wandering patients and this situation requires additional and ears' to help provide a safe environment for the patients_ It is a challenge to ensure that there are always sufficient staff on duty each shift to meet the ideal staff to patient ratio. Additional NHS Professionals Health Care Assietants and Registered Nurses that are requested are sometimes unfilled: Where this situation occurs, staff are redeployed other clinical areas_ have in the past three month introduced SafeCare across the Trust SafeCare enables ward staff see if their staffing levels match the demand and for staff to be moved across the site during each day: The nurse-in charge conducts a census three per day of the number and acuity of the patients and inputs this onto the We cai days; the again they 'eyes from We times

system. SafeCare then calculates the number of nursing hours that are required during this census period and compares it to number of nursing hours available: This allows for the Clinical Site Team to make informed decisions when moving the staff to the area of greatest risk and allows for the efficient use of all available nursing time: In June, 2017 a business case was approved to support a full time band 4 Associate Practitioner (AP) for Falls Prevention and she joined the team in September 2017 . She is actively supporting the Fallstop programme: would like to take this opportunity of thanking you for your letter and can reassure you that we have taken on board your comments and will continue our commitment t0 deliver a safe and effective service to our patients.