Natasha Raghoo

E@EIVE Partnerships in care

29 APR 2014 2 Imperial Place

Maxwell Road

Borehamwood

Herts WD6 1JN

SPRL TIAL NT IE 020 8327 1800

020 8327 1900

. info@partnershipsincare.co.uk

Dr D Skipp www.partnershipsincare.co.uk
Assistant Coroner

Coroner's Office

West Sussex Record Office
Orchard Street

Chichester

West Sussex

PO19 1DD

Monday 28 April 2014

Dear Dr Skipp

| write in response to your Regulation 28 letter dated 6" March 2014 following the inquest
touching the death of Natasha Raghoo which concluded on 21 February 2014. | am grateful
to you for bringing these matters to my attention as Partnerships in Care (“PiC”) take all
patient safety issues very seriously and act to ensure that lessons are learned throughout
the company.

The death of Miss Raghoo was an extremely sad event and very upsetting for her family and
friends and my sympathy goes out to each and every one of them. However, from the
perspective of PiC | want to ensure that the company and its hospitals learn lessons from the
events leading up to and following the death and from the ways in which the communication
was managed to ensure that the quality of services we provide are continually strengthened
and improved.

Issue 1

During the course of the evidence, concern was expressed concerning the training that staff
had received in the techniques of cardio pulmonary resuscitation and the use of the
defibrillator. The latter was reported not to have been used by hospital staff although
available on the ward.

Cardio Pulmonary Resuscitation (CPR) and Defibrillator Training

The nursing staff had all been trained in CPR and use of the defibrillator, and indeed |
understand that the training records were supplied to you confirming this.

INVESTOR IN PEOPLE Partnerships in Care Limited. Registered in England No. 2622784. 2 Imperial Place, Maxwell Road, Borehamwood, Herts WD6 1JN

CPR Techniques

Evidence was heard that two paramedics arrived on the scene following the emergency call.
They had instructed the company staff member to continue with chest compressions and it is
of note that they did not raise any issues about the competency of the staff or the
compressions. The paramedics took over the CPR themselves and did not raise any
concerns over the techniques being used.

A senior paramedic arrived shortly afterwards. He indicated that he felt that the chest
compressions were not of sufficient depth or pace; he then instructed the member of staff to
continue with compressions but to make them deeper and faster. The Senior Paramedic
gave evidence that, the efficacy of CPR is a common issue for those administering CPR and
that, even paramedics in his service use a metronome to assist them maintaining the pace.
Whilst | appreciate that an issue was raised, it seems to derive from a difference in clinical
judgement and it is of note that the two original paramedics did not consider there to be any
issue.

Defibrillator Use

| understand that the evidence showed that our staff had brought the defibrillator to the
scene and unpacked it, but had not utilised it at the time the first paramedics arrived. This
was acknowledged to be a timing issue and, of course, once the paramedics arrived our staff
naturally left them to take the lead with issues such as the use of the defibrillator.

Lessons Learned and changes made

lunderstand that is important to ensure that, when CPR is given, it is as effective as possible
and accordingly, since the incident, a programme of monthly emergency incident drills has
been implemented. This gives staff the opportunity to practice their skills.

At the time of the death, PiC CPR training complied with the NHS requirement for Basic Life
Support. This staff training was provided by an employee of The Dene who had undertaken
an accredited Train the Trainer course. All staff undertaking the training were signed off as
competent by the Trainer and anyone not achieving the standard required would have been
required to repeat the training course until they could evidence their competence.

In 2013, and subsequent to the death, PiC implemented a company-wide training
programme to move from the provision of Basic Life Support to Immediate Life Support. This
training has been delivered to all qualified nurses and doctors across PiC. This training
specifically includes the use of the defibrillator.

Issue 2

Physical observations of blood pressure, pulse and temperature were sporadic and few in
number. This was cause for concern as Miss Raghoo had a raised blood pressure and had
been commenced on treatment. Observations stopped two days prior to death and no
member of staff was able to explain who was responsible for this action.

Evidence was provided that the patient had 17 blood pressure readings taken over 5
consecutive days in the week prior to her death; we do not agree that this was sporadic or
few in number, and as far as I'm aware, there has been no medical evidence criticising this.

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It is acknowledged that PiC was unable to provide written documentary evidence showing
blood pressure readings for the final 2 days of observations. However, clear verbal evidence
was given, by two senior members of staff, that blood pressure readings were continued
during this time but that the new sheet covering these days had been misplaced. Although it
is not known when the sheet was misplaced, it should be noted that the company did not
have control of the original documents following the death as these were removed by the
police. Therefore, | do not believe that these were stopped as your report suggests.

Lessons Learned and changes made

PiC is always seeking to improve its practices and | hope that it will assure you to learn that,
since the time of the sad death of the patient, we have made a number of changes in our
procedures.

In particular, the company has introduced enhanced physical health monitoring procedures.
These include, as a minimum, daily physical observations for each patient which are
conducted every morning by the trained nurse, at the time of the first medication
administration round.

We have also introduced an electronic ‘dashboard’ across PiC. This tool provides staff with
up to date information to ensure that regular physical health screening requirements are
undertaken.

In addition, patients with particular physical health requirements have individual specialised
care plans developed and reviewed by our employed, permanent Advanced Nurse
Practitioner in conjunction with the patient’s primary nurse.

Issue 3

Whilst under the care of The Dene, and on antipsychotic drugs with a raised blood pressure
an electrocardiogram was not carried out because all routine ECGs are performed by a
visiting nurse from a General Practitioners surgery on a set day of the week. An ECG
machine is available within the hospital but is not routinely used.

As you note, there is an ECG machine available at the site. This is regularly used by the
visiting GP and the employed, permanent Advanced Nurse Practitioner.

However, as you will appreciate, the Dene is a psychiatric unit and PiC complies with The
Maudsley Guidelines for such matters as ECG usage. The Maudsley Guidelines in place at
the time of the death (the 10" edition) do not recommend that routine ECGs be carried out
for every patient. We would expect that if there were any enhanced needs for physical
observations or tests of this sort, these would be ordered by either the visiting GP or the
Consultant Psychiatrist responsible for the patient's care.

Further, as a result of the patient’s acute manic state, which had led to her admission, it
would not have been possible to obtain a meaningful ECG reading.

Lessons Learned and changes made

The changes relating to the physical health screening are outlined in Issue 2 above

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3 Changing lives for the better

Issue 4

Staff handovers occur twice daily in the morning and evening. Those finishing a shift hand
on information about the patients to the incoming shift. It was apparent that communication
was inconsistent, particularly when bank or agency staff were involved.

All staff, regardless of their employment status, attend the nursing handover. On the shift in
question, there were no agency staff.

Staff coming late to shift, will be given a separate handover (appropriate to their level and
grade) by the nurse in charge. This is what happened in this case; the Nurse in Charge
gave an appropriate handover to the Healthcare worker.

Lessons Learned and changes made

We understand the importance of ensuring that the handover between shifts is
comprehensive and effective and, since the time of the death, PiC has reviewed and
standardised its handover procedures across the company. The new procedure includes the
completion of a formal handover document which is signed by the Nurse in Charge of the
shift confirming that a complete handover has been given. There is a specific section in the
new handover document relating to physical healthcare.

Issue 5

Communications between staff and family were haphazard and the policy of involving family
in care planning was not clear.

The service is an acute service that provides overspill for South London & Maudsley
(‘SLaM’) patients and patients from other Trusts. Many of these patients only stay in the
service for a matter of days. The very short periods of time spent by the majority of patients
does not allow for significant liaison and input from families and carers. However, the service
does attempt to involve families and carers wherever possible and within the constraints of
patient confidentiality.

In the case of this patient, | know that the staff at The Dene were aware that the patient had
a close relationship with her family and was in contact with them. However, | regret that the
way communication was dealt with in this particular case caused concern to the patient’s
family.

Lessons Learned and changes made

Since the death of Miss Raghoo we have reviewed the way we communicate with families
and carers and communication issues are now discussed at the regular Multi-Disciplinary
Team meetings to ensure that families and carers are consulted with, when the patient gives
their consent for this to happen.

Issue 6

The policy of access to GP services was not clear leading to misunderstanding by the
Princess Royal as to where to send a report.

| regret that | do not understand the premise for the report in relation to this issue.

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4 Changing lives for the better

PiC’s and, in particular, The Dene’s policy for access to GP services is, and was at the time
of the incident, clear. The Dene has a visiting GP attending its services and all long-term
patients are under the care of this GP. Short-term patients, such as Miss Raghoo, remain
registered with their own GP. This arrangement is to my knowledge not dissimilar to that in
place in many psychiatric hospitals.

If the Princess Royal had any misunderstanding about where to send the report then they
could have clarified the position with The Dene. They did not do this. Indeed, when the
patient attended the Princess Royal Hospital, they provided her with a discharge summary to
take with her when she returned to The Dene. This discharge summary was reviewed by the
medical team at The Dene.

Lessons Learned and changes made

Notwithstanding my belief that this does not relate to The Dene, the medical team at the
Dene ensure they contact the general hospital in all cases for a handover and discussion
regarding any patients that attend and receive treatment, thus ensuring appropriate
handover and ongoing care.

Issue 7

Unclear as to whether checking to ensure that when using agency staff they have not
already worked a shift elsewhere that day

Again, | apologise but | am unclear as to the premise underlying this concern. There were
no agency workers on shift at the time of Miss Raghoo’s death and no concerns were raised
about staff on shift having worked anywhere else prior to reporting for work at the Dene that
day.

Lessons Learned and changes made

However, despite it not being clear why this is relevant to this case, PiC has, in its desire to
strengthen its services and practices, reviewed and revised the standard terms and
conditions that the Company now uses when contracting with nursing agencies. All contracts
now entered into include a condition that states that they cannot send us staff who have just
worked a 12 hour shift elsewhere.

Issue 8

Obtaining records, particularly from community services involved with the care of the patient,
was difficult and slow.

As you will know from the evidence that you heard, this was indeed an issue in this case and
| know that the Chief Executive from SLaM has written to you separately setting out the
changes that the Trust has made internally.

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5 Changing lives for the better

Lessons Learned and changes made

Since this incident both PiC and SLaM have worked closely together to improve information
flow. As a result communication between PiC and SLaM has improved greatly thus ensuring
access to patient records is satisfactory.

In particular, a Liaison Nurse attends The Dene from SLaM several days of the week thus
ensuring access to SLaM records directly utilising a VPN link. Strong working relationships
between ourselves and SLaM have also developed since this incident.

Issue 9

The policy on length of time staff are expected to conduct observations, and the quality of
handover from one member of staff to another.

The quality of handovers and the changes made have already been dealt with in Issue 4
above.

All staff are trained on how to undertake observations and records are maintained of the
length of time between observations and the individual undertaking the prescribed
observations.

Lessons Learned and changes made

Since the sad death of Miss Raghoo, PiC has reviewed, revised and reissued its observation
policy and, as explained previously, its handover protocols.

This was followed up by face-to-face meetings with all staff who may undertake observations
or who are involved in handovers explaining both the content of the policies and their
responsibilities in respect of handover and observations. Staff were required to formally
acknowledge that they understand these responsibilities.

The implementation of the observation policy and handover is being regularly audited and
spot checks are carried out.

In conclusion, | am grateful to you for bringing these matters to my attention and | hope that
this letter provides useful information in response to how PiC as a company and, most
importantly, how The Dene hospital have changed practices and learned their lessons.

Yours sincerely

Cu LO’ JO
Joy Chamberlain

Group Chief Executive
Partnerships in Care Group Limited

Partnerships in care

6 Changing lives for the better