Maurice Isaacs

& GIG | 8rd techyd Prifysgol Ysbyty Athrofaol Cymru
Caerdydd a'r Fro University Hospital of Wales

UHB Headquarters

oan H S Cardiff and Vale Heath Park Pare Y Mynydd Bychan
University Health Board = Cardiff, cF14 4xW Caerdydd, CFi4 4XW

Eich cyf/Your ret;

Ein cyf/Our ref: SH-ns-01-5963

Welsh Health Telephone Network:

Direct Line/Llinell untongychol: 02920 745681

Interim Chief Executive

24 January 2017

PRIVATE & CONFIDENTIAL

Mr A Barkley

Senior Coroner
Coroner’s Court
Central Police Station
Cathays Park

Cardiff

CF10 3NN

Dear Mr Barkley
Regulation 28 report — Mr M | (Died 14.06.2016)

Thank you for your letter dated 7 November 2016. The letter was issued to
the University Health Board (UHB) on 11 November 2016, but unfortunately
there is no record of this being officially received. Please accept our sincere
apologies for the fact that this has led to a delay in responding to you. You
have very kindly agreed to extend the deadline for 14 days, which we are
very grateful for.

| have reviewed the points raised within the Regulation 28 report which
relates to the very sad death of Mr I. My response has been informed by key
clinical and managerial colleagues within the Medicine Clinical Board, who
work within the clinical environment in which the care was provided to Mr I.

| recognise that this will have been a difficult time for Mr I’s family and would
wish to offer my sincere condolences on behalf of the University Hospital
Board.

You will be aware that the UHB undertook an internal investigation which was
reported to Welsh Government in 2016. The report detailed numerous
recommendations for the Directorate and Clinical Board and an action plan
was subsequently developed and completed.

For ease of reference, | will respond to each of the matters of concern you
have raised in turn:

« The investigation revealed shortcomings in the way in which Mr
I’s risk of falls was assessed and recorded, e.g. no ciear care plan
was introduced until after the fourth fall. Although there were

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some occasions when Mr | was given 1:1 care it was not
consistent and despite the increasing number of falls he was not
given true 1:1 supervision/observation. This was recommended
within the medical notes and that this should have been in place
at the time of Mr I’s final fall. The reality on the ward was that he
was being observed by a nurse on a 1:4 basis. Despite the ward
being staffed to “agreed staffing levels” the evidence showed
that on the ground, on occasions, there was simply not enough
staff to manage the demands of the ward.

Mr I’s condition was so variable and unpredictable, and against a
background of so many falls, 1:1 care was indicated. The
evidence showed that whilst there was a review of his situation
after each fall, a more ‘holistic’ approach, recognising the
dangers posed by his unpredictable behaviour, and the causes of
that, might have prevented so many falls.

The Medicine Clinical Board, in conjunction with all Directorates, have put in
place the following key changes to identify how risk is assessed and the level
of specialling that a patient requires to support a more holistic approach.
When completing the falls risk assessment, all patients identified as at risk
have a falls care plan commenced. This care plan is reviewed weekly, or
more frequently as the patient's health and requirements change. Since the
tragic incident involving Mr |, the Clinical Board recognises the need for more
robust discussion of the risk assessment outcome and the need for 1:1
specialling with families/carers. Families and carers are now actively
encouraged to share their opinions if they feel 1:1 specialling is not
appropriate for their relative or if they may respond poorly to this type of
enhanced monitoring. Environmental consideration and the assessment for
quiet areas are also considered. Families and carers are encouraged to visit
and stay as long as they deem necessary if they feel that it would benefit their
relative.

All patients with known cognitive impairment have documentation completed
by themselves or by a relative or carer in order to help healthcare staff learn
about the patient as a person. We recognise that in the case of Mr I,
regrettably, the ‘Reach Out To Me’ document had not been completed. All
staff have been reminded of this and it will form part of regular documentation
audits. Behaviour charts are maintained to identify any triggers for falls and
wandering behaviour. Tools such as Intentional Rounding, which ensures that
patients are reviewed every two hours in order to ensure that patients have a
drink, and are offered toileting in a timely manner are well embedded within
all Directorates. Medication reviews are undertaken weekly by the medical
team and Pharmacy colleagues to minimise medication interactions and use
of sedative medication. Daily Board Rounds supported by a multi-disciplinary
team approach are completed to provide a patient centred holistic review.

In addition, the Board and Directorate have engaged in Sensor Mat trials
which can be an alert mechanism to nursing staff to identify wnen patients
are moving and are at risk of a potential fall.

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Nursing staff that have been identified to provide specialling have been
informed that they are not to participate in care that would take them away
from their role of providing specialling. The Clinical Board are currently
undertaking benchmarking of enhanced observational care within other
organisations across Wales and England.

The Health Board has a formal and well embedded process for the management and
escalation of issues in relation to safe staffing leveis. Ward establishments are set
and approved on an annual basis; these are signed off by the Director of Nursing in
the Clinical Board and the Executive Nurse Director. There is a 6 weekly off duty in
place which is subject to weekly review and requests for staff are placed/managed
where there are gaps in covering shifts.

Unfortunately, we know that some ward staff in Mr I's case were unclear on what to
do with regards to documentation to support safe staffing levels. All staff have since
been reminded of how to access and use ‘specialling’ documentation which is
available on the intranet and this was reinforced with staff at a ward meeting held on
12/09/2016 where the appropriate documentation was made available for all to read.

On a daily basis, staffing levels are operationally managed by the Senior Nurses at
ward/departmental level. They liaise with ward sisters and charge nurses and staff
are moved to provide the best cover possible, based on patient need on a daily
basis. Sometimes, Clinical Nurse Specialists and Senior Nurses are also asked to
work clinically in wards and often other additional support staff e.g. physiotherapist
etc are approached to support wards. If there are difficulties covering a
ward/department, the Senior Nurse will approach the Directorate Lead Nurse to see
whether it is possible to release capacity from other areas of the directorate. If this
does not provide a solution, the matter is then escalated to the Clinical Board
Director of Nursing to identify staff who can be released from across the wider
Clinical Board. Every opportunity is undertaken to support safe staffing with the
utilisation of Temporary Staffing and Agency, and on-going recruitment drives.
Deficits in staffing levels, reported by staff through the patient safety incident
reporting system, are reviewed by Executive Directors at the Management Executive
meeting on a weekly basis.

The UHB is currently carrying out a project on the ‘Specialling of patients’ which we
hope to have in place in the Medicine Clinica! Board ward areas in February 2017.

e After the first fall, shortcomings were identified in the way that
the standard Neurological Observations were carried out. They
were not carried out in line with UHB policy. They were
conducted by a Health Care Assistant, who had not been trained
and who failed to conduct one part of the test for a period of six
hours. The omission was not identified by the qualified nurse
whose duty it was to oversee the work of the Health Care
Assistant.

The Medicine Clinical Board has undertaken a review of the delegated tasks
that are completed by non-registered nursing staff. At this point in time, the
Medicine Clinical Board has taken a decision that responsibility for the

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Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Loca! Health Board

completion of neurological observations will be undertaken by registered
nurses only. The UHB is currently reviewing the clinical skills of Health Care
Support Workers and this issue which has arisen in Medicine, will be
considered as part of that review. All registered nurses are aware of their
UHB and NMC requirements to ensure that neurological observations are
undertaken as per UHB policy, and make a clinical decision on the need to
escalate to the relevant clinician, dependant on the results of these
observations.

Arrangements are in place to share learning from this incident for the Clinical
Gerontology Directorate and for the Medicine Clinical Board in February
2017.

The UHB has now also established a Falls Delivery Group, which will be
chaired by an Assistant Director with Executive support from the Director of
Therapies and Health Sciences. The group is multi-disciplinary and has
representation from medicine, nursing, pharmacists and therapists. The aim
of the group is to work with key internal and external stakeholders and
partners to provide expertise, review and monitor practice and promote the
prevention and management of falls resulting in fractures and other
significant injuries across the health community of Cardiff and the Vale of
Glamorgan. The first meeting of this group took place on 20 January 2017.

Your findings at Mr I’s inquest are of relevance to all Clinical Boards in the
University Health Board. A copy of your Regulation 28 report and my
response will be shared with all Clinical Boards with the intention that all
clinical areas will review the actions undertaken to date and assess areas of
clinical risk in their Directorates to minimise risk of reoccurrence of the
matters of concern.

| hope that the information set out in this letter provides you with the
assurance that the Health Board has fully considered the issues raised as a
consequence of the inquest into Mr I’s death, and has taken appropriate
action in response.

Yours sincerely

oy

Interim Chief Executive

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