Graham Watts

Brighton and Sussex INHS|

Your ref: VHD/pjv/INQ30/14 j j itals
Our ref: MK/MJ/MLS/C9/13/142 University Hospita

NHS Trust
27 May 2014
CCS: Headquarters
Miss V Hamilton-Deeley RECEIVE | the Royal sussex County Hospital
HM Coroner : Eastern Road
Coroner's Office ~ 2 JUN 2014 Baar
Woodvale, Lewes Road

BN2 3QB
Dear Miss Hamilton-Deeley

The Late Graham _— date of birth: 24 February 1928

Thank you for your letter of 3 April 2014 and its enclosure. We are grateful to you for
drawing your concerns to our attention. The Trust will always review practice, in order
to identify improvements which can be made in the light of experience and we have
done so in this case. Trust staff routinely feed back information emerging from any
inquest attended by our staff as witnesses - whether or not the Coroner has drawn
attention to this.

We all believe that in order to prevent avoidable deaths, it is essential for Trust staff
to develop effective multi-disciplinary working throughout professions and
departments within the Trust. We have therefore chosen to provide a joint response to
your letter, reflecting our commitment to continuing improvement of the quality of all
our services, using an integrated approach.

The Trust acknowledges and apologises that there were significant shortcomings in the
discharge planning process for Mr Watts, arising from failures by staff to complete
thoroughly all the steps necessary to ensure safe and timely discharge for each
patient. The Trust does not accept that the process itself was deeply flawed, but
acknowledges that it was not implemented adequately on this occasion.

In order to reduce the risk of a recurrence, the Trust has taken several steps, working
closely with the Matron and ward manager responsible for the ward on these issues. It
is the practice on this ward to hold a daily “Board Round”, which staff of several
disciplines are encouraged to attend. Recently a social worker has also started to
attend these meetings, which also assists in patient discharge planning. The details
held on the whiteboard have been adjusted to include more information relevant
specifically to discharge planning. It appears that to some extent, some staff on the
ward may have felt that the information on the Board had made it no longer necessary
to include detailed discharge planning documentation in the individual patient record.
The ward nurses have all had refresher training on the processes they are expected to
go through, including but not limited to the related documentation, before any
patient is discharged from the ward. This has included a reminder of the correct
procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation”
form. The Trust deeply regrets that this form did not accompany Mr Watts on his
discharge as it should have done.

With our partners

S< brighton and sussex K S LS ee
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While the Trust accepts that a change in environment increases the risk of falls, the
Trust also is aware that there is a reduction in the risk of falls when someone is in a
familiar environment, such as back at a Nursing Home in the room they previously
occupied. The Trust accepts that additional and up to date information, over and
above that provided in the doctors’ discharge summary together with the medication
information, about Mr Watts’ present condition and progress should have been
provided to the Nursing Home. This is normally done through contact between the
ward and the Nursing Home on the day before planned discharge, as well as through
the nurse to nurse handover.

The senior nursing staff agree that it is essential that a nurse to nurse discharge
summary be completed for any patient leaving the hospital to go to, or return to,
residential.or nursing home care. They have emphasized the importance of this to the
ward nurses. As part of the programme for developing the skills of junior nurses, the
ward is placing increased emphasis on shadowing senior colleagues, to equip these
junior staff with the skills needed to make robust decisions and to give them role
models to assist with their communication skills.

Each month a snapshot audit is being done of 10 sets of medical records from the ward
to ensure that they reflect an acceptable standard of discharge documentation. For
this ward, the April review of discharge documentation showed 100% compliance with
the requirement for documentation in the discharge planner, and also on the provision
of information about discharge plans to relatives.

The Trust has reviewed the forms currently used for discharge planning and is devising
new paperwork which is intended to facilitate timely documentation, and to
encourage daily consideration of each in-patient’s progress towards discharge.

There is increasing recognition among Trust staff that the nationally widely used term
“Medically Fit for Discharge” (often abbreviated to MFFD) can be very misleading.
There is a growing ground-swell of opinion that it would be less open to
misinterpretation if the phrase “Medically Ready for Discharge” (MRFD) or some
similar form of words were adopted. Mr Watts was ready for discharge in as much as
that he no longer required active medical treatment in an acute hospital at the time
of his discharge. His last set of clinical observations taken during the afternoon
immediately before he left the hospital were entirely satisfactory, with a National
Early Warning Score of zero: there was therefore no reason to identify him as
medically unready for discharge. Given his co-morbidities, and his increased frailty
following the significant illness with which he had been admitted, he was at high risk
of acquiring new infection while he remained in hospital, and the hospital staff were
confident that his ongoing care and rehabilitation needs could be met at Fir Grove.
Nevertheless, this does not excuse the identified shortcomings in the discharge
process, especially in relation to communication with the family and Nursing Home.

The Trust is aiming to start a one year pilot scheme to focus on consistent multi-
disciplinary management of frail elderly patients, led by an individual from the
discipline most relevant to the individual patient’s circumstances, in preparation for
their discharge. Subject to successful recruitment, it is anticipated that the pilot will
start in July 2014 on three wards. This pilot will be evaluated throughout the year as
well as at its conclusion so that the learning from it can be extended throughout the
Trust for the benefit of frail elderly patients.

Thank you once again for raising your concerns with senior Trust staff. We have all
found it useful to review, in the light of these events, the progress that is being made
to increase the safety of future patients in this Trust.

Finally, please pass on our condolences to Mr Watts’ family on their sad loss.

Yours sincerel

Matthew Kershaw [i

Chief Executive Discharge Matron Consultant, Medicine Medico-legal
Services Manager