Dear Mr Pollard Thank you for your letter of the 30t January 2014 setting out your concerns under Regulations 28 of the Coroners (Investigations) Regulations 2013. On the 29th January 2014, you held a Inquest into the death of Leslie Alfred Pates who died on the 2nd April 2013. The medical cause of death was recorded as: 1(a) Sepsis 1(b) Pressure sore 1(c) Immobility/stroke II Vascular dementia, Chronic Obstructive Pulmonary Disease, Hypertension, Stroke At the conclusion of the Inquest you set out a number of concerns_ These concerns were reported to the Trust and we are now in a position to advise you of what action has been taken to address the issues identified_
1. There has been complete breakdown in effective communication between the hospital and the family of the deceased: To improve effective communication between the Integrated Transfer Team and the patients and their immediate carers/family regarding the discharge plan, the following actions are taken: Develop a checklist to ensure all members of the Multidisciplinary Team (MDT) have engaged with patients and their family prior to discharge. being

The Team leader to ensure through the computer systems between social services and the Trust (IAS/EIS systems) that there is documented evidence that all Integrated Transfer Team (ITT) cases have been discussed with patients and their designated carers.
2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient: To ensure the patients ad families wishes are fully raised and given full consideration in the discharge process the following actions have been undertaken: To ensure all patients and families have opportunity to discuss plans and have a dedicated name and contact number for the social worker managing their discharge: Leaflet has been produced and is in publication process for patients and carers about "Leaving our Care" To ensure all newly appointed stafflagency workers are adequately orientated to the hospital and all procedures and policies are outlined from both Tameside MBC and Tameside Foundation Trust (TFT) to the expected standards of practice: All temporary workers located within the Transfer Team will have an induction process and complete the induction checklist within one week of commencing role. Each temporary worker will receive an induction and adequate support and documented regular supervision
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. All patients returning home with care package will have their equipment needs assessed and documented in hospital Social workers to communicate effectively with the Nurse Coordinators so that timely referrals for assessment of equipment needs can be made. The daily length of stay meetings will ensure that the checklist process for discharge is followed. A complex care plan has been formulated for all parties to agree the patient is supported and ready for home Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge: All plans of care for patients must be shared with the patient and, with patient's consent; their next of kin and agreed before discharge: Each member of the ITT should ensure all care plans are prepared accurately and presented before being discussed and shared. This will be monitored through regular supervision of Tameside MBC staff and through daily length of stay: The ITT supervisors will monitor documentation via Social worker IAS system: every fully

The Head of Patient Flow and Team Leader for ITT now have transparency ad ability to view and monitor all social worker involvement with cases through Tameside MBC IAS system. This is monitored daily for all cases known to the ITT.
5. The required 'meeting" between Social Services and the family prior to discharge hospital, simply never took place: To improve communication from the ward staff to the ITT through the induction of robust SHOP board round. A Pilot of "Sick Patients Home Other Plar" (SHOP) is in progress on two medical wards, This is to be escalated across the trust over the next 3 months and become embedded practice: This will improve ward based communication to the discharge team ad is documented. The SHOP process is a full MDT process daily where all patients are discussed and discharge plans agreed daily. This is documented and evidenced by the ITT team: In addition, the profile of the ITT team is being raised through public awareness and increased visibility and open access Creating information boards and posters to display across the wards ad departments to raise awareness of the team to allow patients, families ad carers to have easy access to the team for support and guidance in the discharge process. The team has a social worker available 6 a week to patients and relatives and a Clinical Discharge Facilitator (CDF) available seven days a week, from 0800-2000hrs to speak with patients, staff and relatives for advice CDF team are providing training to new staff on their Corporate Induction about planning discharges. ITT team are training all staff on the Nursing documentation relating to discharge and compiling a data base of all staff trained. hope that these reassurances address the issues that have been raised.