Margaret Walker

5 Boroughs Partnership NHS}

NHS Foundation Trust

Our Ref: JE/DC Chief Executive's Office

Hollins Park House

Your Ref: MJL/SBR/M-Walker Hollins Park

Hollins Lane

Winwick

Warrington

20 May 2014 WA2 8WA

Tel: 01925 664001

Mrs M Jennifer Leeming Fax: 01925 664052
HM Coroner

HM Coroner’s Court
Paderborn House
Civic Centre

Howell Croft North
Bolton BL1 1JW

Dear Mrs Leeming,

Re: Mrs Margaret Walker - deceased

Thank you for letter dated 26 March 2014 with regards to your findings into the death of Mrs
Margaret Walker and the directions given under Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013. The Trust takes the matters described within the letter
extremely seriously and hopes this response addresses the concerns you have raised. In
addition we hope we are able to demonstrate to your satisfaction the learning within the Trust
as a result of your correspondence.

Taking your points in turn | can confirm the Trust have completed the following:

i) Information Concerning Medication

The Trust recognises the vital importance of the recording and sharing of accurate
information with regard to medication. This is covered within our core training programme on
our medicines policy. As a result of this case we have reviewed our policy and processes
and will be issuing further guidance to raise awareness of the medicines reconciliation
process and particularly the specific responsibilities of staff with regard to this.

Your letter states that Mrs Walker was admitted on 4 March 2012; however | would like to
confirm that Mrs Walker was admitted as a detained patient on 4 August 2012. | note your
concerns in the apparent delay in obtaining an accurate medication regime. 6 August 2012
was a Monday and while it was a significant delay (up to 48-hours after admission), it was
the earliest possibility at that time for obtaining GP practice held information needed to
complement other information sources to establish an accurate medication regime. Recently
members of the Medicines Management Team have gained access to the electronic
Summary Care Record for patients; this links to GP practices and provides access to the

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GPs record of the patient's medication in most cases; however, it will not provide clinical
details or blood test results or required ranges.

Routine access to the Summary Care Record is included in the work plan for the Trust’s new
Clinical IT system (RiO). Specifically this will improve medicines reconciliation out of routine
working hours.

The Medicines Management Team provide services on our in-patient wards daily (Monday-
Friday) to support a number of functions including medicines reconciliation. The team’s work
is audited regularly and the accuracy of their work is assured. The Trust has developed and
put in place a process to regularly audit and to report any failings in the medicines
reconciliation process.

Our data shows almost 100% of admissions have a medicine reconciliation completed; the
small number that don’t represent inpatient admissions lasting less than one day/one week-
end.

ii) Recording of Information in Clinical Notes

| would like to reassure you that processes and systems are in place to ensure that records
are kept in line with Trust policies and procedures. There are Trust approved documents for
recording of vital signs and charts for the monitoring of Blood Glucose.

in this instance the staff invoived in this case did not follow policies and procedures and did
not record the clinical information they had in the correct place. The competency of these
staff to undertake the accurate and timely recording of information within clinical notes has
been addressed through supervision and additional training.

In addition, the Trust has also introduced care quality records audits for each named
practitioner, which is undertaken by the ward leadership team. The audits enable managers
to identify the level of completeness and to address any areas of concern, including
incomplete assessments. Record keeping audits and re-audits are undertaken by the Trusts
Records Team and identified improvements from these audits are communicated and
actioned by the Team Managers.

The Trust has also produced a number of Managers Briefing Notes (MBN’s), circulated Trust
wide, reinforcing the importance of recording information in clinical notes, these include:

e MBN circulated 20 June 2013 reinforcing the requirement of completing and
documenting physical health checks.

e As part of the work stream to improve physical health assessment and monitoring, an
MBN was issued January 2014 providing guidance re the completion of Charts for
recording Blood Glucose Monitoring, Glasgow Coma Scale assessment, Fluid
Input/Output recording, Hydration Assessment and Open Wound Assessment in
Mental Health and Learning Disability Services.

e An MBN was issued in April 2014 regarding the Physical health competency
declaration within the (staff's) Personal Development Review process for all nurses,
assistant practitioners and health care assistants.

A key improvement in 2013-14 has been the development of the physical health
competencies process, including a competency self-declaration process linked to
performance reviews and training needs identification, to ensure that our staff understand the

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key elements of managing patients with co-morbid physical health problems. All Trust
policies and procedure for clinical skills and physical health assessments have been updated
and there is a dedicated page on the intranet containing this and other useful information.
We are also piloting a Modified Early Warning System (MEWS) for the deteriorating patient
on both our adult and older people’s wards with the aim of rolling this out to all in-patient
areas.

iii) Cardio-Puimonary Resuscitation and the use of a Defibrillator

In line with National Patient Safety Agency (NPSA) RRR010 “Resuscitation in Mental Health
and Learning Disability inpatient settings’ (November 2008) and Resuscitation Council UK
(RCUK) requirements, all medical staff and registered nurses working within inpatient
settings are expected to be competent to the standard of Immediate Life Support (ILS). All
support workers are expected to be competent to the standard of Basic Life Support (BLS).

BLS and ILS training is mandatory for all staff within our inpatient settings. The training
curriculum for BLS and ILS was in line with RCUK 2010 standards. This covers effective
cardiopulmonary resuscitation including:

e Knowing what actions to take in the event of a medical emergency.

e Knowing how to summon the emergency paramedic service.

e Basic Life Support - maintenance and management of the airway, CPR, immediate
management of anaphylactic reaction, management of the choking patient.

e Immediate Life Support - management of a collapsed casualty, BLS, use of
emergency oxygen, use of an automated external defibrillator, insertion of an airway.

Medical and nursing staff are required to demonstrate and achieve the required level of
competency before being approved.

In this case, while the staff involved in the incident were compliant with their mandatory
training requirements they had not appropriately followed the Trust approved Resuscitation
policy and procedures in relation to the use of the automated external defibrillator. | would
like to reassure you that this has been addressed with the staff in question who has
undergone specific Trust processes in relation to their competency.

In line with NPSA and RCUK guidelines, it is recommended that services undertake practice
drills to support further learning within the clinical environment. The Trust operates an annual
practice drill schedule that includes use of an automated external defibrillator. Practice drills
are undertaken by the Trust resuscitation trainers to ensure correct standards of practice are
demonstrated. Staff are assessed against the RCUK competency framework during practice
drills; the outcomes of practice drills are documented to identify areas of good practice and
areas requiring improvement. Local actions plans are agreed to address any areas of
concern. Records are available which evidence that Sephton Ward have had 4 practice drills
completed between November 2012 and January 2014.

The Trust approved Resuscitation policy and procedures requires local services to undertake
daily checks of the resuscitation equipment including the automated external defibrillator.
These checks are documented; and are subject to annual audit. The outcomes of the annual
audit are scrutinised by the Trust Resuscitation Steering Committee as part of the annual
work programme.

Further to the completion of the Serious Untoward Incident report in relation to this case, an
action plan was developed by the Business Manager. | can confirm that these actions have
been completed and led to the implementation of Trust wide initiatives in relation to the

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management of physical health and diabetes within the Trust in patient facilities. Examples
of this activity include;

e Development of Diabetes guidelines to support delivery of inpatient diabetes care by
nursing staff

e Diabetes Link Nurses/Associates — This initiative was introduced across the Trust and
identified both qualified and non-qualified staff to act as Diabetes leads within their
teams.

e Hospital at Home service — This is a partnership initiative between the Trust and
Wrightington, Wigan and Leigh NHS Foundation Trust that provides direct input from
physical health services at Leigh Infirmary site to the wards at Leigh.

If | can be of any further assistance or you require further information about the steps we
have taken please do not hesitate to contact me.

Yours sincerely

Simon Barber
Chief Executive Officer

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