Jane Stables

Nestor Primecare Services Limited t/a Allied Healthcare

Cavendish House | Allied
Lakhpur Court
Staffordshire Technology Park |
Stafford

Staffordshire ST18 OFX | All about you
/

Ms. N.J. Mundy

HM Senior Coroner for South Yorkshire (East District)
Coroner's Court and Office

Crown Court

College Road

Doncaster

DN1 3HS

Dear Madam

Mrs Jane Bulloch Wilson Stables (Deceased)
DOB: 30 March 1946; DOD: 02 April 2016

| write to provide a response, insofar as | am able to do so, to each of the concerns raised within your
Regulation 28 Report to Prevent Future Deaths dated 15 December 2016; which was issued following
the conclusion of your investigation into the death of Jane Bulloch Wilson Stables.

Taking each of your concerns in turn:-

1. Ineffective communication between the carers and general practitioner regarding ongoing
significant pain levels which were impeding the care provided.

At the commencement of Allied Healthcare's care package (14 March 2016), Mrs Stables was noted
to be suffering from rheumatoid arthritis; contractures to her hands, fingers, feet and toes; and pre-
existing pressure areas/inflammation to both shoulders, her coccyx and right foot. It was also noted
that she did not like having carers and/or being moved as she was suffering from a high degree of
pain.

As HM Senior Coroner is aware, the care provided to Mrs Stables by Allied Healthcare comprised 4 x
30 minute visits per day, with 2 carers attending during each visit.

In addition to the above, Mrs Stables was also visited daily by District Nurses from her GP Centre
(who, for the avoidance of doubt, were not and are not employees of Allied Healthcare). The District
Nurses were primarily responsible for care/treatment of Mrs Stables’ pressure sores; and it was for
this purpose that they were attending.

Mrs Stables' local authority care plan provided for her pain medication to be administered prior to the
arrival of Allied Healthcare's carers; in order to minimise, insofar as possible, the pain experienced by
Mrs Stables when being washed/dressed/repositioned. Mrs Stables' husband retained responsibility
for administering her medication.

Allied Healthcare's attending carers were aware of, and were reporting to their local Allied Healthcare
branch, Mrs Stables' ongoing pain/condition, utilising a standardised Early Warning Score
assessment tool ("EWS"). However, it was, and still is, the responsibility of the attending District
Nurses to escalate any concerns to the patient's GP (particularly when, as was the case here, they
operate out of the patient's GP Practice). On that basis, it was not considered necessary for Allied
Healthcare's staff to contact Mrs Stables' GP directly.

Nestor Primecare Services Limited, trading as Allied Healthcare, is registered in England and Wales No. 1963820
Registered Office: Cavendish House, Lakhpur Court, Staffordshire Technology Park, Stafford, Staffordshire ST18 OFX

For the avoidance of doubt, if District Nurses are not in attendance, Allied Healthcare staff would of
course communicate directly with a GP should that be considered necessary,

I can confirm that Allied Healthcare has, however, introduced a new system in which:-

a. As above, carers report any substantive EWS change to their local Allied Healthcare branch
(this was already in place at the time of Mrs Stables' death).

b. Each local branch now has access to an Allied Healthcare Lead Nurse; who will, following a
referral from the branch staff, either: (i) contact a patient's GP if considered necessary; or (ii)
provide advice/guidance.

c. The Lead Nurse will also perform a review of the patient's documentation, including care
plans, to ensure that appropriate care is being delivered to a high standard. Where
necessary, the Lead Nurse will suggest amendments to a patient's care plan.

Training as to the above system was initially provided to carers at the end of 2015; and has since
been discussed regularly at branch/team meetings throughout the year (which occur every 3-months).
The system is also discussed as necessary with individual staff during 1:1 supervision sessions.

Please note that the above system is intended to operate in addition to the primary role of the District
Nurses; and is not intended to replace their involvement.

2. Failure of staff to follow care plans which were in place leading to development and
progression of pressure sores.

As stated above, it is recorded within Mrs Stables' records that she has pre-existing pressure sores at
the commencement of Allied Healthcare's care package (14 March 2016) to both of her shoulders; her
Coccyx and also her right foot. District Nurses were attending on a daily basis in order to treat these
sores.

Mrs Stables was being regularly repositioned by Allied Healthcare's carers in accordance with her
care plan; however, it is recorded that Mrs Stables was able to turn from her side to her back and
therefore would regularly not stay in the same position.

Concerns regarding Mrs Stables' pressure sores deteriorating were reported by carers on Allied
Healthcare's Complaints, Incidents, Accidents, Monitoring system ("CIAMs") on Monday 28" March
(a Bank Holiday). The concern raised was that Mrs Stables' pressure sores had ‘burst’. Mrs Stables!
husband had already called the District Nurse; who had confirmed that they would attend as soon as
possible. Later that day, Mr Stables confirmed that the District Nurse had indeed attended and re-
dressed the sores. Due to the attendance of the District Nurse (who, as stated above, had
responsibility at that time for escalation to the GP) the CIAMs report was closed the day after it had
been opened.

| can confirm that the following changes to practice/policy have been implemented since Mrs Stables'
death:-

a. The care plan document has been amended so that it is simpler; more accessible; and easier
to follow. This includes a visual front page which provides an overview/summary of the
patient.

Further, a tool has been built into the care plan which generates questions regarding the
patient's condition (for example, skin integrity); and depending upon the responses to the
questions, flags that a referral to the local branch/Lead Nurse is mandated (see above in this
respect).

Nestor Primecare Services, trading as Allied Healthcare, is registered in England and Wales No. 1963820
Registered Office: Cavendish House, Lakphur Court, Staffordshire Technology Park, Stafford, Staffordshire ST18 OFX

All Field Care Supervisors have been trained in the process of how to write a care plan using
the amended template document. A guidance document was also created to support their use
of the new plan. Allied Healthcare's carers (who follow, but do not write, the care plans) were
informed of the changes; and shown the new format of care plan in team meetings following
roll-out in September 2016

The effectiveness of the amended care plan will be reviewed on an ongoing basis.

b. Acare coach/buddy system has been introduced. This is a system in which senior and
experienced carers support/mentor less experienced carers; to ensure that they are delivering
excellent standards of care at all times. This includes ensuring compliance with care plans
and maintaining high standards of record-keeping. Care coaches/buddies initially support
carers for 20 hours during the first few weeks of their employment; and if any issues are
highlighted then the care coaching will be extended as needed. Following completion of the
care coaching period, the carer receives ongoing support from the local branch Field Care
Supervisor.

c. Regular reviews of records/documentation are also performed by the senior and experienced
carers. This will be undertaken at least once in every six months or more frequently if there
are any concerns identified with a particular carer or customer. These reviews are known as
"field assessments".

d. All reports recorded on CIAMs regarding any form of mark on a patient's body will now
automatically be referred to Allied Healthcare's customer service team; who will ensure that
all appropriate/necessary referrals have been made prior to a report being closed on the
system. This includes, in respect of pressure sores, a safeguarding referral to the local
authority.

Finally, | can confirm that Allied Healthcare has policies/procedures in place in respect of tissue
viability and assisting with pressure sore care; which are monitored/reviewed by the clinical
governance team, who will also make any amendments considered necessary. This is undertaken at
a minimum of every two years but more frequently if guidelines change (for example, NICE
guidelines).

3. Failure to adequately document care that had been provided with regard to key matters.

An account of care provided has been included within Mrs Stables’ records following each attendance
by an Allied Healthcare carer.

| can confirm that training is provided to all carers during their induction as to how and what to write in
a client's records. The new system of field assessment checks will also ensure that high standards of
record-keeping are maintained; and also that where any issues are identified, immediate action is
taken.

Finally, | can confirm that Allied Healthcare has policies/procedures in place in respect of record-
keeping; which are monitored/reviewed by the clinical governance team, who will also make any
amendments considered necessary. As stated above, all policies are reviewed every two years or
should guidelines change

Nestor Primecare Services, trading as Allied Healthcare, is registered in England and Wales No. 1963820
Registered Office: Cavendish House, Lakphur Court, Staffordshire Technology Park, Stafford, Staffordshire ST18 OFX

4. Lack of a clear understanding regarding slide sheets: when they should be used and how
they should be used.

| can confirm that HM Senior Coroner's concerns in this respect are acknowledged by Allied
Healthcare; and that a review of practices/policies/procedures relating to the use of slide sheets will
be performed as soon as possible. An update as to the outcome of this review will then be provided to
HM Senior Coroner.

5. Despite carers saying they had training on movement and handling and were aware of the
importance of record-keeping; it would appear that they are not implementing that training
and thus the training needs to be scrutinised and reviewed and also effectiveness of such
training audited.

| confirm that all of Allied Healthcare's training documents are currently being reviewed; and that this
process is undertaken every two years — or sooner, if guidelines change.

| can also confirm that a new system has now been introduced in which any clinical training material
will be overseen/approved by a qualified clinician.

Finally, and as stated above, the standard of care provided to patients during movement/handling is
now regularly monitored by way of the care coach/buddy and field assessment system.

Should you require any further information please do not hesitate to contact me.

Yours faithfully

Chief Financial Officer

Nestor Primecare Services, trading as Allied Healthcare, is registered in England and Wales No. 1963820
Registered Office: Cavendish House, Lakphur Court, Staffordshire Technology Park, Stafford, Staffordshire ST18 OFX

NHS)

Rotherham Doncaster

and South Humber
NHS Foundation Trust

Executive Medical Director
Woodfield House, Tickhill Road Site, Tickhill Road
B;
Email :
Telephone : (01302) 796226

Text only phone for deaf/hard of hearing: 07771933869

Date: 8 March 2017

Your Ref: as

Ms N J Mundy

Senior Coroner

Coroner’s Court and Office
Crown Court

College Road

Doncaster

DN1 3HS

Dear Ms Mundy

Re: Jane Bulloch Wilson Stables (Deceased)
DOB 30.03.1946 - DOD 02.04.2016

I write further to my letter of 8 February 2017 which was delivered by me personally to your Court on
9 February 2017.

Within that letter I said that I would update you with a further report in 28 days. I hope this
communication can be seen as the second stage of the Trust response to your Regulation 28 report.

In my communication of 8 February I proposed 6 actions. I would like to update you with regard to
each of the points in that letter.

In addition I made the error of calling one of the District Nurses Fo That is because I
had a previous communication within the Trust stating that this was her name. Of course, her name is
ae I would like to apologise if this confused you in any way.

I am enclosing the following documents which will be referred to within this report.

a) Letter to the General Practitioner
b) Letter to Mr

c) Powerpoint presentation by Po

Leading the way with care

Kathryn Singh — Chief Executive |... (asd

In relation to points one and two from my communication of 8 February, a meeting was held on
24 February 2017 between myself and the relevant District Nurses and their Line Managers. I
chaired this meeting. I provided the attendees with a summary of my understanding of the
case regarding Regulation 28 report. The participants were given the opportunity of reading
this summary. They had already been sent a copy of your Regulation 28 report in advance.

A full and frank discussion took place at this meeting. It was both professional and cordial. I
produced the summary of the learning from that event with some actions. It included the need
to consider a direct dialogue between professionals (including the GP) in relation to pain
management if this was not optimised regardless of whether patients and/or carers maintained
their own communication channels with pain management professionals.

One of the attendees was a Service Manager in the Community Nursing Team.
She said that the Community Nursing Service would share information and lessons learned at
their monthly senior nurse meeting chaired by her or by fellow attendee, i! The
next meeting was due to be held on 30 March 2017. All team leaders, sisters and charge
nurses are expected to attend, or at least to have one member attend to represent a cluster.
She has told me clearly that the Regulation 28 learning would be on the agenda and that she
would send me minutes once this meeting had concluded.

HE then went on the tell me that the sisters or charge nurses would go on to chair
cluster meetings to disseminate all relevant information discussed at the 30 March meeting.
She said that she would be more than happy to forward on minutes from the cluster meetings
to demonstrate that learning had been disseminated.

I believe that this also deals with point six from the action list from my letter of 8°" February
2017.

| our Trust Physiotherapy Professional Lead as well as a key contact with your
Court.

She has prepared training sessions on the issue of pain management in patients with dementia
and cognitive impairment. This is a rolling training programme with further dates planned on 5
April, 17 May, 15 June, 5 September and 4 October 2017. I have taken the liberty of enclosing
print outs of the slides HMM uses for her training session. She tells me that she will
incorporate the learning for the Regulation 28 into new slides for future training sessions.

In relation to point_three of my 8 February letter I can confirm that I have had a
communication ah I enclose a copy of the letter that I wrote to him. I am
pleased to report that he has responded enthusiastically to my invite to meet with him. My
secretary has organised this for Friday 10 March 2017. He will be accompanied by his son. In
relation to point four of my 8 February letter I will ask him whether he would consider
discussing his experiences of being a carer for somebody with a physical health disorder at our
Trust Board. If he agrees to this, I will then liaise with colleagues who organise this to see
whether this could be facilitated as part of our monthly Board of Directors “Patient Story”.

In relation to point five of my 8 February letter I can confirm that I have had a dialogue with
the GP, MI on ciose a copy of a letter I sent to the GP following our communications.

Leading the way with care

Kathryn Singh — Chief Executive PY

I hope that this demonstrates that we have taken your Regulation 28 report seriously and have
attempted to address it through both internal dialogue and communication with key stakeholders such
as the family and the General Practitioner.

I hope that our learning will be ongoing from this incident and in particular I am looking forward to my
meeting this Friday vit a

Please do not hesitate to contact me if you believe that further actions are required or if you have
questions regarding the Trust response.

Yours sincerely

Executive Medical Director

Encs.

Leading the way with care

Kathryn Singh — Chief Executive Po