Ranjan Mistry

Tameside Hospital NHS

NHS Foundation Tru

Quality & Governance Unit
Tameside General Hospital
Fountain Street
Ashton-Under-Lyne
Tameside

OL6 SRW

Telephone: 0161 922 4466
Fax: 0161 922 6190

Date: 14/03/2016

Your Ref: JSP/ER/02302-2015

Mr John Pollard
Senior Coroner for Manchester South
The Coroner's Court

1 Mount Tabor

Stockport SK1 3AG

Dear Mr Pollard,

Re: Regulation 28: Report to Prevent Future Deaths following Inquest into the death

of Ranjan Raman Mistry (Deceased)

! write further to your fetter dated 4°° March 2016 enclosing a Regulation 28 Report issued
at the conclusion ot the inquest touching upon the death of Ranjan Raman Mistry, which
tock place on 2” February 2016. | am, of course, very sorry that you had cause to issue

this report.
| hope to be able to address your concerns, as set out in section 6 of your report, to your

Satisfaction, in this letter | have addressed the areas of concern, adopting the same
numbering in section 5 of your report as follows:

You stated:

1. The evidence showed that there was no, or no sufficient, assessment of her Falls

Risk,

The records indicale that there was a falls assessment undertaken for Mrs Mistry. This
was updated and reviewed several limes during her admission. The Trust acknowledges
the Coroner's observations that the assessment was not sufficiently completed and the
Falls assessment tool should have been updated and reviewed after Mrs Mistry was found

to have been on the floor following unwitnessed events on the 14/09/15 and the 17/09/15.

The Trust has initiated one to one training and support for the members of staff involved
and fs currently undertaking a review ef the documentalion as a result of the Coroner's
comments. This piece of work will also align to actions and improvement plans we have in

place as part of the Trust-wide Patient Safety Work stream and from recommendations

following the Trust’s participation in the National Falls Audit
The Trust is also focusing on falls srevention and falls assessment in the wider context.
Working with our community partners, service users and supporting agencies to jook al
improving the quality and lifestyle of Tameside residents and identifying and assessing
those patients who may be of particular risk in relation to falls, and agreeing how we
ensure pathway continuity. This involves ensuring that information held by the GP and
community services and other healtheare and social services provide an integrated view of
the patient's overall picture

t diagnosis of osteoporosis

We will aiso be looking at the wider picture in respect of earlie
and identification of patients at higher risk of a bony injury from a fail, intervention and

reablement and the benefit of exercise and mobility therapy meaning that peaple and their
carers are less dependent on intensive services and less likely to need admission to
hospital and to have to mobilise and be eared for in unfamitiar environments.

2. The Neurological observations charts were either never completed or had been fos

fa

from the notes

The Trust has a Falls Policy in place which clearly inciudes a flowchart which relates fo the
requirement to assess the patient following a fall or suspected fall. The Falis Policy and
flowchart indicaies that neurological observations would only be appropriate where a head
injury was indicated or suspected. The Trust acknowledges that in the unwitnessed event
involving Mrs Mistry on the 17/02/2016 a head injury could not be ruled out. in this event
the flowchart indicates the taking of neurological observations (Unwitnessed fall and was
verbalising thut she had banged her head). However staff did not commence the charts.
There is na evidence to suggest that these charts had been tost fram the records. Any
inference to this would be conjecture. This indicates that the requirement for staff to
undertake neurological observations as cited on the flowchart needs lo be reinforced and
practices monitored to ensure robust implementation of the policy standards

in view of this, the flowchart has been reissued to ail areas and Matrons and Ward
Managers have been asked to ensure thet where there is an unwitnessed fall and the
patient is nol able to verify whether or not they have injured their head or there is any
doubt as to this, neurological observations should be taken in line with the policy and these

should be charted and recorded in the medical records.

3. There was clear evidence thal the medicat staff were not reading for even looking at}
the nursing notes, and the nurses were similarly not looking at the medical entries

The decision to use the records of a patient is a clinical decision for individuat clinical staff
on a continuous basis. The Trust is not unique in that nursing and medica! staff record
their observations and interactions separately in the patient's medica! records. This is a
matter of practicality from the user's viewpoint and allows the medical and nursing staff to
access and update their records at the same time without hindering each other but also
allows the staff to contemporaneous records and to access the most recent records which
fall within their main area/discipline of Practice without having te find entries amongst other
disciplines entries. However the Trust acknowledges the Coroner's observations that this
traditional approach to records keeping in practice can sometimes lead to a fragmented
view of the patient's overall care and inconsistency in knowledge of recent interventions if

those medical and nursing staff do not have methods of keeping updated with the status

and condition of the patient.
To ensure that staff maintain an overview of the patient from a medical and nursing
perspective the Trust has introduced Board rounds when multidisciplinary teams including
discharge case managers meet to discuss and agree the approach to the management of
the patient, these are held on the Wards daily and augment information provided at shift
handover. Nursing staff allend Ward Rounds with medical staff to ensure that they are
aware of the patient plan and that they can ensure that patients and relatives are updated
Additionally the multidisciplinary team will held formal and informal MOT meetings where
patient have complex needs

The Trust also has an olectronic patient system and information such as test results and
letters, appointments and other information can be accessed by appropriate staff and is
used alongside the handwritten notes. As is happening Nationally the Trust is moving
towards a paner light system of medical records whieh should Support a more accessible

and seamless approach to medical records

4. Ihe hand-over sheets for each shift were being shredded by the nurses @s soon as the
shift was completed. Whilst it is appreciated that these cannot be placed on the record of
an individual patient for reasons of confidentiality, there is no reason why they could not be
ied on the wards and retained for say 14 days which would allow further reference te be
made io them. should this be deemed necessary or helpful.

The Coroner’s observalians are noted and the Trust acknowledges that the Trust does not
keep an archived copy of handover sheets, this is for many reasons inciuding
confidentiality and to ensure that (he sheet being referred to is an up to date one and not
one from a previous date. However following the Coroner's observations the Trust
recognises that there is no reason why handover sheets which are electronically produced
could not be electronically archived to provide a record of what information was being
communicated at handover at a point in time. This would as the Coroner observes provide
@ record should it be necessary to refer to them.

As a result the Trust will be considering introducing a systern of archiving at Ward and
Departmental level to support the availability of these al a future date.

5. Although an “Incident Report” was carried out in this case, the details available to the
Coroners court were sketchy and inadequate.

The Trust has a standard in place which details the expectations regarding processes for
reporting of and management of incidents within the Trust. The type, Process for and level
of incident investigation is proportionate to the impact and level of harm sustained by the
patient. For an event where the patient is found on the floor following an unwitnessed
event which was ascertained at the time to have resulted in no harm (as occurred in Mrs
Mistry's case) the investigation is undertaken is concise and local and the important aspect
of the interventions are to review the falls risk assessment and to try to reduce the risk of a
fall occurring again to either that individual patient or to other patients within the hospital
environment.

The Trust has initiated a guidance document which is available online for staff involved in
a concise and local ialls investigation and as previously mentioned is Currently undertaking
a review of the documentation as a resuit of the Coroner's comment and to align actions
from recommendations following the Trust's participation in the National Falls Audit.

The Trust has been recognised as having outstanding levels of Openness and

transparency in learning from mistakes and has been ranked 8th out of 230 Trusts in

relation to a report published in March 2016 by the Department of Health.
! do take your concerns seriously and i hope that | have addressed your concerns and

reassured you of all that the Trust has already undertaken and is currently undertaking, in
order to prevent the recurrence of a similar set of circumstances in the future.

Should you have any further questions arising from the contents of this letter, please do
not hesitate to contact me.

Yours sincerely
fj

! Cid
Karen James
Chief Executive

cc. Monitor

COC
Tameside anid Glossop CCG