East Riding and Hull

Noted (AI summary) • The Trust has established daily operational controls to mitigate staffing pressures in real time. • Daily staffing meetings take place across all sites, where ward-level escalations relating to actual versus planned staffing, changes in acuity, and red flag indicators are reviewed by dedicated staffing representatives. • Information from these meetings feeds directly into twice-daily Trust-wide safe staffing meetings chaired by a Nurse Director, providing senior clinical oversight of staffing gaps, mitigations and risk management. NHS England stated the local staffing concerns for Ward 90 fall outside its usual role and remit, noting that Hull University Teaching Hospitals NHS Trust is best placed to respond and has presented a business case to increase nursing staff. NHS England also disputed the clarity of the term “TAG nursing care.”

Noted (AI summary) NHS England acknowledges the concerns raised and explains its commitment to improving Electronic Patient Records (EPRs) across all NHS Trusts and supporting the sharing of critical clinical information across NHS organisations. It highlights ongoing national work to address Reports to Prevent Future Deaths.

Noted (AI summary) NHS England highlights existing functionalities such as the National Care Records Service (NCRS) and the SystmOne out-of-hours system that enable access to patient's Summary Care Record (SCR). They also note that Holderness Health migrated from EMIS to TPP SystmOne with GP Connect enabled to improve interoperability. Holderness Health confirms it migrated to TPP SystmOne with GP Connect enabled for interoperability, but the patient's surgery was 14 years ago and not considered a significant active problem. The CQC contacted the GP practice and Out of Hours provider to establish circumstances and intended actions. They state they ensure that they look closely at how providers deal with incoming correspondence, coding, and sharing of information during inspections, and were satisfied with the significant event analysis undertaken. The RCGP will highlight the case to their health informatics group to influence discussions with NHS England and will also highlight the concerns to The Professional Record Standards Body (PRSB).

Noted (AI summary) Following a site check, the council confirms existing signage is in place and in good condition. They request further information regarding the reported number of previous collisions at the location.

Noted (AI summary) The DVLA acknowledges the coroner's concerns, explains the current driver licensing requirements, and states that their processes and policies are kept under review. They mention a call for evidence to gather views on the medical driver licensing process, and the responses are being analyzed.

Noted (AI summary) The surgery has implemented measures including utilizing the task functionality in TPP SystmOne for clearer communication and providing additional training to staff regarding the importance of good record-keeping; they have also recruited a Data Quality and IT Officer. CHCP states they cannot provide feedback on some concerns as there was no referral made to CHCP Community Nursing by the hospital or surgery; however, they detailed how CHCP and the hospital transfer care records currently. The Trust is reminding staff to consider whether patients' care packages require revision and re-assessment upon discharge and to make appropriate referrals. The Trust also confirms that triangulation meetings are taking place in relation to complex Tissue Viability Nursing cases and plans are underway to establish similar processes for other community providers. CQC will discuss the concerns raised about Mrs Heath’s death at their next engagement meeting with the Hull University Teaching Hospitals NHS Trust and will make an appropriate regulatory response if they are not assured that improvements have been made. The NMC is investigating the concerns raised to identify whether they need to take regulatory action in relation to a professional on their register. They are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future. NHS England relays that the GP Surgery implemented improvements to their processes, including mandating use of the Task Functionality element of the SystemOne clinical software, and arranging additional training on what to record in the patient record. Bimonthly meetings take place between CHCP and HUTH Tissue Viability Nurses.

Noted (AI summary) Hull University Teaching Hospitals acknowledges the coroner's concerns regarding discharge information, but clarifies that a Trusted Assessor Referral Form (TARF) detailing the patient's frailty and mobility was completed and submitted to Social Services. The hospital also noted the discharge summary included a request to the GP to follow up on blood pressure.