Adam Withers

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Comrmiss ion Making the health sector - . _ ne
work for patients Quality, Delivery. Sustainability.

NHS Improvement
(Monitor and the NHS Trust
Development Authority)

Wellington House
133-155 Waterloo Road
London
15 January 2016 SE 8UG
020 3747 0000
Letter to: CEOs Trusts and Foundation Trusts
Finance Directors Trusts and Foundation Trusts
Medical Directors Trusts and Foundation Trusts
Directors of Nursing Trusts and Foundation Trusts

Dear Colleague,

We are all aware that the NHS, and providers specifically, have been under great
pressure as we seek to improve quality outcomes for patients within the financial
resources available. However, the size of this year’s provider sector deficit makes it
clear that, collectively, we need to focus more on financial rigour as one of the routes
to excellent quality.

We recognise that both our organisations — NHS Improvement and the CQC — have
an important role in enabling every trust to deliver that balance. We also recognise
that how we do our work, the signals we send and how we work together, are an
important influence on whether you can deliver that balance or not.

We have therefore been discussing between ourselves, and with senior provider
colleagues, what more we can do to help and support you and we wanted to share
the early outcomes of that work. ‘Early outcomes’ because, at this point, this is a
strategic statement of intent and we want you to tell us what we have to do differently
to secure the right finance/quality balance that we all need.

Success is delivering the right quality outcomes within the resources available

We want to start off by being clear that, from our perspective, quality and financial
objectives cannot trump one another. We know that, in the past, there was a
perception that delivering financial targets was more important than delivering the
right quality outcomes; and that, more recently, improving quality was more
important than staying in financial surplus.

We want to clearly and unequivocally state, with the full support of our other arms’
length body colleagues, that your task as provider leaders is to deliver the right
quality outcomes within the resources available.

That is how we will both measure success and that is how the NHS Improvement
regulatory framework and the CQC inspection regime will be framed going forward.
Some changes will be needed to make this happen in exactly the way we now want.

We will involve you in how we make’ those changes ~ for example through the
consultations that we will shortly be launching on the CQC’s future strategy anda
single new NHS Improvement regulatory framework for providers.

CQC and NHS Improvement working together on a single national framework

We recognise that it is particularly important that you get a single clear, consistent
message from both of us on this issue. There has been a perception in the past that
our organisations have had greater focuses on different sides of the quality/finance
balance, potentially creating unhelpful mixed messages.

So, we will jointly design the approach the CQC will use to assess trusts’ use of
resources. We are also looking at how the CQC can use the financial data NHS
Improvement holds and use the expertise of NHS Improvement staff in reaching its
judgements on use of resources. Similarly, as NHS Improvement develops its view
of the role of quality in the new, single, provider regulatory framework, we will do this
jointly with the CQC and NHS England. We will also be sharing revised National
Quality Board staffing guidance and a new metric looking at care hours per patient
day that we will both use in looking at how trusts manage staffing resources.

In practical terms, we want regulators and commissioners to rely on each other's
work, rather than duplicating effort, and we want to create a single unified framework
with a single way of measuring success that we all use. We want this to bring greater
clarity and consistency and reduce the regulatory burden, as you have asked for.

NHS Improvement and CQC working together on turnarounds

One of NHS Improvement’s early priorities will be to work with organisations with
large deficits to help them return to surplus. There is an incorrect assumption that
this can only be done at the expense of quality. So we will, again, be working
together closely so that we can all be sure that, even in the trusts facing some of the
biggest financial challenges, it is possible to balance finance and quality.

We hope this gives you a clear statement of our joint intent - success is delivering
the right quality outcomes within the resources available — and how we want to
translate that intent into the way we work in future. Please provide us with any
comments you have on this letter and tell us what more we can do — our email
addresses are below. It would help if you used "JOINT NHSI/CQC LETTER’ as the

subject of any email you send us.

fe CS lige PaO
Ae

Professor Sir Mike Richards

Chief Executive Chief Inspector of Hospitals

NHS Improvement Care Quality Commission
Jim.Mackey@monitor.gov.uk Mike.Richards@cqc.org.uk

Jim Mackey

Philip Dunne MP

. Minister of State for Health

Department
of Health

Richmond House

79 Whitehall

London

; ; SW1A 2NS

Ms Alison Hewitt Tel: 020 7210 4850

Assistant Coroner

HM Coroner for Surrey
H.M. Coroner’s Court
Station Approach
Woking

Surrey

GU22 7AP

¥ yc Ce Loc

Thank you for your letter of 17 February 2016, following the inquest into the death of
Adam Withers. I was sorry to hear of his death and wish to extend my condolences to
his family and I apologise for delay in providing this response.

There are two concerns for the Department’s attention. The first concerns the
destruction of original paper patient records after they have been transferred to
electronic format following a patient’s death. You are concerned that such practice,
when it is apparent that the death must be reported to either police or coroner, could
undermine any police or coroner investigation. The Trust considered it was adhering
to the NHS Code of Practice on Records Management when the paper record was
destroyed after converting it to electronic format. You are unsure whether this was a
correct interpretation of the Code and consider that no clear guidance on this issue
exists.

Our view is that original paper records should not be destroyed after a patient's death
where the death may be subject to investigation. I fully support the view that the NHS
must be totally candid in its dealings with coroner or police investigations.

This raises a question about whether the Trust acted appropriately in destroying the
paper record following Mr Withers’ death. It is not clear from the information
available whether the Trust was aware that a coroner’s investigation was going to
take place. Destroying the paper record might have been justifiable if that took place
before the Trust was aware of the possibility of an investigation. Destruction would
have been much less justifiable where an investigation was already underway.

The NHS Records Management Code of Practice is currently under review and a
revised Code is due to be published when the review is complete. Clear guidance on
the point you raise will be added to the revised Code before publication.

Your second concern relates to insufficient staffing levels both on Elgar Ward at
Epsom General and in acute psychiatric wards in general. The Trust informed you at
the inquest that there are no nationally set “safe staffing levels” for acute psychiatric
wards. You are concerned that this could leave patients in such wards at risk due to
inadequate supervision, observation and intervention.

As set out in the NHS Constitution, patients have the right to be treated to a
professional standard of care, by appropriately qualified and experienced staff, ina
properly approved or registered organisation that meets required levels of safety and
quality. Reports on the failings at Mid Staffs highlighted the importance of the
appropriate staffing levels to the delivery of safe and effective care. The Care Quality
Commission’s (CQC) Fundamental Standards require care and treatment to be
provided in a safe way, and that includes safe levels of staffing.

Responsibility for staffing rests (as it has always done) with Trust boards. Trusts’
staffing arrangements should enable the right numbers and skill mix of staff at the
right time to deliver quality care and patient safety while doing so efficiently, taking
into account local factors such as acuity, case mix and how to respond to fluctuations

in workload.

This was underlined by:

e recent correspondence - a letter on safe staffing and efficiency was sent to NHS
Trusts in October 2015 from NHS Improvement, CQC, NHSE, the Chief
Nursing Officer and the National Institute for Health and Care Excellence;
underlined by a letter in January 2016 from the Chief Executive-designate of
NHS Improvement, Jim Mackey, and the Care Quality Commission’s Chief
Inspector of Hospitals, Professor Sir Mike Richards. Copies of these letters are
enclosed.

e Lord Carter's review highlighted the importance of getting staffing right as a
means of increasing the productivity and efficiency of the health service while
providing good quality, safe care; and

e publication in July 2016 of refreshed National Quality Board (NQB) guidance
on Safe and Sustainable Staffing.

https://www.england.nhs.uk/wp-content/uploads/2013/04/ngb-guidance.pdf

This refreshed guidance acts as a resource to support the decisions that trust Boards
need to make, bringing together judgements about eg casemix and patterns of demand

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Department
of Health

to ensure their arrangements underpin safety while still being affordable and
sustainable.

It emphasises that Trusts’ focus should be on patient outcomes rather than relying on
input measures such as crude numbers or ratios of staff.

We do not agree that a minimum staffing level for services would be a “guarantee for
safety”: the evidence base is lacking and minimum staffing numbers and ratios would
not take account of local circumstances, skill mix or case mix. Following publication
of the revised guidance by NQB, further outputs will be developed by the national
programme for individual settings including mental health and learning disability
settings.

hope that this reply is helpful and I am grateful to you for bringing the
circumstances of Mr Withers’ death to my attention.

PHILIP DUNNE

Surrey and Borders Partnership NAS

NES Fo ation, Trust

Our Ref: FEAvc Trust Headquarters

18 Mole Business Park
Leatherhead

11 April 2016 Surrey KT22 7AD

Alison Hewitt

Tel: 01372 216292
Fax: 01372 217100

Assistant Coroner for Surrey Email: T sisiSY

Sent via email

Dear Ms Hewitt

Inquest into the death of Adam Withers - REGULATION 28 REPORT TO PREVENT
FUTURE DEATHS

Further to the recent conclusion of the inquest into Adam Wither'’s death on 9 May 2014,
you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with
the Regulation 28 report to prevent future deaths, stating that during the course of the
inquest the evidence revealed matters giving rise to concern. We would like start our
response, by offering our sincere condolences to the Withers’ family for their loss.

The areas of concern you raised that relate to our Trust and our responses are detailed
below:

1.

it was clear from the evidence that nursing staff involved in Adam Wither's care
failed to record sufficiently his presentation and their interactions with him.

We acknowledge that our record keeping practice did not meet our desired and
expecied quality levels in this instance and we have learnt from these identified
deficiencies. We have already instigated work to further improve the quality of our
engagement with people using our adult inpatient services, by ensuring that all
interactions are meaningful, using a process of purposeful engagement (a modified
form of intentional rounding). The purposeful engagement process assists our staff in
ensuring continuous assessment of individuals so timely interventions can be
undertaken when necessary. As part of this process we expect all staff in these
services to record interactions in the person’s clinical records in a timely way.

We have also revised our Observation Policy to include much clearer guidance on how,
when and where people should record all clinical interventions. This includes a review
of the assessment section of this policy, which clearly states that all people that use our
inpatient services will have a comprehensive Risk Assessment. This will include

Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD

0300 55 55 222 F_01372 217111 www.sabp.nhs.uk

looking at risk of suicide, absconding, self-harm, violence, vulnerability to exploitation
and self-neglect.

lt is further outlined that this assessment will be recorded in the person’s
multidisciplinary clinical records, along with the joint decision regarding the level of
observations assessed, as being most appropriate. This record will include details
about specific elements of risk, including any relevant trigger factors to be considered
when carrying out the observations. There is also a clear expectation that where
specific risks have been identified by the referrer, those people awaiting assessment
should be kept within eyesight observation.

To ensure wider understanding of the observation expectations, we have issued a
Trust-wide Clinical Risk Alert clearly outlining our expectations in this regard.

, ltwas clear from the evidence that any note made in a patient's record should
be made contemporaneously or, if made later, should be timed, dated and
labelled as retrospective. This is necessary to ensure all notes are accurate and

reliable.

We have since reviewed our Records Management Policy which has a section outlining
the ‘Standards for Record Keeping’. Under these standards there is clear expectation
that:
a) All records will be factual, consistent, accurate and evidence-based. Where
records are professional opinions, this must be clearly stated.
b) Records will be written as soon as possible after a contact has occurred,
providing current information on the care and condition of the person who uses
our services (within 24 hours).

It is also our expectation that all our registered staff work within their relevant
professional codes of practice. The NMC state that, in line with local policy, staff should
put the date and time on all records. This should be in real time and chronological
order, and be as close to the actual time as possible (the contemporaneous record).

In an emergency where staff are unable to record the times we would expect them to
highlight that the record/entry is retrospective, but should still follow a chronological
format of proceedings. Our use of the electronic patient record system in our Acute
Services now removes any doubt about record entry time as every entry now leaves a
clear audit trail which can be reviewed as required. Quality is further maintained when
we share learning from our record keeping audits which we undertake as part of our
clinical audit program.

We have added the issues identified in the Regulation 28 report and our resulting
actions to our corporate action plan, which we share with commissioners to ensure we
continue to embed learning from issues raised. We would like to offer our sincere
condolences again to the Withers family for their loss. We hope that the steps we have
taken as outlined above assure you and Adam's family that we have learnt and

continue to learn from his death. Please do not hesitate to contact me or Jo Young,
Director of Quality and Deputy Chief Executive (Nurse Director), if you require any
further information.

Yours sincerely

Fiona Edwards
Chief Executive

ce
- Director of Quality and Deputy Chief Executive (Nurse Director)
Co-Medical Director

- Co-Medical Director
~ Director of Mental Health
Director Risk & Safety (DDoN)