Dennis Redmore

oN, G IG Bwrdd lechyd Prifysgol Reply to:
“jo Abertawe Bro Morgannwg Colly Read, Hospital
\ NHS University Health Board Eine

v
ro

Direct line/Rhif llinell union:01656 754194

BFax/ffacs:
Your ref/Eich Cyf:
Our Ref/Ein Cyf: JA/jw Dyddiad/Date: 27*" September 2017

Mr. Andrew Barkley,

HM Senior Coroner,

South Wales Central Area,
Rock Grounds,

First Floor,

Aberdare.

CF44 7AE

Dear Mr. Barkley,
Inquest - The late Dennis Redmore

| write further to your correspondence dated 9'" August 2017 regarding the above and
the Regulation 28 notification issued.

The Regulation 28 was issued as a result of the inquest completed on 3 August 2017
which concluded that Mr Redmore died as a result of the effects of a head injury which
he sustained when he fell in hospital. The evidence did not reveal a clear cause for the
fall but it is likely that his medical condition, both acute and chronic, contributed.

You detailed your concerns in respect of:

Failure to monitor Mr Redmore neurologically

Failure to act upon NEWS observations

Failure to undertake observations in line with local and national guidance

Lack of appropriate management of the nurse responsible for undertaking the
observations

Please find below a resume of the actions we are currently undertaking and those
planned. These are described in detail in the attached action plan.

e Chairman/Cadeirydd: Andrew Davles

« Interim Chief Executive/ Prif Weithredydd: Alexandra Howells

ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot. SA12 7BR.
Telephone: (01656) 752752

Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg

ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board

www. abm.wales.nhs.uk

Action Plan/Actions Undertaken

The following have been incorporated into a formal action plan with clear timescales
and responsibilities assigned to key individuals in undertaking and monitoring of the
required actions as follows:

e Staff to be reminded of the need to adhere to the ABMU neurological guidelines

e Ward sister to reiterate to the nursing team on AMU the Leadership and
delegation responsibilities of the nurse in charge of each shift

e For the month of October 2017 documentation to be reviewed (audit) on all
patients who have sustained a fall on AMU which will include compliance with
neurological observations

e Learning from the above audit to be shared with staff in AMU and actions agreed
for implementation

e Outreach team are currently auditing NEWS compliance across all acute wards
in a rolling programme

e Training Needs Analysis (TNA) to be undertaken in relation to need for ALERT
and Beach training in AMU

e Feedback from review of current Falls Policy and revised documentation
currently on trial in Princess of Wales

e Monitor this action plan monthly to ensure compliance and adherence to
timescale
In addition, the above actions will be reviewed by the Unit Nurse Director and Unit
Medical Director and a summary report will be provided to the Quality and Patient
Safety Committee in April 2018.

On the 10% March 2017 a Spot the Sick Patient Steering Group was set up which meet
on a bi-monthly basis. One of the aims of the Group is to improve the recognition,
treatment and outcome of deteriorating patients in hospital. Enclosed is a copy of the
Terms of Reference of the Group for your information.

{ trust that the action plan to address the matters of concern raised in the Regulation 28
notice are to your satisfaction and provide with the required level of assurance.

Yours sincerely,

Alexandra Howells
INTERIM CHIEF EXECUTIVE.

‘ G IG Bwrdd Iechyd Prifysgol
ntiirc. | Abertawe Bro Morgannwg
N HS University Health Board

Terms of Reference — Spotting the Sick Patient Steering Group

Type and nature
This is a standing group that aims to improve the recognition, treatment and outcomes
of deteriorating patients in hospital. It will do this by:
© coordinating the efforts of hospital (Unit) — based groups with the same
aims
¢ agreeing on standard case definitions, monitoring arrangements and
treatments
e facilitating collection, analysis and reporting of clinical data

Executive sponsors

Hamish Laing, Rory Farrelly

Chairperson and vice-chairperson

Chair: Assistant Medical Director, Patient Safety.
Vice Chair: TBC

Members/Composition
Each Unit to be represented by one senior medical and one senior nursing
representative
Critical Care Outreach
Emergency Medicine
Medical Director's Department
Paediatrics
Representative of the RRAILS Steering Group
Innovation and OD / Service Improvement team
Critical Care
Resus Committee

Formation Details

* The care of hospital patients who clinically deteriorate is one of the HB’s main
safety concerns, as reflected by its place as one of 7 Quality Priorities in the
Quality Strategy.
The previous Steering Group’s main purpose was the running of an
improvement project to investigate obstacles and test small scale changes. This
group is designed to implement the findings of that project on all wards and
Emergency Departments.
It will also further test refinements to the system as dictated by experience, new
scientific evidence, national initiatives etc.
It will coordinate the collection, analysis and feedback of performance data to
improvement teams, Unit Management, ABMUHB management and Welsh
Government as appropriate.

Goals and or objectives
4. Reduce avoidable mortality and morbidity in this group of patients
2. Improve the function of systems that enable early recognition and treatment
of deteriorating patients

Deliverables

A number of outcome and process measures will need to be agreed by the
group that allow continuous improvement and the necessary governance
assurances.
The following data items are required by WG:

* The number of patients identified as positive to sepsis screening requiring a
new response in a 24 hour period.

* Number who received all six elements of the sepsis bundle within one hour.

* Number of patients who received a positive screening for sepsis but did not
receive a diagnosis of sepsis.

Other useful figures would include cardiac arrest rates; time between
deterioration and resuscitation; mortality rates for sepsis.
2

Jurisdiction
The Group is an advisory group that helps the Unit teams deliver the above
improvements. it will work by developing an ABMUHB consensus to
recommend standardisation of best practice.

Resources and Budget
No identified budget.

Governance
The Group reports to the Quality and Safety Committee via the Q&S Forum
every 2 months.
Decision-making will be by consensus.
Quorum will be Chair/Vice Chair plus representatives from the 4 acute Units.

Communications
Meetings will be held every 2 months with urgent issues communicated /
decided by email. Minutes will be circulated with a week of the meeting.

Relationships to other groups
The Group will work closely with the RRAILS Steering Group that has similar
aims at an all-Wales level.

Evaluation of the effectiveness of the committee/group

The Group will be judged by the data members collect and report, as detailed
above.

Reviewed September 2017

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