Dear Mr Salter Regulation 28 Report following the inquest touching the death of Connor Sparrowhawk am writing to you to respond to concerns raised by your investigation into the circumstances surrounding preventable death of Connor Sparrowhawk: In your letter of 3 November, you raised two specific concerns and will respond to these in turn: Bathing observations for people with epilepsy You recognised that a blanket ban on bathing was not considered good practice by the CQC and that line of sight observations posed difficulties in terms of patient privacy and dignity. Nonetheless yoU had residual concerns about the effectiveness of of sound observations and asked the Trust to consider our practice in this regard. The Clinical Director for Learning Disability Services has led this piece of work alongside members of the Epilepsy Clinical Area of Practice group within the division: Although a comprehensive Epilepsy Map and Toolkit have been developed which cover all areas of risk, decision been made to write a new protocol specifically for bathing: This has been drafted by Consultant Nurse , again in conjunction with a range of practitioners. The document is called Protocol for the Safe Bathing and Showering of People with Epilepsy and has just been through a consultation process among senior clinical staff members. As a result of this, suggestions have been made as to some additions that are required to make it applicable to every speciality across the Trust rather than just the Learning Disability Division: These are being incorporated in the final draft which will then be ratified through the usual Trust processes_ expect this to have happened within the next month. In the meantime, the draft document has been circulated to staff in the Trust's learning disability inpatient units as it is already fit for purpose for use in these areas We will send you a copy of the Protocol document as soon as it is ratified, but would like to assure you that it is a comprehensive, evidence-based document: It includes the requirement for a comprehensive assessment;, risk assessment and risk management plan to be in place: The central tenet of the Protocol is that staff must be present at all times when a person is bathing and to have the person in their line of sight; unless there is a documented reason for otherwise. The patient must have also had a formal, documented, capacity assessment to ensure are able to make the decisions to participate or not participate with the risk management plan; Capturing risks associated with epilepsy on RiO You were concerned that RiO, the electronic patient record, did not have an appropriate place to record details about a person's epilepsy. This has been considered by who is an Informatics Clinician, the OpenRiO Learning Disability Clinical Lead and a Community Learning Disability Nurse by background_ Floor , the the line has We doing they

hhas advised me that appropriate assessment forms from the paper based Epilepsy Toolkit are being built on OpenRiO and will be added to the next release which is issued on 28 January 2016. When change requests are made to the OpenRiO team these are 'packaged' together built into the system and then released in effect as a new version of the RiO software These Epilepsy assessments will be for the principal use of Learning Disability services, however they will also be available for use by other Trust services that would benefit from the use of specialist Epilepsy assessments The release of the new version of RiO with the epilepsy forms will be accompanied by a comprehensive communication plan to ensure staff are aware of their availability: This will include the following: Email to all staff across the Trust announcing the new RiO release and describing the new items included in the release Information about new and updated forms is presented on the RiO welcome screen, where all RiO users have to manually select an information sharing agreement button prior to accessing the system Information about the release and new items included in the regular RiO newsletter personalised email from_ Ito all staff working in the learning disability divisions with information about how the electronic epilepsy forms should be used Cascade through Clinical Records Group and divisional governance groups It is important that staff record risks around all physical health problems and not just epilepsy change request has also been made with regards to overarching RiO risk assessment form for mental health and learning disability services. This will provide a specific prompt for physical health risks to be noted: We expect this to be available in a future OpenRiO release planned to occur in March 2016. In the meantime, there is guidance available for staff within the comprehensive Learning Disability Service Specific Guidance for RiO which advises them that physical health risks (with specific mention of epilepsy) should be noted in the 'Other Risk Behaviours' section of the existing form has undertaken considerable work to promote this guidance within the division. Compliance with policies and guidelines and with record keeping standards is assessed on an ongoing basis through management supervision and the peer review process. Audits are also regularly performed with an Epilepsy audit, bathing risk audit and physical health audit having been undertaken in the learning disability division in last quarter: The results of these are collated and will inform further improvements that are required trust the information provided above gives the necessary assurance that your reflections and concerns have been taken extremely seriously and resulted in tangible changes to the way in which we manage the risks associated with epilepsy. We will send you the new Protocol for the Safe Bathing and Showering of People with Epilepsy as soon as they have been ratified, and you will not hesitate to contact me should you need any further information in the intervening period.