Dear Ms Hunt; Reference: Regulation 28 Report from Birmingham and Solihull Coroner to Prevent Future Deaths relating to the death of Mildred Joan Griffiths which concluded the death was as the result of natural causes_ write in response to your Regulation 28 report regarding the death of Mildred Joan Griffiths within which you raised a matter of concern regarding use of the Braden Pressure Ulcer Risk assessment tool at St Giles Nursing Home, Birmingham when the Community Healthcare Trust use the Walsall Tool, In responding to your concerns we have again reviewed the evidence available regarding the use of pressure ulcer risk tools and would make particular_reference to documents from the National Institute for Health and Care Excellence (NICE): The role of NICE is to producing evidence-based guidance and advice for health, public health and social care practitioners, develop quality standards and performance metrics for those providing and commissioning health, public health and social care services and provide a range of information services for commissioners, practitioners and managers across the spectrum of health and social care: The documents of particular relevance are: Pressure_ulcers: prevention and management (CG179) Evidence-based recommendations on the prevention and management of pressure ulcers. Clinical guideline. Published April 2014. Pressure ulcers; Pathway of NICE evidence on preventing and managing pressure ulcers in all age groups in primary care and community settings in an interactive_ flowchart: NICE Pathway Published January 2012. Last updated November 2017 Pressure_ulcers (QS89) Evidence-based statements to deliver quality improvements in the prevention, assessment and management of pressure ulcers Quality standard. Published June 2015 In summary with regard to pressure ulcer risk assessment NICE states "Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk" The two most commonly used pressure ulcer risk tools in the UK are Waterlow and Braden with no current evidence that either one is more effective at identifying risk than the other: The use of any risk tool should not outweigh clinical judgement and there are issues around sensitivity, specificity and also inter-rater reliability on all risk tools. Avery Healthcare Group 3 Cygnet Drive Swan Valley Northampton NN4 9BS t: 01604 675566 HealthInvestor Residential LaingBuisson WINNER enquiries@averyheallhcare.co.uk Awards 2016 care provider wwwaveryhealthcare: co.uk WINNER of the year Awaeds Residential Care 2016 Larger Organisation Company Registration Number: 08599361 Avery

The Walsall tool is used locally by Birmingham Community Healthcare Trust and while we have found one small study related to recent validation of the tool published in 2000, this is limited. We also note that it was designed for use in the community and includes Carer Input as a category which is not appropriate for use in a care home environment: This tool has very limited use nationally and is specific to a local area. St Giles cares for patients from Solihull and other areas who do not use the Walsall tool either: We believe that this could also cause further confusion between professionals_ We also note the following points: The resident who passed away on this occasion was unable to tolerate repositioning, and would frequently reposition herself on to her back, indicating this was where she was most comfortable and would also refuse repositioning: This would have lent itself to deterioration of the wound, regardless of the risk assessment tool being used: The resident moved into the home with leg plaster cast in situ further decreasing her mobility and making repositioning difficult: The local Tissue Viability Nurse was supportive of the care and treatment which had been given by the team at St Giles Nursing Home, and was aware that degradation of the wound may occur owing to a lack of compliance with repositioning At Avery Healthcare we pride ourselves on the low prevalence of home acquired pressure ulcers within our care homes We care for over 3000 residents and have an average home acquired prevalence of less than 1.5%. This compares to national rates of between 4.7-
32.1% in hospitals and up to 22% in nursing homes (NICE) We use the Braden risk tool to support staff with assessing risk throughout England as it has had studies conducted specifically for the older age group, covers the main areas of risk and has in our experience (and for which there is weak evidence) better inter-rater reliability: The average prevalence rate for home acquired pressure ulcers at St Giles nursing home is 2.3% year to date and there have been several months this year where there have been no home acquired pressure ulcers in the home We are confident that the risk tool which we use and the systems and staff training which we have in place are effective but have conducted a root cause analysis in this case to ensure that organisational learning can take place. Thus having reviewed your recommendation and the evidence we propose to continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards_