Elaine Jobe

Devon Partnership
NHS Trust

Trust Headquarters

Wonford House Hospital

: re Dryden Road
RECEIVER 25 SEP 270% Exeter

EX2 SAF

7 01392 2088
Dr E Earland Telephone: 66
HM Senlor Coroner Web: www.devonpartnership.nhs.uk

Exeter and Greater Devon Coroner’s Office
Room 226 — ae

Devon County Hall
Exeter 23 September 2014

EX2 4QD

Dear Dr Earland
Re: Elaine Jobe (deceased) — Inquest 9 to 13 June 2014
Regulation 28 Report to Prevent Future Deaths

Thank you for your letter of 11 August 2014 which we received on the 13 August 2014 following the
inquest into the death of Elaine Jobe. As an organisation we are committed to learning from these
tragic events and have since receiving your report and recommendations taken the opportunity to
share your findings with the service involved as well as across the wider trust.

As you will be aware the Trust undertook a Root Cause Analysis Investigation following the death, the
Root Cause Analysis report contained a number of recommendations; all of which were accepted and
the actions were completed. It is clear following review of your report and consideration of your
recommendation that there remain improvements that can be made to prevent future deaths of this

nature,

| have attached a report which details our response to your recommendation and each of your matters
of concern. Whilst we have been able to complete the actions that were identified in the original Root
Cause Analysis the additional actions which are detailed on the attached report are all expected to be
completed by January 2015 and will be monitored through our quality assurance processes.

| hope that the actions described demonstrate our commitment to the learning we have undertaken. If
you required any further information please do not hesitate to contact me. ©

Yours sincerely , ;

Melanie Waiker
Chief Executive

Chair: JulieDent CBE - Chief Executive: Melanie Walker!

Devon Partnership NHS)

NHS Trust

Trust response to the Regulation 28 Report to Prevent Future Deaths following
the inquest in to the death of Elaine Jobe

The coroner’s report identified three matters of concern, each of these have been reviewed
and the following report responds to each of these in turn.

1. Lack of Record Keeping

Inadequate/lack of record keeping on the Rio of:-
(i) Risk assessments and details of those persons making the assessments

(ii) Lack of information regarding the levels of observations and the persons actually making
the observations.

Since the sad death of Elaine the following changes to practice have been made and can be
evidenced.

(i) The Trust has Best Practice and Consistency of Recording on Rio for inpatient services,
which includes risk assessments. Within 7 hours of admission, a risk assessment is
completed by the admitting nurse and doctor. The time and names of the staff completing
the assessment are automatically generated and inputted by the electronic patient record
system on Rio.

Risk assessments are to be updated on the inpatient service weekly. Risk is discussed on a
daily basis in the morning patient review meetings, during handovers and at ward rounds
reviews are documented directly onto the electronic patient care record.

(ii) The Trust Inpatient Service Engagement and Safety Policy sets clear expectations on the
recording of observation levels, both in terms of directly onto the electronic care record for
any patient on heightened levels of observation and for allocating staff to carry out the
observations.

Level 1 hourly observation is the minimum requirement. Some patients dependent on their
risk management plan, will be on heightened levels 2-4. Staff are allocated these duties on
an hourly rota. Staff are aware of their allocated slots by completion of the Staff Allocation
Chart, please see attached. These forms are completed and available in a prominent
position in the ward office where staff have access and know where to locate them. Once
they are no longer required, after each day, they are removed and archived for 2 years as
per Trust Policy.

Clinical recording of the hourly observations for Level 2-4 are recorded directly onto the
patient’s electronic care record after every hour by the nurse who has completed the
observations.

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2. Training

Records of training of staff in the making of risk assessment and in understanding the
meaning of the different levels of observations and implementation of the same.

Since the sad death of Elaine the trust has reviewed its arrangements and put in to place the
following. The Trust requires registered and unregistered staff to be trained in Level 7 Risk
Management and all registered staff to be trained to Level 2. Training is repeated every 3
years. Training reports show that all staff have completed Levels 1 and 2 dependent on their
registration.

Training in the Inpatient Services Engagement and Safety Policy is undertaken on the ward
as training needs to take account of any environmental and risk factors specific to the ward.
Training for new staff is part of the ward induction programme and for existing staff, training
is updated following any review of policy, paying particular attention to any changes in the
policy that require a change in practice.

3. Communication of Patient Status to Incoming Staff

Communication of patient status with other members of staff and identification of a named
nurse with responsibility for each patient on every shift needs to be reviewed so all staff are
clear as to which patients they must monitor.

Since the death of Elaine the ward has an allocation board that is completed for every 24-
hour period, showing the staff on duty and which patients they are allocated to. The board is
in a prominent position on the ward so that staff and patients can see it. Next to this board is
a staff photo board to help patients recognise staff members if they are new to the ward.

At. the start of each shift, a shift planner is completed, which we are able to provide if
needed. Amongst other areas the planner also shows which staff are allocated to which
patient. These are displayed prominently in the ward office where all staff have access. At
the end of each shift these are removed and replaced with a new one for the current shift,
ensuring only the current planner is displayed. The planners once removed from the office
are kept and archived for 2 years. The Trust also. has minimum Best Practice Clinical Shift
Handover Standards. The Standards include prompts for information on every patient that is
needed to be handed over to oncoming staff.

Current Assurance Measures are received by:-

¢ Monthly clinical records monitoring

e Executive safety walkarounds

e¢ Peer Visits

e Supervision

¢ Training Records

« ‘Incident reporting via Risk Management System

Assurance from the CQC inspection on the 3-7 February 2014 on the inpatient wards
at NDDH found that:-

“There were high levels of engagement with patients to monitor their mental wellbeing”.

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“Effective risk assessment and risk management policies and procedures were understood
and followed by staff’.

“We attended handover meetings on both wards during this visit and saw care plans and
risk assessments were displayed for staff to see and used to guide the team discussion.. We
saw information was continually updated during the handover’.

“Patients are informed about different levels of observation by their named or allocated
nurse, which is in the information booklet in every bedroom. For example, a patient told us
they wanted to harm themselves but said “I feel very safe here” and “ all of the staff are very
caring they’re always checking and asking if you are ok”

“Patients consistently praise the quality of engagement and support they receive from staff”

Additional action to be taken following Regulation 28 Report

The Trust has policies, standards and guidance in place for the areas of concern noted in
the report. It is not seen as required to introduce new standards, but to ensure the
embeddedness of those currently in place. The Trust has several assurance measures in
place, but further actions as described below will be put in place to provide additional
assurance.

ACTION
Risk Management

1/ Additional training has occurred during July and August. Although all staff were in date
before the additional training, it is planned that all staff will have additional face-to-face
training from the Clinical Risk Practice Education Facilitator by the end of December 2014.

2! The Facilitator will provide feedback on risk assessments and formulating risk
management plans based on the Standard Operating Procedures and best practice. Each
month a random sample of risk assessments will be reviewed to demonstrate competency.

By Ward manager, consultant psychiatrist, senior nurse, Clinical Risk Practice Education
Facilitator

To be completed by January 2015
Inpatient Services Engagement and Safety

3/ The policy is currently under review, once this is completed, (deadline 31° October 2014),
local ward-based training will be delivered on the policy and evidence collected.

4/ Random monthly audits of patients on Levels 2-4 to ensure recording of observation
levels are embedded as per the policy in both the electronic patient record and on the staff
allocation record

By Ward manager, charge nurse & senior nurse

To be completed by January 2015

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Handover Practice Standards

5/ The Practice Standards have been reviewed in September by senior nurses and ward
managers and agreed and as part of the Trust annual audit plan, this has been an area
identified for audit for completion by the end of 2014. Planned Nov 2014

6/ In addition to the audit - ward manager and senior nurse will attend handovers
periodically to review embeddedness of practice standards

To be completed by December 2014

Communication

7/ Random audit of the shift planners to be carried out to ensure completion of all areas.
By Ward manager

To be completed by December 2015

8/ Staff to introduce themselves to each patient they are allocated at the beginning of the
shift. Practice compliance will be audited twice weekly until it is embedded

By Ward Managers and deputies
To be completed by January 2015

Monitoring and assurance of actions

The actions detailed will be added to the Directorates Quality Improvement Plan and our
central risk management system. Progress against these actions will be reported to the
Directorate Governance meetings and through to our Quality and Safety Committee.. Our
Experience, Safety and Risk team will monitor progress and receive evidence to
demonstrate that the actions have been completed.

Date: 24 September 2014

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