Elsie Hayward

Ysbyty Athrofaol Cymru

University Hospital of Wales

oo. UHB Headquarters

Cardiff and Vale Heath Park Pare Y Mynydd Bychan
University Health Board — Cardiff, cri4.4xw Caerdydd, CFI4 aX W

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Professor Adam Cairns
Chief Executive
12 May 2015

Mr A Barkley

Senior Coroner
Coroner's Court
Central Police Station
Cathays Park

Cardiff

CF10 3NN

Dear Mr Barkley
Regulation 28 Report, Elsie May Hayward (died 10 January 2015)

Thank you for your letter dated 19 March 2015 which was received by my office on
26 March 2015.

| have reviewed the points raised within the Regulation 28 report following the
inquest regarding the death of Mrs Elsie May Hayward. My response has been
informed by senior clinicians responsible for the clinical care provided to Mrs
Hayward.

| would of course wish to extend my sincere condolences to the family on behalf of
the University Health Board (UHB).

You will be aware that the University Health Board undertook and _ internal
investigation conducted by a |i: & Bone Health Programme Manager
and a Consultant Nurse for Older Vulnerable Adults prior to the
inquest. e report detailed a series of recommendations for the UHB and a
continuous improvement plan was subsequently developed. A summary of the

actions being taken forward include:
e At Ward level:

° Board rounds, safety briefings and MDT meetings are held to discuss
risks, actions and raise awareness of the risks of Falls for patients on
anti-coagulation.

° A Disciplinary investigation in to the practice of an individual nurse is to
commence due to repeated failures to follow UHB policies and
procedures following a patient fall

° General staff in this clinical area are being retrained

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e Local compliance audits are to be maintained
° A Training strategy has been developed and implemented

e Medical staff (including medical students) induction will be revised to
include the practical aspects of ward based falls assessment tools/use
of bedrails.

This incident, the findings of the investigating and the areas of concern within the
Regulation 28 report have been discussed at the UHB Quality, Safety and
Experience Committee on 21 April 2015 and also at the Public Board meeting last
week on 5 May 2015.

In addition to the measures being taken forward by the Medicine Clinical Board to
address the local issues identified, the Executive Nurse Director and Medical
Director have issued a Situation, Background, Assessment and Recommendation
(SBAR) report across all Clinical Boards within the UHB to ensure that the learning
from this case is shared and leads to improvements across the whole organisation.

An Internal Audit of the processes in place for the management of falls within the |
UHB was carried out during 2014 and was reported to the Audit Committee in April |
2014. The level of assurance given as to the effectiveness of the system of internal
control in place to manage the risk associated with Prevention & Management of
Falls within the UHB was assessed as Substantial Assurance. The UHB will now
give further consideration to the need for a further Internal Audit over the coming
months.

For ease of reference | have set out below the UHB’s response to the points you
have raised in the Regulation 28 report:

1 On7 January 2015 medical staff were having to care for 50% more patients
over what is generally considered to be a safe staff to patient ratio. The
evidence showed that the team was significantly overstretched and as a
result were not able to oversee the care of this lady. Because of the
pressures on the team it is likely that there were deficiencies in the care
afforded to her which may have contributed to her repeated falls.

The pressures on staff that were caring for Mrs Hayward during her stay in
hospital have been recognised as significant. There were several factors that
contributed to this. Over the Christmas period the acuity of in-patients coupled
with the level of admissions led to a situation where a number of medical patients
were admitted to outlying beds in other specialties. This meant that the medical
staff had to care for more than their usual number of patients. We recognise that
this is unacceptable and that a safe staff to patient ratio is absolutely paramount
to maintain the safety of our patients. Currently there are no national recognised
standards for medical staffing levels although this is currently being considered
by the Royal College of Physicians (RCP) and the UHB will work with the RCP to
agree staff requirements and standards for the medical management of patients
who are outliers.

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To avoid this situation in the future the UHB is taking forward a number of
actions:

The Clinical Director for Internal Medicine has worked with the junior doctors, led
by the Chief Resident (SpR) to agree a process for covering vacancies due to
short term sickness/absence to ensure that staffing is not compromised.

Annual! winter planning incorporates the need for additional medical beds over
the winter months to accommodate the anticipated additional demand. Planning
for Winter 2015 will incorporate the lessons learned from last year to ensure that
there are sufficient beds on each hospital site and ensure that as far as
reasonably possible there are no medical outliers.

In times of extreme pressure, the Medical Director makes representation to all
Clinical Boards to make sure that as many medical staff are undertaking generic
medical duties as possible to increase capacity in areas which are under more
pressure.

Additionally the UHB continues to prioritise issues of patient flow and monitors
workload pressures for the multi-disciplinary team and recognises associated
risks. The Medicine Clinical Board (MCB) will continue to work with the UHB
patient flow work stream in order to safely manage patient flow through the
organisation. Risks identified will be managed via the Risk Register and acted
upon accordingly.

Despite clear guidance and directive the neuro observations on the
deceased following her head injury were not undertaken in accordance with
the Health Boards procedure and the NICE national guidance.

As previously described, the case has been discussed at various senior and
executive committees including the UHB Board and UHB Quality, Safety and
Patient Experience Committee. It has also been discussed at the Medicine
Nursing and Midwifery Board with particular reference to neurological
observations.

More recently, Welsh Government has issued Patient Safety Notice
PSN/O009/April 2015 - Awareness of NICE Clinical Guidelines on head injuries -
and this has been issued to all Clinical Boards to remind them of the importance
of this particular guidance. Within the medicine Clinical Board, Lead and senior
nurses will ensure further dissemination of this information to ward sisters by the
end of May 2015.

There will be a planned audit by the end of July 2015 of any known patient fallers
with a head injury to give assurance that staff are complying with the
requirements of the NICE Guidance and relevant UHB policies for the
management of patients following falls.

The nurse responsible for Mrs Hayward’s care is currently under investigation in
line with UHB policy. This issue is also highlighted in the SBAR circulated on
behalf of the Executive Nurse Director and the Medical Director.

3 There were extensive omissions in the note taking and a clear
inconsistency between nursing notes and clinical notes resulting in
confusion and a breakdown in communication between the nursing staff
and the medical team.

The omissions and inconsistencies in notetaking has been recognised and
immediate action has been taken to remove the “core-care plan” and staff will
now write individualised care plans for all patients. Further checks have been
made in all other areas within Medicine to ensure the core care plan is not being
used, The “real time” documentation has also been removed so that only one
clinical note is in use.

The Medicine Clinical Board representatives at the Vulnerable Adult Risk
Management Group (VARMG) will support the development and dissemination of
a new care plan to the clinical areas, utilising champions from the newly formed
Falls Focus Group as required.

The Ward Sister has been reminded of the need to ensure safety briefings are
undertaken with multidisciplinary staff to ensure that issues in relation to safety
are communicated.

The revised nursing establishments will facilitate a clinical nurse being present at
Board rounds, ward rounds and Multi-disciplinary Team meetings so that
communication can be improved. There is a recognition that this will not be fully
effective until all the nurse recruitment has been completed but is imminent.

The UHB, in line with all other Health Boards in Wales does not have a single
electronic patient record in place but will continue with all Wales work to progress
this agenda which would inevitably bring significant patient safety benefits.

The continuous improvement plan has been presented and discussed at the
Medicine Clinical Board formal Board meeting and has also been shared at the UHB
Quality, Safety and Patient Experience Committee meeting. The Directorate is
required to regularly review the improvement plan and provide assurance to the
various quality and safety monitoring mechanisms. An update on progress will be
presented at the September 2015 Quality, Safety and Experience Committee.

| hope that the information set out in this letter and the attached continuous
improvement plan provides you with assurance that the Health Board has fully
considered the issues raised both as a consequence of the internal investigation into
this incident and also of your Regulation 28 report of 19 March 2015 and has taken
action in response.

If you require any further information please do not hesitate to contact me.

Yours sincerely

Professor Adam Cairns
Chief Executive

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