Rose Workman

Ms K Skerrett

Senior Coroner for Gloucestershire
Gloucestershire Coroners Court
Corinium Avenue

NHS}

Gloucestershire

Care Services
NHS Trust

Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth

Gioucester

GL3 4AW

Tel: 0300 421 8320

Barnwood Email:_Micheal.Richardson@glos-care.nhs.uk
Gloucester Web: www.glos-care.nhs.uk
GL4 3DG

Wednesday, 28 June 2017

Dear Ms Skerrett,

Submission from Gloucestershire Care Services NHS Trust following the
Coroner's Inquest into the death of RW (DOB: 9/7/39 DOD: 17/6/16) on 22 June
2017

Gloucestershire Care Services NHS Trust (the Trust) recognises that the Coroner's
Inquest into the death of RW who died on 17 June 2016 arrived at the conclusion of
Natural Causes, appended with a narrative conclusion of the circumstances
surrounding her death.

Whilst you were assured that steps had been taken by the Trust since the death of
RW as referred to in our Duty of Candour letter to RW's family, you requested for
further assurances, particularly in relation to your duty to consider whether to issue a
Prevention of Future Deaths ("PFD") notice. The Trust hereby submits the following
report which we hope will provide you with assurance.

1. That the district nursing service employs measures to ensure that
patients are effectively monitored of their ongoing condition(s).

Several initiatives have either already, or continue to be, implemented which are
resulting in our district nurses and health care support workers being able to more
effectively monitor any changes in patients’ health and well-being whilst under their
care, including a sudden onset of changes as well as any gradual ones.

Firstly our electronic clinical patient record “SystmOne” has undergone extensive re-
engineering with all our community multidisciplinary integrated team “units” (sections
of the record split into localities). This re-engineering was clinically led, including

colleagues from each profession and was launched April-May 2017. Colleagues are
already reporting that the system is now easier to navigate. Clinical records and any
recording templates are now much easier to input data into and for clinicians any
changes in the patient's condition are now more visible. For example, a
multidisciplinary review template is available on the patient record within all
community clinical professional modules such as nursing, physiotherapy and
occupational therapy. This review template is now completed whenever the patient is
reviewed or where there are changes in the patient's condition.

Other improvements on our electronic records system include for community nursing
services a reintroduction of the “nursing process” (Roper model) and care plan
documents as well as SBAR (Situation, Background, Assessment and
Recommendation) reporting frameworks which provides a clearer structure for
communicating deterioration of improvement in a patient. Every care plan and
assessment within the electronic system has a section for the review date to be
recorded.

This re-engineered record system now has a patient “non-adherence” questionnaire
available which is another important tool for clinicians to monitor any changes in a
patients’ condition, which was previously not available. If a patient is not compliant
with the care that is offered, the questionnaire prompts the clinician to explore this
using several questions including whether the patient has the mental capacity to
make decisions.

Refresher training for the National Early Warning Score (NEWS) is being
undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest
evidence. The Trust is also currently driving forward a “deteriorating patient” quality
improvement programme. This reflects the current work of many NHS organisations
who are trying to generally improve the competencies of their qualified and non-
qualified clinical workforce to be able to detect a deterioration in a patient's health
status quickly and effectively and; then feeling more equipped to communicate any
changes to other clinicians in a standardised way using this evidence based
approach for patient care.

The Trust has a quality improvement working group which has refreshed the NEWS
paperwork and algorithms to ensure they are commensurate with the work
programme of the South West Academic Health Science Network. In addition to this,
a policy has recently been created that combines two previous policies which
covered NEWS and the management of sepsis. This policy is due for ratification at
the Trust’s Clinical Reference Group in July 2017 and will be used as cascade
teaching material in clinical teams. In order to ensure that this work is fully driven and
embedded within community and hospital teams across the Trust, a “Clinical Lead”
has been appointed and will work immediately with our clinicians to ensure that there
are consistent clinically led deteriorating patient practices occurring across ail of our
services.

Monitoring of any deteriorating patient has been embedded in our recently
reengineered clinical record (SystmOne). An easy to use NEWS calculator score is
now available and within this there are prompts to remind clinicians of the “Sepsis
Six’ indicators.

Workload capacity and its effective management within our clinical services also
needs to be satisfactory for patients to be effectively monitored. A “capacity and
demand” model was introduced into Community Nursing in Gloucester in October
2016. This was developed by clinicians and supports the planned and timely
allocation of patients who receive care. This resource allocation tool supports
suitable time allocation for wound care and colleagues have been strongly advised to
apply a rating score and work to a standard operating procedure that supports
patient care.

An ‘unscheduled care’ ledger (on SystmOne) was also introduced to reduce the
impact on those workloads associated with unplanned visits which are referred into
our nursing team for an urgent patient contact. This ensures that there are nurses
holding the position of shift lead each day and who have an overview of all
colleagues’ workloads, demands and unpredicted care requirements.

To enhance communications nurses are now supported to attend GP practice based
meetings on a planned basis to discuss those patients with more complex needs and
those that are identified to be an unplanned hospital admission risk, as well as those
at the end of their life. In addition all teams have a process for linking with their
affiliated GP practice at least daily, either by telephone or in person. We are also
progressing with having more scheduled multidisciplinary cluster meetings which will
act as an open forum for nurses, physiotherapists and occupational therapists to
discuss and care plan for particular patients on their caseloads.

Recruitment to Staff Nurse level posts remains strong across the Trust; however
recruitment to District Nurse posts remains challenging (as mirrored nationally). The
Trust has mitigated some of the risk by doubling the number of Professional Leads,
Senior District Nurses for the Gloucester locality from October 2016. Colleagues
work in assigned teams attached to identified GP practices. For the team in question
with the RW case a second District Nurse was also employed in August 2016 to
support the workload and patient care. We recognise that risks remain where there
may be high levels of sickness; however this is monitored closely by operational
managers who continue efforts with recruitment. In addition, constructive discussions
are currently in place with Gloucestershire Clinical Commissioning Group to
determine the scope of a new district nursing service specification that is both
sustainable and coherent with the plans and vision of the “One Gloucestershire”
Service Transformation Programme (STP).

We also continue as an organisation to provide specialist Practitioner Training for
nurse colleagues at degree and masters level in order for them to achieve their
District Nurse qualification - this is a long term approach with regards to our
succession planning i.e. growing staff within.

2. That the district nursing service carry out regular top to toe skin
assessments, including the regular checking of pressure areas,
nutrition, weight and hydration status.

Our Professional Leads for Community Nursing run monthly Continuous Professional
Development sessions for community nurses across the localities; the Braden Risk

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Chair: inorid Barker Chief Executive: Katie Norton Understandina Yeu

Assessment tool and Malnutrition Universal Screening Tool (MUST) are refresher
topics that frequently occur and colleagues are encouraged to attend.

The Braden tool is used to assess the risk of a patient developing a pressure ulcer
and is used in conjunction with the nurses’ clinical judgement. It consists of six
subscales which measure elements of risk that contribute to either higher intensity
and duration of pressure, or lower tissue tolerance for pressure i.e. sensory
perception, moisture, activity, mobility, friction, and shear. The MUST assessment
involves measuring height and weight to obtain a body mass index and together with
other risk factors such as a patient's current medical conditions establishes an
overall risk for malnutrition.

Braden, MUST and physical top-to-toe assessments are now incorporated fully into
our clinical record system (SystmOne). For example, for documenting wound care
the improved record system provides the facility for wounds to be better described
including the date the wounds started, were reviewed and healed. Another example
is the top-to-toe assessment which is a question-prompt template with blank boxes
for different parts of the body which are required to be completed. Clear professional
guidance has been issued to all nurses regarding the need to conduct these
assessments at admission to the caseload and re-assessed at a frequency
according to need. This clinical practice is now reviewed as part of quality assurance
visits across all localities to ensure it is carried out. Weighing scales have been
issued to each locality and where a patients weight cannot be obtained to calculate
the MUST score the ulnar measurement is used as advocated by Trust policy.

In view of the issues raised at the inquest in terms of the availability of scales and
other equipment during the time of RW’s death, our deputy director of nursing is
currently seeking assurance from all localities that there are no issues with the
accessing or using of essential clinical equipment. No problems have been identified
but should any be found then measures will immediately be put in place to rectify
them.

lt should also be noted that pressure ulcer prevention and awareness is a
recognised risk for the organisation and is one of our quality priorities for 2017-18. A
quality improvement graup to address this is in place. Since May 2017 we have
moved towards implementing a range of actions to raise awareness of pressure
ulcers and their prevention across services. We are currently observing an increase
in the reporting of grade 1 (very low grade pressure ulcers) which indicates a
growing awareness of the risks of developing pressure ulcers and the need for early
detection.

The Trust's incident reporting system (Datix) is also a tool clinician's use for raising
concerns for patients whose status has changed quickly and or unexpectedly e.g.
unexpected deaths or cardiac events. The “learning assurance framework’ that is
then subsequently employed (which includes a low threshold for requesting root
cause analyses) aims to ensure that as much learning as possible is obtained and
embedded the organisation in order to improve practice.

3. That the district nursing service has effective handover procedures in
place and protected time to carry these out.

A Standard Operating Procedure for handovers was produced in August 2016, two
months after RW's death. This now provides structure and expectation for handovers
within each of our community nursing teams. Time to complete the handover is
applied to the SystmOne ledgers previously mentioned and colleagues are strongly
encouraged to attend them. A quality review visit has identified that occasionally due
to operational pressures nurses have not been able to attend some handovers.
However, this is currently being actively monitored by our operational managers to
determine whether this is a significant issue.

We have two approaches for handovers that clinicians are directed to use:

1) A situation report (‘sit-rep’) which is a concise handover similar to what is in
place in ward environments
2) A ‘deep dive’ caseloads review.

A standard operating procedure (SOP) provides a steer for when to use either
format. Our Professional Leads now endeavour to attend these handovers and they
support decision making, patient care progression and; clinicians are directed to
record handover discussions into our SystmOne record for the patient.

Recent quality review visits have identified that some teams occasionally do not
achieve the requirements of the SOP for handovers — this has been identified as a
risk in the quality review report for the Trust and because of this, team managers and
professional leads are currently managing the issue and are required to provide
assurance that compliance is being met.

This response and the issues and learning that have been highlighted from the
inquest, will be discussed at the Trusts Quality and Performance Committee on 31
August 2017. This is a Trust Board sub-committee, chaired by a Non-Executive
which examines the performance, quality and safety measures of all aspects of the
Trust’s perfarmance, holding managers and leaders to account in order to ensure
where identified, actions and improvements are completed.

We hope that this response although detailed provides you with the assurance that
we have taken and continue to take learning from incidents like these seriously. We
also hope it goes a significant way towards addressing the issues you have
highlighted for the prevention of future deaths, and that this evidences our
commitment to providing the best possible care and support for our patients.

We would like to take the opportunity to again offer our sincere condolences to the
family of RW for their loss last year.

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Chair: inarid Barker Chief Executive: Katie Norton Understandina ou

Please do not hesitate to contact us should you require any further information
including any Trust documentation related to this report.

Yours sincerely

Susan Field Michael Richardson
Director of Nursing Deputy Director of Nursing

CC: Candace Plouffe, Chief Operating Officer
Sian Thomas, Deputy Chief Operating Officer

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