Dear Ms Thomas Re _ Mr Harold Graham Wonfor (deceased) Following the conclusion of the Inquest hearing into the death of Mr Harold Graham Wonfor on 14 September 2017 and your subsequent letter dated 20 November 2017 purauant t0 paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, write to inform 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 Inqueets heard by the Central and South East Coroners in September 2017 and the matters of concern relate to the management of falls within the Trust Acknowledgment by the Sonior 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 a8 outlined in my response. The rate of patient falls and patient falls resulting in harm to patients are key patient safety measures which the Trust monitors monthly as part of our quality indicators. also fom part of the core patient safety component of the Board priorities for 2017/18, Reports are received monthly to the 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 confired results for October 2017 show the falls rate is
5.83 per 1,000 occupied bed which is below our target for the The confimed falls national rate from the 2015 National Falls Audit was 6.6 per 1,000 occupied bed the Trust overall had a confirmed 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. We They days, year: days;

The National Falls Audit also reports a patient harm rate i.e. where the harm to the patient; a8 a direct consequence of the fall is severe or death as 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 a8 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 again 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 a8 if are at risk of falling' on the basis that these patients 'often have newly acquired risk factors (euch a8 acute illness, delirium, cardiovascular disease , impaired mobility , medication or syncope syndrome) and are exposed to unfamiliar surroundings, which them at increased risk of 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 to 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 patients 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 results were published on 22 November 2017 , two days after the Trust received the three Regulation 28 reports Table demonstrates current perforance and the improvements seen across the three hospitals: Table 1 _ Comparative data from the 2015 and the 2017 Natlonal Falle Audlt Site Delirium Continence BP % Modlcatlon Vision % Call bell Mobility % 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 KECH 60
65.2
88.2
91.7
66.7
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 falls all occurred on the frailty Ward at the William Harvey Hospital; this ward often has confused, wandering patients and this situation requires additional 'eyes and ears' to help provide 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 Assistants and Registered Nurses that are requested are sometimes unfilled Where this situation occurs, staff are redeployed from other clinical areas_ We 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 We a days; the thoy falling puts

a census three times per day of the number and acuity of the patients and inputs this onto the system. SafeCare then calculates the number of nursing hours that are required during this census period and compares it to the number of nursing hours available. This allows for tha Clinical Site Team t0 make infomed decisions when 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 to deliver a safe and effective service to our patiente.