Henry Powell

Leicestershire Partnership

NHS Trust

From the Executive Office A University Teaching Trust

Direct dial Lakeside House
4 Smith Way

Our ref: Grove Park
Enderby

Leicester

30 March 2015 LE19 1SS

Tel: 0116 295 0030
Fax: 0116 295 0842
Mrs L Brown www. leicspt.nhs.uk

H M Assistant Coroner |
Leicester City & South Leicester |
The Town Hall |

Town Hall Square h, cava ange |
Leicester :
LE1 9BG

Dear Mrs Brown,
Re. Henry Denis Whitwell POWELL

Further to your report dated 18 February 2015, in accordance with paragraph 7, Schedule 5
of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013, | offer the following response.

We have investigated the matters you raised in your report, relating to concerns about
discharge care planning, the conflict currently between the policies governing transfer
arrangements between University Hospitals of Leicester NHS Trust (UHL) and
Leicestershire Partnership NHS Trust (LPT), the inadequate co-ordination between
services, and the communications between stakeholders in the provision and ordering of bed
rail equipment.

Please note that the scope of our response relates to adults over the age of 18 years and
each concern is addressed in turn below. The LPT Action Plan that follows from our
responses is at the Annex and will be monitored by Board’s Quality Assurance Committee.

1. The discharge care planning was inappropriate and there was a significant
misunderstanding regarding the intended and appropriate use of the bed rails
which suggested insufficient training of discharge staff.

Health care professionals working for LPT will discharge patients with bed rails and
order bed rails where assessed as appropriate. This takes place predominately in
community in-patient services. It may also occur in Mental Health Services for Older
People (MHSOP), Adult Mental Health and Learning Disability Services.

Our health care professionals working within an in-patient setting are trained in the
appropriate use of bed rails through the essential to role falls training. All staff
working within these areas have undertaken a clinical workbook that incorporates
falls training. The clinical workbook is being replaced with a continuous roll out
training programme for all healthcare professionals. Currently compliance records
for falls training is held locally on each ward. We are in the process of establishing
how training compliance can be reported on divisionally to enable wider scrutiny.
Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller

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From May 2015 falls training will be included on the Trust's centralised training
database (ulearn) system giving a more systematic approach to recording and
monitoring of compliance to falls training.

The correct use of bed rails is included within the staff induction, and also in the
annual update mandatory moving and handling training for all our healthcare staff.

The Integrated Community Equipment Service (ICES) will be providing essential
training for staff that are able to assess patients for bed rails and order bed rails,
especially when transferring from hospital to community environments. When this
training becomes available LPT will support staff to attend.

There is a conflict currently between the policies governing transfer
arrangements between hospital (UHL) and community (LPT) and the provision
and ordering of equipment, which can now be done directly by the hospital.

Our Lead Nurse for Community Services, Community Health Service division is
leading the development of a shared policy for the safe use of bedrails.
Representatives from LPT, UHL, ICES and West Leicestershire Clinical
Commissioning Group have met and agreed the areas for development and wider
consideration. The draft combined policy will be available for each organisation to
adopt by the end of April 2015.

A standardised assessment and risk assessment flowchart to determine the
appropriateness of bedrails for individual patients has been devised for use in all
organisations. This will ensure that patients will be assessed for the safe use of bed
rails using the same process regardless of the environment in which they are cared
for. The risk assessment will be used in conjunction with a standardised care plan
for patients assessed as suitable for use of bed rails. These will be available within
the shared policy and as separate workable documents. The development of a
standardised approach to risk assessment and care planning will aid communication
and transfer arrangements of patients.

Co-ordination between services is inadequate, resulting in equipment being
ordered by the hospital, but not thereafter being followed up or assessed in the
community.

The newly devised shared policy for the safe use of bedrails will include the
responsibilities of staff when transferring patients, stating when and who will provide
on-going risk assessments. For patients discharged from healthcare services with an
on-going need for bed rail use with formal or in-formal carers a minimum standard of
information will be provided. The local authorities have been involved to determine
the most appropriate transfer of care arrangements for those patients who do not
have a continued health care need.

The ICES will be including a message within their newsletter to alert all staff to the
need to share bed rail assessments, risk assessments and the type of bed rail
provision on discharge. The communication from ICES will be delivered to all
healthcare professionals across the organisations including LPT's healthcare
professional staff that are able to order equipment.

Equipment is supplied by a single gatekeeper, NRS Healthcare, and an alert
system is intended to ensure communication has taken place between all

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Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller

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54

stakeholders, but | was advised that this system has not been implemented;
early implementation would assist in resolving the current difficulties.

An alert on the NRS Healthcare ordering system has been put in place.
The alert requires the healthcare professional ordering the equipment to confirm that
a full assessment and risk assessment has been completed that supports the bed
rails are a safe and appropriate for the individual patient. The system will not allow
the order for bed rails to be placed if the risk assessment is not confirmed

LPT takes these concerns very seriously and | trust that you will be satisfied that we have

taken the appropriate measures to prevent such an occurrence happening again

Yours sincerel

Dr Peter Miller
Chief Executive

Annex: LPT Action Plan

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University Hospitals of Leicester INHS

NHS Trust

Direct Lire:
Fax No:

E’Mail:

Your Ref a

Our Ref:

10 April 2015

Mrs C Mason

HM Coroner

The Coroner's Court,
Town Hall,

Town Hall Square,
Leicester

LE1 9BG

Dear Mrs Mason
Re: Henry Dennis Whitwell Powell

| write further to your Regulation 28 sent to us on 18 February 2015, and | am
now in a position to respond. | note that the matters of concern are as follows:-

1. The discharge care planning is felt to be inappropriate with misunderstanding
regarding the appropriate use of bed rails.

2. There was felt to be a conflict between the policies governing transfer
arrangements between my Trust and the Community Services, and the
provision and ordering of equipment.

3. Co-ordination between services provided by UHL and LPT was felt to be
inadequate.

4. Implementation of an alert system to ensure communication between all
stakeholders has not been implemented.

Since the conclusion of this inquest | can report that we have taken steps to
strengthen our processes

In light of what occurred in this case, our Lead Discharge Nurse has met with
all staff working in the Trust, who are authorised to order bed rails for
discharge, to ensure they are up to date with the procedure for ordering bed
rails and to ensure they fully understand how to use the bed rail risk
assessment matrix for patients who are at risk of slipping, sliding or rolling out
of bed. She has used this case to emphasise the importance of strictly
University Hospitals of Leicester NHS Trust includes
Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary
Website: www. lei rhospitals.nhs.uk
Chairman: Mr Karamjit Singh Chief Executive: Mr John Adler

adhering to the approved process for discharge including when bed rails are
to be provided. Supported by our Acting Chief Nurse, she will ensure that
training is provided to relevant staff on the Trust's processes for discharge
and this will include training on bed rails risk assessment.

All staff authorised to order bed rails are all now aware of their responsibility
to forward a copy the risk assessment and care plan undertaken by UHL staff
to the person responsible for the patient's care in the community setting
following discharge from UHL and the information will also be recorded on the
electronic transfer letter on ICE and audited. In addition, our Acting Chief
Nurse will ensure that the Manual Handling Team will review the manual
handling training undertaken by Ward staff, to ensure they are able to
understand and interpret the risk assessment matrix, to aid their decision
making, for the use of bed rails for patients who are at risk of slipping, sliding
or rolling out of bed in the hospital setting.

This case has been discussed at the recent CMG Health and Safety Board
and it was agreed that details of bed rail risk assessments will be recorded in
the metrics that we collect and which provide an indication of current concerns
within the clinical setting. In particular, we will be strengthening our guidance
on the meaning of patient mobility to improve the quality of our bed rail risk
assessments.

Our Acting Chief Nurse will ensure that all of the above action will be
completed by June 2015.

On your second and third concerns | am pleased to be able to confirm that my
Trust and Leicestershire Partnership Trust are working together to remove
any conflict between our respective bed rail policies. Our Lead Discharge
Nurse is working collaboratively with representatives from community
hospitals, community nursing and NRS to agree a joint working policy for the
safe use of bedrails. The working group have met twice to agree the process
of assessment; development of a care plan and handover arrangements
following transfer from hospital. A further meeting is scheduled for 10" April
2015, to make final adjustments to the policy, before this is sent for
ratification. Our Acting Chief Nurse will ensure that this work will have
occurred by May 2015. In addition, our Discharge Policy will be reviewed and
will advise staff to consult the joint policy for the safe use of bedrails. This
work will be completed by the end of June 2015.

In addition, to ensure Trust-wide learning, this case will be discussed at UHL's
Falls’ Group which is chaired by a senior clinician and also at the next
meeting of the Trust's Nursing Executive Team which is chaired by our Acting
Chief Nurse.

On your fourth point our Lead Discharge has confirmed that an alert system is
now in place on the electronic ordering system to prompt staff to consider a
bed rails risk assessment. If this information is not completed, then the
system will prevent bed rails being ordered.

University Hospitals of Leicester NHS Trust includes
Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary
Website: www. leicesterhospitals.nhs.uk
Chairman: Mr Karamjit Singh Chief Executive: Mr John Adler

| trust that this response provides you with the assurance that we take these
matters seriously

If you would like any further information please do not hesitate to contact me

Yours sincerely

John Adler
Chief Executive

cc John Adler, Chief Executive

Assistant Director (Head of Legal Services)
Acting Chief Nurse

University Hospitals of Leicester NHS Trust includes

Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary

Website: www.|leicesterhospitals.nhs.uk
Chairman: Mr Karamjit Singh Chief Executive; Mr Johr