Hilda Haughton

From the Lord Prior of Brampton
AG Parliamentary Under Secretary of State for NHS Productivity (Lords)

Department

of Health

Case 1001818

Mr J . Pollard Michmond Howse
Senior Coroner London
Coroner’s Court SWIA 2NS
1 Mount Tabor Street Tel: 020 7210 4850
Stockport

SK1 3AG

21 DEC 2015

Thank you for your letter of 4 November 2015, following the inquest into the death
of Hilda Haughton. I was sorry to hear of Mrs Haughton’s death and wish to
extend my condolences to her family.

I was concerned to read of the injuries sustained by Mrs Haughton whilst she was a
patient at Tameside Hospital. I note that you have requested a direct response from
the hospital in relation to the improper use of cot rails on Mrs Haughton’s bed and
a lack of candour shown by hospital staff to the family. I expect Tameside
Hospital to fully address these concerns, and I have asked to see a copy of its
response to you.

The issue you raise for the Department concerns the speed of closing for fire doors
held open by electromagnetic devices, in hospitals in England. The system means
that hospitals can programme the speed at which their fire doors automatically
close in the event of a fire or other emergency. However, the faster the closing
time, the greater the force with which the doors close.

You report that Tameside Hospital has, in the wake of Mrs Haughton’s death,
increased the closing time of their fire doors from three seconds to six seconds to
reduce the speed and force with which the doors close. However you question
whether this is an adequate response and suggest that the potential dangers of fire
doors, held open with similar types of door fastener, need to be raised with all
hospitals.

The relevant British Standard covering the requirements for such devices is BS EN
1154: 1997 Building hardware — Controlled door closing devices — Requirements
and test methods. This British Standard allows a degree of flexibility in the speed
at which doors should close of between 3 and 20 seconds.

It is not therefore in the Department’s power to control how long it should take for
fire doors to close in NHS premises. Such matters are for local management to
decide in light of legislation, advice from relevant professional bodies and in line
with recognised safety standards.

Having considered the circumstances of this particular tragic incident and made
reference to the British Standard, the Department has issued an Estates and
Facilities Safety Alert to the NHS in England.

The Alert reference is EFA/2015/006 and was published via the Department’s
Central Alerting System on Thursday, 3rd December 2015. The alert will also be
published by the devolved health administrations in Wales, Scotland and Northern
Ireland (who have been consulted on the content of the alert) on the same day.

The purpose of the alert is to raise awareness of the circumstances of the incident
you have reported and to set out necessary action to be taken, within defined
timescales, to reduce the risk of similar incidents in the future. The actions set out
in the alert are not restricted to fire doors held open by electromagnetic devices,
and are intended to cover all self-closing fire doors.

This alert follows an earlier safety alert issued to the NHS in 2004, which stated
that: “Any remote or unsupervised release of self-closing fire doors may injure
occupants. The responsible person should only carry out fire alarm tests and/or
remotely release self-closing fire doors if arrangements (so far as is reasonably
practicable) are in place to safeguard the occupants from injury, e.g. by a door
striking the occupant.”

A copy of the Estates and Facilities Safety Alert is attached for your information.
I am grateful to you for bringing the circumstances of Mrs Haughton’s death to my

attention and hope that her family can take some comfort from the actions the
Department is taking to reduce the risk of a similar occurrence in the future.

irs —

DAVID PRIOR

Tameside Hospital NHS)

NHS Foundation Trust

“emery

KN.

Tameside General Hospital

Quality and Governance Department ; .

Silver ‘Springs . t Fountain Street

Tameside General Hospital >) Ashton-Under-Lyne
Tameside

OL6 SRW

Ashton-Under-Lyne
OL6 SRW

Telephone: 0161 922 4466 Telephone: 0161 922 6000

Fax: 0161 922 6190

27" November 2015

Your ref: JSP/GB/01246-2015

Mr John Pollard

Senior Coroner for Manchester South
The Coroner's Court

1 Mount Tabor

Stockport SK1 3AG

Dear Mr Pollard

Inquest: Hilda Haughton

| write in response to your Regulation 28 Report dated 29 October 2015,
issued at the conclusion of the inquest touching upon the death of Hilda
Haughton, which took place between 26 and 27 October 2015.

In your report you have raised one concern with Tameside Hospital NHS
Foundation Trust about a fall which occurred on 6 May 2015 on Ward 41 at
Tameside General Hospital. Your concern is that there was a “lack of
candour” by the hospital staff in respect of that fall.

| hope this response provides you with the reassurance you require to this
concern. | hope that your concern can be addressed firstly with specific
reference to the incident referred to on 6 May 2015, as well as by explaining
to you the Trust's attitude and culture regarding openness and candour.

Incident on 6 May 2015

| wish to take this opportunity to make it clear that the incident on 6 May 2015
did not invoke the Statutory Duty of Candour under Regulation 20 (2) of the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An
unwitnessed fall occurred on or around 04:50 on 6 May 2015. The medical
records demonstrate that following this Mrs Haughton was given a head-to-

‘a
Everyone

6

Matters # a

The Trust’s attitude towards candour

The Trust has been very proactive in relation to ensuring Duty of Candour,
Trust policies have been reviewed and consideration continues to be given
regarding statutory obligation when reviewing and updating policies and

procedures.

The Trust was comprehensively inspected by the CQC in May this year and
they commented in their report that they were particularly pleased with the
progress the Trust had made with candour and with the governance

processes put in place to support this.

| along with my leadership team have a strong leadership ethos regarding
candour and believe that leading by example is key in demonstrating the
Trust's commitment in relation to candour. My Director of Quality and
Governance and | both regularly meet with families and patients to discuss
their experiences and to apologise when things go wrong.

During February and March 2015 the Trust ran several workshops which were
delivered by external facilitators and were attended by a wide range of staff
which focused on investigations, Root Cause Analysis and incorporated
communication and supported the culture of reporting and openness. We
trained over 75 staff in this and Being Open and Duty of Candour was central

to the training.

In order to ensure the Trust is transparent and learns from incidents,
complaints and claims we have commissioned a significant number of
independent expert reports to ensure transparency and openness with our
patients, relatives and carers which we share with them and with our staff for

learning.

The Trust's processes for openness and candour encourage local meetings
with medical and nursing and support staff with patients, families and carers
to discuss management plans and promote effective communication and early
resolution of any questions or concerns.

The Trust has commissioned a number of patient experience films with our
patients and their relatives to ensure that their perspective and _ their
experiences are shared with staff and that we learn from these. One of the
consistent messages in these is the importance of communication and how
this effects the patients and families perception and how this influences their
view of the Services in relation to openness and candour. These are available
on the Trust intranet and public internet and focus on both the negative

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