Joyce Hartford

Priden

. The Pennine Acute Hospitals NHS |
Pennine

NHS Trust

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el North Manchester General Hospital
Delaunays Road

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Manchester
M8 5RB

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Mrs L Hashmi

H M Coroner

H M Coroner's Court

The Phoenix Centre

Church Street

Heywood
OL10 1LR

Dear Mrs Hashmi,
Re: Inquest into the death of Mrs Joyce Hartford

| am responding to the recent Regulation 28 report to prevent future deaths, served to the Trust
on 15" July 2015. You raised the following matters of concern with the Trust:

During the course of the inquest hearing it became apparent that the nursing tools (in
particular, the ‘Purpose T’), assessments, records, associated documentation and nursing
discharge summary were incomplete and/or inaccurate. Whilst | was told that the Trust, to
its credit, had been conducting audits since the Summer of 2014 in order to improve nurse
record keeping, Mrs Hartford died in January 2015 and the evidence at inquest did not
disclose any material improvement in overall standards.

As this was not the first case over which | had presided that involved concerns arising from
record keeping that fell below expectation (over and above the aforementioned) |
considered that | was under an obligation to bring this to your attention.

Continued...

Chief Executive, Dr Gillian Fairfield

harman, Mr John Jesky

Pridein . :
Pennine

The Pennine Acute Hospitals NHS)

NHS Trust

Following the receipt of the Regulation 28 | would wish to advise you of the following actions
both within Ward T7 where Mrs Hartford was admitted and across the Trust:

Action taken within Ward T7

We are undertaking a review of current documentation to ensure it meets all Trust
standards and therefore supports improvements in care delivery. On a monthly basis the
ward is audited using the nursing metrics which includes the quality of record keeping.
Since January 2015 Ward T7 has recruited into a number of vacant registered nurse
posts; as part of the induction for these new staff we have developed an induction
booklet which includes the requirement for a senior member of the nursing team to
observe the staff member undertaking various tasks to confirm that these are being
performed competently — this includes completion of documentation such as District
Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools (involves nursing
staff using predetermined questions to ask patients on a regular basis about care needs
and includes checks on the patient environment.)

There are also weekly audits of documentation undertaken by the Clinical Matron/Unit
Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at
the time of the audit. These include accurate and timely completion of risk assessments,
use of appropriate care plans and timely reassessments.

SKIN bundle training has also been provided by the Equipment Co-ordinator who is a
member of the Tissue Viability team.

For early detection and management of pressure ulcers the use of scenario training on
the completion of the PurposeT tool is now in place. The introduction of an air flow
mattress store on the unit now ensures that patients who have suffered a fractured neck
of femur are admitted to the Unit from A&E directly onto a ‘presioco’ mattress.

Since February 2015, the Unit has achieved 90% and above in the Nursing Care
Indicators Audit except for May when the results reduced to 84% and this reduction was
responded to immediately recognising that this was related to a trial of incorporating
nursing documentation within the medical records. This was addressed and results
improved to 92% in June, 95% in July and 93% in August.

Communication and dissemination of actions and lessons learnt is made through a
variety of methods including: newsletters, safety huddles, handover sheets, and
resource and training boards and when indicated on a one to one basis.

| am pleased to advise that since 4" May 2015, Ward T7 has not reported any avoidable
hospital acquired pressure ulcers.

Continued......

Chief Executive, Dr Gillian Fairfield

oan ~~ =
airman, Mr John Jesky

Pridein

; The Pennine Acute Hospitals INHS|
Pennine

NHS Trust

Trust wide initiatives

We would wish to assure you that we are fully aware of the need to continue to improve the
quality of documentation within the organisation and the following initiatives are underway:

¢ Over the past 18 months Nursing Metrics have been introduced, part of which involves
audit of the quality of nursing documentation in the case notes.

¢ Over the last 12 months we have also reviewed the process of developing, reviewing
and ratifying nursing documents to implement a more rigorous governance process
through our Nursing Documentation Group and the Nursing and Midwifery Board. This
project is ongoing. The Nursing Documentation Group has widened its remit to cover
Allied Health Professionals and Maternity documentation. The main objective is to align
documentation control and development processes across specialities.

¢ With the support of the Chief Nurse, we have now secured the support of a team from
the Trust Development Agency to help improve record keeping and a Trust wide
documentation standardisation project is underway.

* The Trust has also commenced the implementation of the ‘EVOLVE’ system which will
introduce electronic records across the Trust. This will be piloted later this year and is
projected to start on 17" November and run for 4 weeks with a Trust wide rollout
projected to take 4 months starting in January 2016. The Project brief is to replace all
clinical documentation with electronic forms hosted within the Evolve electronic case-
note system. This will help mandate the completion of key patient assessments. The first
phase of forms to be piloted on two wards at NMGH will focus on nursing assessment
documents, associated care plans and referrals and will include nutritional assessments,
falls and bed rails risk assessments, dementia screening and the pressure ulcer care
plan.

e The Trust is also introducing Ward Accreditation, a new project which will help us to
monitor safe practice by measuring the quality of nursing care delivered by ward teams.
As part of this project we will be checking and monitoring the quality of record keeping
including patient assessments.

Could | please extend my sincere condolences to Mrs Hartford’s family.
If there is any further information that you require please do not hesitate to contact me.

Yours sincerely

Deputy Chief Nurse)
igned on behalf o (Chief Nurse)

Chairman, Mr John Jesky Chief Executive, Dr Gillian Fairfield

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