Doreen England

KD,

(©) Birmingham and Solihull NHS)

Mental Health NHS Foundation Trust

Chair & Chief Executive’s Office
Unit 1, B1

50 Summer Hill Road
Ladywood

Birmingham B1 3RB

Tel: 0121 301 1319
Fax: 0121 301 1301

Our Ref: JS/DF/CEO Corres

18 September 2015

Mrs Louise Hunt

HM Senior Coroner, Coroners Court
Birmingham and Solihull Areas

50 Newton Street

Birmingham

B4 6NE

Dear Mrs Hunt
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

| am writing further to your letter dated 23 July 2015 pursuant to Regulation 28 of the
Coroners (Investigations) Regulations 2013.

Thank you for informing me of your concerns relating to the care provided to Mrs Doreen
England by Birmingham and Solihull Mental Health NHS Foundation Trust. | can assure you
that these have been taken very seriously.

In your letter of 23 July 2015, you raised the following matters of concern:-

1. Despite a waterlow score on admission confirming that Mrs England was at high risk
of pressure sore formation, no care plan was prepared. Staff at the inquest confirmed
that they had a lack of knowledge about pressure sore formation and how to prevent
pressure sores occurring. Staff working on mental health wards dealing with elderly
patients must have a clear understanding of basic medical care, in particular how
pressure sores occur and what steps are required to address those at high risk.

2. Since these events staff confirmed at the inquest that they had still not had training on
pressure sore formation and prevention.

3. Rosemary Suite had no leadership at the time. Staff were completing paperwork but
not then actioning risks that were identified. The consultant and ward doctor were on
leave at the same time and medical cover was only available from doctors off site
who had to be requested to attend. The ward and Trust need to ensure that there is
clear leadership on the ward with adequate medical cover.

Chair: Sue Davis, CBE Chief Executive: John Short

PALS Patient Advice and Liaison Service Customer Care Mon - Fri, 8am - 8pm
Tel: 0800 953 0045 Text: 07985883 509 Email: pals@bsmbhft.nhs.uk Website: www.bsmbft.nhs.uk

Ra
POY As ‘ P
VV Impreving mental health wellbeing

Usp Co

was to write to you again in March 2016 to confirm that all future actions have indeed been
delivered. | will diarise this matter and ensure that you receive a letter to this effect.

Yours sincerely

Jer srork.

John Short
Chief Executive

KJ
RECEIVED

2 2 SEP 2015 From Ben Gummer MP

Parliamentary Under Secretary of State for Care Quality

Department OSES
of H ealt h Richmond House
79 Whitehall
London
SW1A 2NS

Tel: 020 7210 4850

Mrs Louise Hunt
HM Senior Coroner — Birmingham and Solihull
50 Newton Street

Birmingham
B4 6NE 21 SEP 2015

17" September 2016

Dear Mrs Hunt

Thank you for your letter to Secretary of State about the death of Ms Doreen
England. I am responding as the Minister with responsibility for care quality at
the Department of Health.

I was saddened to read of the circumstances surrounding Ms England’s death.
The standard of care described in your report is disappointing and unacceptable.
Please pass my condolences to Ms England’s family and loved ones.

You detailed the treatment received by Ms England following her admission to
the Juniper Centre, culminating in her death 30 September 2014.

The report noted a number of concerns including the following;

e Staff working on mental health wards not being trained in pressure sore
formation and prevention; and

e Registered Mental Health Nurses (RMNS) training curriculum not
covering the subject of pressure sores in any detail.

I note that you have also asked NHS England to respond to your findings and I
understand that Sir Bruce Keogh — National Medical Director at NHSE has
responded to your report. Mrs England’s case has been tabled for discussion at

the Quality Surveillance Group in order to address the deficiencies in care and to
look at what needs to happen to prevent any recurrence.

With regard to your concerns about staff training, I have consulted Health
Education England (HEE), which is the body established to help improve the
quality of care delivered to patients by ensuring that our future workforce is
available in the right numbers with the right skills, values and competencies to
meet their needs.

While HEE have a responsibility for promoting high quality education and
training, they are not responsible for setting curricula or the standards of training;
in this instance this would be the responsibility of the Nursing and Midwifery
Council (NMC). Nevertheless, HEE have confirmed that they will work with the
NMC to influence training and curricula as appropriate.

HEE do take account of the impact of actions on the whole health and social care
workforce, especially where the performance of the whole system is so
inherently interlinked.

Health Education England Strategic Framework 2014 -29 — Framework 15
builds upon a Strategic Intent Document published in February 2013 and the
feedback to that and the refresh published in July 2013 and can be found at
https://hee.nhs.uk/2014/06/03/framework-15-health-education-england-strategic-
framework-2014-29/

Framework 15 identified the five characteristics required of the future workforce
to meet the needs of future patients. One of which is the need for a workforce
with adaptable skills, responsive to evidence and innovation to enable ‘whole
person’ care, with specialisation driven by patient rather than professional needs.

HEE plans to undertake a long term piece of work to review the curricula of all
NHS commissioned training programmes to include areas of health, including
learning disability, mental illness, physical illness and physical ill health and
social support needs. Working with regulatory bodies, HEE will agree the
standards and content for education and training; this is anticipated to be
completed by April 2017.

I hope that this infoyfnation is useful. Thank you for bringing the circumstances
of Ms England’s déath to our attention.

BEN GUMMER

RECEIVED
09 SEP 2015

H.M. Senior Coroner

England

Bruce Keogh

Medical Directorate

6" Floor, Skipton House
80 London Road

SE1 6LH

bruce.keogh@nhs.net

4" September 2015

Mrs Louise Hunt
Birmingham & Solihull Areas
Coroner’s Court

50 Newton Street
Birimingham

B4 6NE

Your ref: 003059/2014 - DOREEN ENGLAND (LH/AS)

Dear Mrs Hunt,
Re: Doreen England, Deceased

NHS England has received your regulation report dated 23 July 2015 relating to
the unfortunate death of Doreen England. It was upsetting to read of the
significant failures of care that contributed to her death and we are saddened to
hear of this deficiency in care delivery and extend sincere apologies to the family
of Mrs England.

There are aspects of care in that have been highlighted in the report which
demonstrate an urgent need for rectification. In particular there is a lack of an
appropriate response to assessing Mrs England at high risk of developing
pressure sores. Her risk had clearly been identified and documented on at least
‘two occasions but had not resulted in appropriate delivery of care. In situations
like this whilst staff may not have the necessary skills to respond themselves to
the risk identified, there should have had ready access to specialists, specialist

equipment and easily accessible advice.

High quality care for all, now and for future generations

It is also a significant concern that at the time of the inquest the organisation
involved does not appear to have responded in correcting these issues. We are
in communication with Birmingham Cross City CCG which has undertaken a
significant amount of work in relation to this case already and who commission

the service and will also ensure CQC are aware of the case.

NHS England has oversight of such issues as the convenor of local quality
surveillance groups (QSGs) which bring together the commissioners and
regulators in local areas. In this case, the matter has been tabled for discussion
in our Quality Surveillance Group, where we will oversee the need for a specific
action plan and seek assurance that the deficiencies in care have been
addressed in order to prevent a recurrence. We will ensure you are made aware

of the outcome and actions resulting from these efforts.

| hope that this response containing details of the action proposed provides

assurance.

Yours sincerely,

ul \

mae

Bruce Keogh KBE) MD, DSc, FRCS, FRCP
National Medical Director
NHS England

High quality care for all, now and for future generations