Margaret Postill

| NHS}

j Tameside and Glossop

Integrated Care
NHS Foundation Trust

Tameside General Hospital
Fountain Street
Ashton-under-Lyne

OL6 SRW

Tel: 0161 922 6000

Her Majesty's Senior Coroner for Manchester South
HM Coroner's Office

The Coroner's Court

1 Mount Tabor

Stockport

SK1 3AG

26 October 2017

Dear Ms Mutch
Inquest: Margaret Postill

| write further to the inquest touching upon the death of Margaret Postill, at the conclusion of which | was
sorry to learn that you indicated that you would be issuing a Regulation 28 Report to the Trust as a result of
your concerns regarding the standard of clinical documentation within the Emergency Department (ED).

As | understand it, during the course of the inquest, evidence was provided by Locum ED Consultant |

with respect to Ms Postill’s care and management within the ED, specifically in relation to the
Management plan surrounding a potential CT head scan. During the course of his evidence EE was
asked to refer directly to the notes made by the Advanced Nurse Practitioner outlining the rationale for the
non completion of a CT head scan and the subsequent management olan i oc it difficult to
decipher the documented notes and when asked whether this was acceptable, advised that the ED
department can be exceptionally busy, sometimes to the detriment of clear and legible documentation.

After concluding the evidence, you asked that enquiries be made by the Trust’s Legal Services Manager, who
was present to support the witnesses, as to the implementation of electronic documentation with the ED. You
were advised that this was to be rolled out in November this year. Despite this further information having
been provided, you stated that you had residual concerns that there appeared to be a culture at the Trust
whereby senior doctors were accepting of poor documentation and as a result you confirmed that you still felt
it necessary to utilise your powers and issue a Regulation 28 Report to the Trust. We presume this cultural
concern stems from a number of inquests you have heard, as opposed to this specific hearing.

Being equally concerned by your views on this, | have sought to obtain some clarification in respect to your
concerns, specifically with regards the potential culture of poor documentation within the ED Department.

Within the ED, a Board Round is held three times a day every day, to discuss issues and concerns with all
clinicians on duty. The Board Round is overseen by a Senior ED Consultant. It is reiterated during Board Round
that it is the expectation of the Trust and the Senior Consultants in charge of the ED that documentation must
be completed in full and to a legible standard. This message is regularly reinforced so that clinicians are fully
aware of their expectations.

Cea disability
BG confident Chief Executive — Karen James Ww ‘in|
EMPLOYER Chairman = Paut Connellan

INHS|

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Where it is identified that clinicians are not complying with the expected standards in terms of documentation,
a formal discussion with a Senior EO Consultant or the Clinical Lead for the ED will take place, at which time
the expectations are again reiterated in respect to full and clear documentation. Reflective development of
this nature is included within that clinician’s Personal Development Plan in order to ensure that they have
appropriately reflected upon their mistakes in order to demonstrate learning has been undertaken to avoid
future reoccurrence, ED documentation is also randomly audited to ensure compliance with the Trust
expectations. Where issues are identified these will be picked up and dealt with as per the above mentioned
process.

All new clinicians who join the Trust receive detailed information regarding Trust Policy and Protocol, including
information regarding the expectations in respect of documentation. Documentation is an issue that is also
often picked up at both the Grand Round for clinicians and at Trust training sessions/clinical meetings to
ensure that the message is reinforced not only in the ED Department but on a Trust wide basis.

As advised at the inquest by the Trust’s Legal Services Manager, the Trust is to implement a fully electronic
documentation system within the ED at the end of November. This system will replace handwritten
documentation, which will ensure that issues regarding illegibility of handwriting are eliminated, as all
clinicians within the ED will be required to type their clinical notes in to the system, thereby making it easier
for subsequent clinicians involved with the care to review the notes and manage the patient accordingly.

At the inquest hearing, | understand that submissions were sought from the Trust Legal Services Manager as to
the electronic system that was to be introduced within the ED Department, but information regarding the
‘culture’ of poor documentation was not considered. At the time submissions were requested, it was not
possible for the Trust's Legal Services Manager to proficiently address you on matters with respect to ‘culture’
without first obtaining some further information and clarification to assist. We would assert that the Trust is
aware of the importance of good record keeping and to aid and assist this it is implementing the electronic
data capture system in recognition of this.

We would hope that once you have had a chance to consider this further information with respect to
documentation within the ED Department you will be reassured that there is clear evidence that there is nota
cultural acceptance of poor documentation with the ED Department and that the department, particularly the
Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to
documentation and where these expectations are not met, that action is taken to ensure reflective learning is
undertaken to prevent future reoccurrence. | can assure you that this is a message which is constantly being
reinforced. Furthermore, electronic documentation is also to be introduced to ensure that illegible
documentation does not impact upon the care and management of patient's within the ED Department.

tam disappointed to hear that the evidence heard gave cause for concern and t would wish to reassure you
that the Trust take issues of this nature exceptionally seriously and it is for this reason that we have taken
immediate action to ensure that you are provided with the reassurance needed. | hope in light of this that you
will feel it is not necessary to issue a Regulation 28 Report after all.

Please do not hesitate to contact me should you require any further information to assist

Yours sincerely

a

piece & Bere ~

John Fletcher
Director of Quality & Governance

disability

fident Chiet Executive - Karen lames. yw ‘in|
EMPLOYER, Chairman — Paul Cannellan

Everyone
Matters.

e camper,

HM Senior Coroner Ms A Mutch OBE
The Coroner's Court Manchester South
1 Mount Tabor

Stockport

SKI 3AG

Your ref: 7480/CLE

8 February 2018

Dear Madam

Re Mrs. MEP, Sunnyside Care Home

Following receipt of the Regulation 28 report and covering letier of 21] December 2017, | write
on behalf of HC-One to outline the content of our policy and procedure relating to falls
prevention and care and also the specific actions we have taken to improve outcomes for
Residents and address the specific concerns you raised in the report, both at home level and
also across the group of homes.

We, at HC-One, recognise that falls and their subsequent outcomes are serious risks to people
who live in our care homes.

We know ihat slips, trips and falls are a major cause of injury in the older population and that in
care homes, falls account for around 90% of reporiable injuries to Residents and those
Residents aged 65 and over are at the highest risk of falling.

We recognise that a fall, or fear of falling, can dramaiically reduce the quality of life fora
Resident, as there is a risk they could suffer any of the following:

Increased social isolation, particularly if they become bed bound

Increased problems with maintaining their independence due to any injury

Increasing tendency towards depression and possible mental health problems
Increased physical and emotional dependence, possible due jo a lack of confidence

HC-One is committed to enabling Residents to live a full and active life. We embrace the
concept of keeping Residents as independent and as mobile as possible whilst minimising risk
to their health, safety and wellbeing.

All of the above facis are included in the preamble to our Falls prevention and management
policy.

2

HC-One

1701325 351100 F 01325 351144

Comespondence & Registered Office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH

Registered in England and Wales: HC-One Limited, registration no. 07712656; Mendian Healthcare Limited, registration no. 01952719;

HC-One Beamish Limited, registration no, 05217764; HC-One Oval Limited, registration no. 10257888: RV Care Homes Limited, registration no. 07417290:

sear e Cempory,

We continually review the NICE guidance in relation to falls and implement new technologies
to support Residenis and ensure thai our policy and procedures reflect this guidance, which
we have completed again specifically following receipt of the Regulation 28 report.

Within the policy there is a specific section entitled Assessment and Prevention. This section
details the following:

It is important to identify all Residents who may be at a risk of falling and as such, thorough
assessments should be conducted. A Multi factorial Falls Risk Assessment will inform the
development and implementation of a daily plan of care.

e All Residents must have a comprehensive Falls Risk Assessment completed prior to
admission. Residents identified to be ‘at risk’ on the Pre-Admission Assessment, must
then be re-assessed on admission in their new environment.

e Residents identified as ‘at risk' must have a full review on a monthly basis, or more
frequently as the Resident's condition dictates.

e Anew assessment must be completed following a fall and/or if the physical or
psychological condition of the Resident changes.

e Aplan of care must be in place for mobilising, including the use of mobilisation aids.
The use of walking aids and other equipment should be considered, affer assessment
by a physiotherapist or occupational therapist where a potential risk has been
identified.

e The use of assistive technology should be considered, where appropriate.

All assessments and reviews must be fully documented and recorded in the Resident's care
file.

Assessments will identify predisposing factors which may lead to falls such as:

Undiagnosed Infection

History of falls

History of chronic illness

Reduced mobility/unsteady gait and muscle weakness
Diagnosis of osteoporosis

The individuals perceived functional ability and fears relating to falls
Unfamiliar surroundings/disorientation

Environmental and clothing/footwear hazards

Alcohol use

Medicines

Postural hypotension or episodes of dizziness
Constipation

Impaired cognition/depression

Reduced eyesight

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Altered bowel or bladder habits including incontinence or urgency
Disturbed sleep pattern

Use of antipsychotic medicines

Foot care

Use of a wheel chair which requires the use of lap straps

ee © © ®

The policy then goes on to define the following:

Person specific risk factors and preventative measures

The risk factors associated with Resident falls rarely exist in isolation, therefore effective falls
management requires a preventative, holistic and person cenired approach that considers alf
of the contributory and person specific risk factors.

Residents are at a greater risk of falling during the first three months following admission, or
where a cognitive disability is present and this should be reflected in their individual care
plans.

The person specific risk factors are mainly related fo:

Drugs and alcohol use, including prescribed medicines

Age related physiological changes (e.g. vision}

Medical conditions (e.g. stroke, Parkinson's disease}

Instability, balance and physical inactivity

Footweor or foot care issues

Lack of or incorrect use and servicing of mobility aids and postural care
Pain

Cognition, memory and mental health problems

The policy also includes the following:
Post Fall Protocol

Following a fall, immediate action must be taken to ensure the safety and comfort of the
Resident. Staff must not leave the Resident unattended and immediate assistance should be
summoned. It is important that they are assessed and examined prompily to see if they are
injured. This will help to inform decisions about safe handling and ensure that any injuries are
treated in a timely manner.

All fails must be properly recorded and investigated

As soon as possible, after the fall, an incident report must be completed and the incident
should be logged on Datix. The incident report should be comprehensive and give a clear
picture of what happened and what immediate action was taken.

The incident must be investigated in order to identify what happened, how it happened and
why it happened. You must learn from the incident and take action in order to reduce the

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likelihood of further falls and/or minimise the risk of harm in the future. Care plans and risk
assessments will be reviewed and reformulated as necessary.

Particular attention should be given to Residents who have experienced more than one fall in
a week or more than three ina month. The more falls a Resident has had the greater the falls
risk.

Even if a fall is minor and causes no injury, you must siill investigate and try to prevent it
happening again. An increasing number of minor falls is likely to result in a more serious fall in
the future.

Trend Analysis

Datix can be utilised in order to carry out trend analysis. An analysis of your falls will helo you
identify any trends and any areas of concern to target, from which you can take suitable
action. You can also monitor whether the preventative actions you have taken are having
the desired effect in reducing the number of falls and the harm caused following a fall.

You could analyse the falls of a particular Resident or look at all your falls. Datix can show you
many things, including where your falls are happening, their location, the time of falls and the
level of harm caused. For example, a falls analysis may identify that many falls are taking
place in a particular location around the same time of day.

Reporis are available on a dashboard within Datix, which is the electronic risk management
system used by the company.

Review of care practices, specifically relating to falls

Following any accident or incident, that has affected Resident health or well-being an
incident record is completed by the home team and uploaded onto the electronic Risk
Management system mentioned above.

This system captures any untoward event that occurs, whether it causes harm or not so we
can review any near misses- predominately this is falls, ill health, medicines errors, safeguarding
referrals and complaints.

Once the incident is entered on Datix, the appropriate area and specialist teams are notified
and depending on the nature/severity of the incident, this will advise who will undertake the
investigation.

Falls are reported at group level, area level, home level and also at individual Resident level
through our internal reporting systems, where we can ultimately see the how the individual
Residents care is supported.

Ai Home level fhere is a three monthly falls audit, which includes details of the falls team
meeting discussions and a monthly review through the Key Clinical Indicators (KCI) report,
which helps identify key high risk Residents for staff at the home to follow up on and as part of
the Resident of the day programme, the care plan will be checked.

< Page 4 of 6

Scrutiny at area level by the Area Directors (AD) has been increased in terms of the quality of
the completion of assessment and evaluation through the review of falls as part of their
monthly home visit and the Quality Regulation Managers (QRM) on their internal inspection
visits.

The Clinical Quality team undertake a monthly review and follow up with the ADs and the
Managing Directors on the ‘quality calls’, which have been initiated since the incident and
have now become routine across the group of homes.

Falls and serious incident trends are discussed at the quarterly Quality Governance Group
{QGG} and learning is shared across the group. This is ihe company's bed to Board
governance structure. The frequency of follow up actions from the QGG has increased toa
monthly basis, following this incident, to provide clear accountability and mapping of
improvements in working to reduce falls and ensure appropriate assessment and evaluation
following each fall at individual home and group level.

As mentioned previously, we continually review the NICE guidance in relation to falls and
implement new technologies to support Residents.

All of these actions assist to ensure that our policy is being followed at home level and that risk
assessments are being appropriately completed and that post-fall evaluations are being
carried out and documented.

Initial local actions

The AD aitended the home on the 24 October 2017 to share ihe findings from the case with
the team at the home and the following actions were agreed:

e Sample falls risk assessments were shared wiih the staff team to ensure full
understanding of expectations in relation to {he completion of the falls risk assessments,
in particular in relation to evaluation and assessment of a resident following a fall.

e A Clinical risk register has been implemented and shared with the operational team,
which identifies any Residents with falls and the date of the last care plan audit. This is
reviewed monthly and key actions agreed to reduce further risk by the Home Manager
and also Area Quality Directors via monthly clinical review meetings.

e The falls flow chart has been implemented at the home giving clear guidance on what
actions to take following a fall within Sunnyside.

e The review of falls is part of our daily quality assurance and the Home Manager's daily
diary prompts a review daily of any accidents or incidents and this includes a review of
ihe records completed by the care team which includes the falls risk assessment.

* The daily flash meeting is undertaken 7 days per week and any accidents or incidents
are discussed with the team. The Home Manager/ Deputy Home Manager records this
and checks any additional actions are completed, including referral to the GP and to

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URare Company

update the falls risk assessment, which is completed by the senior care staff. The falls risk
assessments are reviewed and updated by the home's internal falls team, which
comprises all the Heads of Department in the home and are subject io audit every
three months. This team was set up in the home afer the incident and has been
effective in pulling staff together to improve knowledge, accountability and uliimately
outcomes for Residents through increased awareness, diligence and good record
keeping.

e Each accident/incident record has a 24 hour observation record and an additional
clinical walk round, which is undertaken by the Deputy / Home Manager to review
Residents who are unwell, have fallen, have a peg or catheter eic. to make sure their
care needs are effectively met on a daily basis. This is then fed back to the team at the
flash meeting where any concerns are identified. This has now been implemented io
ensure that the person is checked by a senior person following a fall and this process is
audited by ithe operational team and the internal inspection team.

e The area team support the monthly review of all of these actions and | can confirm that
since the incident in October, the audits have identified that these actions have been
effective and risk assessments are being appropriately compleied and residents are
being appropriately assessed following a fall or other incident.

I do hope this information is helpful and offers you the assurance that we, at HC-One, have
taken the issues raised very seriously and are committed to learning and working to prevent
recurrence of such incidents.

Yours sincerely

Head of Standards and Compliance

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