Robert Jones

Northern Devon Healthcare NHS |

NHS Trust

incorporating community services in Exeter, East and Mid Devon

Dr Alison Diamond

Chief Executive

RE CEIVED 2 0 MAR 2015 North Devon District Hospital
Raleigh Park

Barnstaple

Devon

EX31 4JB

Private and Confidential —

Dr Elizabeth Earland

H.M Senior Coroner

Exeter and Greater Devon Coroner’s Office
Room 226, Devon County Hall

Topsham Road

Exeter EX2 4QD

Thursday 12" March 2015
Dear Dr Earland

Thank you for your letter dated 21° January 2015, which enclosed the Regulation 28 Report that
you had prepared following the Inquest into the death of Mr Robert Alan Jones in addition to the
CD recording of the Inquest and a copy of the Record of Inquest.

Please find the Northern Devon Healthcare NHS Trust’s response to section six, ‘action should be
taken’, of the Regulation 28 Report.

(1) Revise the Trust’s falls policy to include the recommended frequency and duration of
neurological observations based on NICE guidance for patients where head injury has
occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of
care.

The Trust’s falls policy (enclosed) has been revised to include information relating to the frequency
and duration of neurological observations (in line with the relevant NICE guidelines) and published
on the Trust’s policy website. The policy includes a post falls checklist (enclosed) which details
how often and for how long neurological observations should be recorded. The Trust’s bedside
handover and safety briefing standard operating procedure clearly identifies information relating to
patient falls (including their risk of falls) is a key component in shift to shift communication, and
must be included in handover. Bedside handovers are audited via observation and reports and
actions provided to wards and teams where there are gaps in information being shared.
Improvement is measured by re-audit. A link from the falls policy will be put in to the Bedside
Handover of Safety Briefing Standard Operating Procedure & vice versa.

(2) Implement a system to ensure the Multi Disciplinary Team (MDT) is aware of the total
number of falls.

page 1 of 2

Northern Devon Healthcare NHS

NHS Trust

incorporating community services in Exeter, East and Mid Devon

As per (1), this information is included in safety briefings, which are multi-disciplinary events.
Additionally, the Trust’s post falls checklist allows staff to record multiple falls on the same
document, ensuring that information relation to falls is held in a central place. The trust is
implementing a system that requires the post falls checklist to be filed with the patient's
physiological observations / neurological observations chart, which is reviewed by the Multi
Disciplinary Team on a daily basis.

(3) Ensure delivery of targeted training on performing neurological observations for
nursing staff at South Molton Community Hospital and as a general communication across
the Trust.

Targeted training on performing neurological observations for nursing staff is in place and all
registered nurses completed this training by the end of February 2015. Additionally, training
relating to reduced consciousness (AVPU — Alert, to Voice, Pain Unconscious) has been delivered
to non-registered support staff.

To support the actions detailed above, the Trust will issue a Patient Safety Alert, which will
communicate the need for neurological observations when a head injury has occurred or cannot
be ruled out, completion of the post falls checklist, to include the frequency and duration of
observations, to ensure the post falls checklist is filed with the patient’s observation chart for ease
of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls
risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are
disseminated across the whole Trust to clinical and managerial leads.

| hope that this response provides you with assurance that the Trust has taken seriously the
findings of the Regulation 28 Report, but please do not hesitate to contact me should you require
further information.

Chief Executive_

’

-DRS GIBB MURCH GILLARD BOWYER & GEARY
The Health Centre 9/10 East Street South Molton N Devon EX36 3BZ
Tel: (01769) 573101 Fax: (01769) 574371
Email: healthcentre.southmolton@nhs.net
Christopher A Gibb BM DA MRCGP DRCOG DPD
Helena J Murch MB BCh MRCGP DFFP
Jonathan D Gillard MB ChB MRCGP_

Justin D Bowyer MBBS MRCGP MRCP

Rebecca A Geary MB ChB MRCGP °

CAG/al

16 February 2015 RECEIVED 2 3 res 20)

Dr E A Earland

HM Senior Coroner

Exeter and Greater Devon Coroner's Office
Room 226 ;

Devon County Hall

Topsham Road

Exeter EX2 4QD

Your ref: |
File No: YY

Dear Dr Earland
Robert JONES Deceased — DOD: 01/04/2014

Thank you for your letter of 21 January 2015. | fully agree with your report and
recommendations.

The recommended actions are primarily the responsibility of the hospital trust: | enclose a copy
of their Action Plan which | have just received from EEE, (Viatron of South Molton
Community Hospital and which | believe satisfactorily addresses all your concerns and
recommended actions.

1 will be sharing this Action Plan with all GP colleagues in my practice and will be having
ongoing discussions with the Community Hospital management team to ensure that these
actions become firmly embedded into practice.

Please do let me know if you have any further questions or concerns.

Yours sincerely

Dr Chris Gibb

Actions to be taken following Coroners Report pertaining to an accidental death as South Molton

Community Hospital.

Date of report 9°" February 2015

Author Edith Breeze matron South Molton Community hospital

Recommendation _

‘Action

itcome:.

Revise the trust falls policy to
include the recommended
frequency and duration of
neurological observations based on
NICE guidance for patients where
head injury has occurred or cannot
be ruled out and inclusion of relent
history of falls in handovers

Falls Policy updated with a review date
September 2016

To include revised post Falls check list
identifying frequency and duration of
neurological observation to be taken
following a fall involving a head injury
Post falls check list provide in each in-
patient folder as a prompt for both
substantive and bank staff to follow for
a patient

2 trainee assistant practitioners to
work with a multi-disciplined team
instigate and embed falls assessment
and cascade this outcomes onto
relevant staff. For example community
falls nurse, occupational therapist and
physiotherapist.

Falls screening undertaken on every
admission to include TRIP and
implementation of Falls Assessment
plan

CT scan as soon as Stroke Symptoms
are evident

Specialist nurse in community to
attend on ward to follow up on
patients who are presenting with falls
on the

Lying and standing Blood Pressure to
be monitored on all patients were
practicable

Completed

Completed and
implemented

Implemented

On-going

Currently being
implemented

On-going
On-going

On-going

| Implement a system to ensure the
Multi-disciplinary team is aware of
the total number of fails

The introduction of the falls Sticker to
insert into patients notes following
each fall top provide concise but
relevant information of harm caused
and immediate action. This is a brightly
coloured sticker to draw attention to
the entries. This has been trialled
successfully in other areas.

Regular safety-briefing throughout
each shift with.the multi-disciplinary
teams

Beds side handovers that include the

¢
To Implemented by
February 2015

Currently being

embedded into practice

and being monitored

patients on each shift

As above

Ensure safe delivery of targeted
training on performing
neurological observation for
nursing staff at South Molton
Community Hospital and as a
general communisation of the
Trust

Delivery of targeted training on
performing neurological observations
for nursing staff at south Molton
Delivery of targeted training for all
heath care assistance in the
understanding and reporting of a
patient with a reduced Alert, to Voice,
pain and unresponsive [AVPU] scoring

All registered nurse will
have completed this
training by February
2015 this is currently
being implemented and j
staff sign off being
achieved

All of the above will be discussed at individual /group supervisions and monitored for compliance
Further group discussion with the ward meeting and minute will be shared with all disciplines to ensure a

shared leaning

1

me