Barbara Johnson

Saving lives, NHS

Improving lives Northern Care Alliance
ee NHS Group

Salford | Oldham | Bury | Rochdale | North Manchester

Ref: PD/Ib Group Director of Patient Safety
Group Headquarters

3" Floor

19 April 2018 Mayo Building
Stott Lane

Salford

M6 8HD

—
Strictly Private & Confidential

Ms Rachel Galloway

Assistant Coroner

Coroner Area Manchester South
1 Mount Tabor Street

Stockport

Cheshire

SK1 3AG

Dear Ms Galloway
Re: Barbara Johnson

Thank you for your letter dated 21 March 2018 enclosing a Regulation 28 Report in respect of the
above deceased.

The Trust was unfortunately unaware of this inquest until receipt of your letter. | note you are
concemed that junior doctors working at Trafford General Hospital routinely ignored the printout of
an ECG which was not considered and/or used to form clinical interpretation and judgement.

| can advise that whilst the two junior doctors concerned were technically employed by Pennine
Acute NHS Trust, who are the administrative lead employer for all junior doctors across Greater
Manchester, Cumbria & Lancashire, they were placed at Tameside General Hospital who acted as
the Host Trust. The Host Trust is responsible for the quality of care delivered to patients and direct
supervision of a trainee ona day-to-day basis. Pennine Acute Trust, as the lead employer, are
simply the administrative employer of the junior doctors, having responsibility for HR issues such as
Pay and sick leave, but are not responsible for the quality of training and care at a Host Trust.

As such, ! would suggest that Trafford General Hospital were responsible for the quality of the care
provided to Barbara Johnson, and for the quality of care and direction supervision of the junior
doctors. Therefore, Pennine Acute Trust is unable to implement change at Tameside General
Hospital and we request that the Regulation 28 Report is amended and addressed to Tameside
Hospital, who have the power to take action to address the concerns within your report.

CE

NHS

. Saving lives, _
Improving lives Northern Care Alliance
_—_—_—————ee NHS Group

Salford | Oldham 1 Bury | Rochdale | North Manchester

! would also like to respectfully refer to the Chief Coroner's Guidance No.5, paragraph 11, which
states that a Regulation 28 report should only be sent once “the coroner has considered all
documents, evidence and information’. \t further states a coroner has a duty to report the matter to
the organisation who has the power to take action, as per paragraph 10(5) of the guidance. In
future, if there are any concems regarding this organisation, please could you or your officers make
contact with Head of Legal Services, so that the Trust has
an appropriate opportunity to present evidence and submissions as is envisaged by the Chief
Coroner's Guidance.

Should you require any further information then please do not hesitate to contact me.
(look forward to hearing from you.

Yours sincerely

Group Director of Patient Safety

NHS

— Greater Manchester
RECE Sy Mental Health
30 APR 233] NHS Foundation Trust

Trust Management Offices
1* Floor, The Curve

Bury New Road

Prestwich

M25 3BL

wun Ce

Tel: 0161 357 1326

th s
24" April 2018 Web: www.gmmb,nhs.uk

PRIVATE & CONFIDENTIAL
Ms Rachel Galloway

HM Assistant Coroner

1 Mount Tabor St

Stockport

SKi 3AG

Dear Ms Galloway

Re: Regulation 28 report to Prevent Future Deaths issued to GMMH following
the Inquest of Ms Barbara Johnson, which concluded 16th March 2018

Following the outcome of the Trust's Root Cause Analysis investigation into the death of Ms
Johnson and the subsequent inquest and concerns raised | would like to inform you and Ms
Johnson's family of the actions taken by the Trust. For ease of reading, | have highlighted the
concerns raised by you during Ms Johnson inquest with the Trust response beneath each point,

There was an apparent lack of training or instruction to nursing staff regarding
handovers between shifts and no training or refresher training on the importance of
handover and what should be included in the handover information. There is a reliance
upon staff to familiarise themselves with the handover policy. In this instance, pertinent
information such as a marked decrease in fluid consumption and the patient presenting
with slurred speech was not handed over. | was advised that there is no local or national
policy requiring refresher training or on the importance of handover and what should
be included in handover which gave rise for your concern

GMMH does have a handover procedure and this is available on the Trust Intranet where all
staff have access to the most up to date version of this procedure, Follawing learning from Ms
Johnson's death the Trust accepts that there is a need to further promote the use of our
handover procedure and to ensure staff are updated as to its contents. In order to address
this the Trust will ensure that the process and expectations of staff when conducting or being
part of a handover are included in the local induction template of all new nursing and nursing
assistant staff.

The Trust is committed to safeguarding children, young people and vulnerable adults and
requires all staff and volunteers to share this commitment.
Greater Manchester Mental Health NHS Foundation Trust, The Curve, Bury New Road,
Prestwich, Manchester M25 3BL (Tel: 0161 773 9121)

improving Lives

| would also like to assure you that the process and expectations of handovers has been
featured in the ward business meetings and will be shared through the local nurses’ forums.
Through these meetings, all existing staff will have been made aware of their responsibilities
in relation to ensuring thorough handovers take place.

In order to evidence that staff have a good understanding of handover process and their
responsibilities a local audit will also be undertaken by the Matron/Operational Manager and
be completed by June 2018. A local learning event which discussed the learning generated by
the Trust investigation into Ms Johnsons death has already been held but to further embed
and share leaming, a further Trust wide event will be held and will include the learning in
relation to the importance of good handovers .

The Trust's Corporate Nursing Team are also completing a Trust wide audit to better
understand practice and variance around handover management across the Trust. The audit
will be complete by the end of June 2018 with the analysis and report to be finalised by August
2018 and presented to our Quality Governance Committee which is the sub-committee to the
board. This report will inform Trust wide actions on the management of handovers going
forward. We would be happy to share the results from this audit with you on completion as
we are keen to be able to offer yourself and Ms Johnsons family assurance of how seriously
the Trust have taken on board the concerns that have been raised following Ms Johnsons
death.

Secondly, you note concerns that the nursing assistant did not appear to inform the
qualified nurse on duty (or a doctor) of the marked decrease in fiuid consumption over
a period of a few days prior to Ms Johnsons death. The qualified nurse on duty on the
day of Barbara's death was unaware of the marked decrease and did not accept that it
was her role to familiarise herself in the patient fluid charts. This plus other factors
resulted in a lack of medical review of the patient or any clinical response in the days
prior to death.

The use of a fluid intake chart is important for some of our service users where there are
concerns about their fluid consumption. The Trust accepts that it is vitally important that
nursing assistants and nursing staff understand the purpose of the fluid intake chart and when
to escalate concerns. In order to address this alt nursing assistants in the Trafford division will
trained on the use of fluid balance charts and when to escalate concerns. This will be over seen
by the Matron/Operational Manager and be completed by 30.6.18.

As described above, the planned Trust wide handover audit will review all aspects of the
handover process and expectations of staff who are handing over or taking part in a handover
will be added into the local induction program for all new staff. Included in this will be the
need to inform a nurse or doctor about changes to the patient's presentation including any
physical observations such as fluid intake.

Similarly, existing staff will be made aware of their responsibilities through the team business
meetings and nurses’ forums. The Matron/Operational Manager will oversee this and this will
be completed by 31/05/2018.

The local audit discussed above will be carried out to demonstrate staff understanding of
handovers and their responsibilities. In addition to this a weekly audit of fluid intake charts will
be completed for 3 months by the Ward Managers to ensure that staff continue to complete
these charts and that any cases that require escalation to a doctor have been progressed.

Furthermore a recent change to Trust policy will ensure that any new support staff Bands 2 to
4 will have a nationally regulated competency based qualification which will ensure that staff
are clear and competent in the core aspects of their role.

Finally, you note that it is of concern that the fluid charts would often not include all the
liquids consumed by the patient and that there appeared to be reliance upon
unrecorded liquids, which might have been consumed when considering the fluid
charts. Your concern was that such reliance makes the purpose of keeping a fluid chart
obsolete.

Concems pertaining to fluid intake charts and their usage were taken to the Trust's Physical
Health Committee (PHC) on 11.4.18. This group discussed alterations to the existing charts and
training requirements for staff as well as how any agreed training will be delivered. Through
this group Staff have been made aware of the need to ensure that all fluids that are offered
and or consumed are recorded on the fluid intake chart as well as self-reported consumption
of drinks.

Furthermore Trust leads have been identified to consider how dietetics can be part of the Trust
induction program, as well as reviewing training being delivered in other parts of the Trust to
produce a Trust-wide package which in addition to the action already taken or planned will
include the issue you have raised above.

| hope that this response has provided some assurance to you and Ms Johnsons family and
has demonstrated that as a Trust we have taken the concerns you have raised very seriously
and will be utilising relevant local and Trust-wide forums to share this learning and steps being
taken to address the concerns raised.

Yours sincerely

Dr Chris Daly
Medical Director

a

Dep artment Steve Barclay MP
of Health Minister of State for Health
Your reference: 7255/CLB 39 Victoria Street
Our reference: PFD 1125656 eure
Ms Rachel Galloway Tel: 020 7210 4850
HM Assistant Coroner, Manchester South
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
\5 May 2018

\ Ach

Thank you for your letter of 21 March to the Secretary of State for Health and
Social Care about the death of Mrs Barbara Johnson. I am responding as
Minister with portfolio responsibility for professional regulation.

Firstly, I would like to say how saddened I was to read of the circumstances
surrounding Mrs Johnson’s death. Please pass my condolences to her family
and loved ones. I appreciate this must be a difficult time for them.

The matter of concer that you ask the Department of Health and Social Care
to address is that on the importance of effective patient handover between
nursing shifts. I understand from your report that in Mrs Johnson’s case,
pertinent information, such as a marked decrease in fluid consumption, was not
handed over.

Nursing handover is a group of skills, qualities and abilities conducted in a
huge variety of forms.

In modern healthcare, although formal large group handovers between shifts do
often still take place, more common are the individual handovers between
teams or individual staff, sometimes staff who work for different organisations.
Communicating effectively to another caregiver the correct information,
clarifying understanding, and agreeing a shared plan of what will happen now
and who will do it as a result of the information handed over is a complex
activity encompassing a number of skills.

Communication, transfer of clinical information, and care planning for a
patient are all pre-registration competencies studied on all nursing programmes
in a variety of ways. The manner in which this is evidenced is both academic

and more importantly in clinical practice, supervised and assessed by an
appropriate healthcare professional.

A person seeking admission to the NMC’s register must, among other things,
satisfy the NMC that they hold an approved qualification attesting to the
standard of proficiency that the NMC consider necessary for safe and effective
practice as a nurse at the point of entry to the register.

In March 2018, the NMC published its new standards of proficiency. These
standards include requirements that, at the point of registration, the registered
nurse will be able to:

e Provide clear verbal, digital and written information and instructions
when delegating or handing over responsibility of care;

e Demonstrate the ability to keep complete, clear, accurate and timely
records;

e Demonstrate the ability to monitor and evaluate the quality of care
delivered by others in the team and lay carers;

e Understand the principles and processes involved in planning and
facilitating the safe discharge and transition of people between
caseloads, settings and services; and

e Demonstrate the ability to work in partnership with people, families and
carers to continuously monitor, evaluate and reassess the effectiveness of
all agreed nursing care plans and care, sharing decision making and
readjusting agreed goals, documenting progress and decisions made.

Once nurses are registered with the NMC they are required throughout their
careers to uphold and act in accordance with the professional standards
contained within the NMC’s Code: Professional standards of practice and
behaviour for nurses and midwives (2015).

The preamble to the Code emphasises that when joining the register and when
renewing their registration, nurses and midwives commit to upholding these
standards and that this commitment to professional standards is fundamental to
being part of a profession. The following aspects of the Code are relevant to
the matter of concern raised in your report:

e Paragraph 6.2 of the Code states that nurses must maintain the
knowledge and skills they need for safe and effective practice.

ae

Department
of Health

® Section 8 of the Code concerns nurses working cooperatively and
provides that nurses must maintain effective communication with
colleagues, keep colleagues informed when sharing the care of
individuals with other healthcare professionals, work with colleagues to
preserve the safety of those receiving care and share information to
identify and reduce risk.

e Section 10 of the Code relates to the responsibility of nurses to keep
clear and accurate records relevant to their practice and provides that
nurses must complete all records at the time or as soon as possible after
an event; identify any risks or problems that have arisen and the steps
taken to dealt with them, so that colleagues who use the records have all
the information they need; complete all records accurately and without
falsification, taking immediate and appropriate action if they become
aware that someone has not kept to those requirements.

e Paragraph 13.5 provides that nurses must complete the necessary
training before carrying out a new role.

In appropriate circumstances, the NMC enforce the standards set out in the
Code through fitness to practise proceedings. Fitness to practise proceedings
can result in the provision of advice by the NMC, the issue of a warning or the
acceptance of undertakings by a nurse or midwife to take agreed steps in order
to remedy concerns about their practice, Other sanctions available to fitness to
practise panels include the imposition of a caution, a condition of practice
order or the suspension or removal! of the nurse from the register.

Further, in order to maintain their registration with the NMC, every nurse must
‘revalidate’ every three years to ensure that they practise safely and effectively.

The revalidation process requires the nurse to demonstrate that they have
practised for at least 450 hours, obtained at least 35 hours of continuous
professional development (including 20 hours of participatory learning),
reflected on their practice and obtained five pieces of practice related feedback.
The NMC does not prescribe any particular type of continuous professional
development. It is for individual nurses to decide what activity is most useful
to their development as a professional.

The standard of nurse training is the responsibility of the NMC, which has the
general function of promoting high standards of education and co-ordinating all
stages of education to ensure that nursing students and newly qualified nurses
are equipped with the knowledge, skills and attitudes essential for professional
practice.

The training curricula for nursing trainees is set by individual Higher
Educational Institutions (HEIs) and has to meet the Standards of Education and
Training set by the NMC. Whilst curricula do not necessarily highlight
specific conditions or processes for nurses to be aware of, they instead
emphasise the skills and approaches that a nurse must develop in order to
ensure accurate and appropriate care is provided for their patients.

Care assistants are expected to undertake the care certificate which includes the
importance of accurate and timely communication of any change in the
patient's condition.

I should point out that we would expect individual organisations to have
policies and procedures in place on the conduct of handovers that include the
capture of physical healthcare information.

We would expect training on Trust handover policy to feature as part of the
induction process provided by individual trusts. I understand NHS England’s
letter to you of 30 April makes the point that, while there may not be specific
refresher training on effective patient handover, this topic would be picked up
in other areas of training, for example, risk assessment and management which
form part of core training for mental health staff.

In clinical practice, there are several tools afforded to nurses to be able to
handover a patient more effectively. Many trusts are now adopting the SBAR
(Situation, Background, Assessment and Recommendation) process for
handovers which provides a clear structure and ensures that not only is key
information communicated, but clarity on the response .

Following Mrs Johnson’s death, I am informed that the Greater Manchester
Mental Health NHS Foundation Trust has identified that there is a need to
further promote its handover procedure and to make sure staff are updated on
its contents.

To address this, the Trust will include the handover process and expectations in
the local induction template for all new nursing and nursing assistant staff. The
process and expectations for handovers have been shared in ward meetings and

ae

Department
of Health

through nurse forums. An audit will be completed by June 2018 of
compliance.

In addition, I am advised that all training assistants in the Trafford division will
be trained on the use of fluid balance charts and when to escalate concerns by
the end of June. A fluid chart audit will be conducted and the need to inform a
nurse or doctor about changes to the patient’s presentation will be included in
induction and awareness raised among staff.

Finally, it is essential that staff in mental health settings also meet patients
physical health needs. Under its inspection regime, the Care Quality
Commission (CQC) is responsible for assessing the safety of care and
treatment provided. To support mental health providers to comply with the
standards, CQC published a guide in May 2017 setting out the evidence needed
to demonstrate that the physical health needs of people with mental illnesses
are being met.

I hope this information is helpful. Thank you for bringing the circumstances of
Mrs Johnson’s death to our attention.

was
=

STEPHEN BARCLAY MP

RECEIVED
04 MAY 2018
xD

NHS iy, 0

YEARS

England = sz*5

Professor Stephen Powis

Rachel Galloway National Medical Director
HM Assistant Coroner Skipton House
Coroners Court 80 London Road
1 Mount Tabor Street SE1 6LH

Stockport SK1 3AG

O™ april 2018

Dear Ms Rachel Galloway

Re: Regulation 28 Report to Prevent Future Deaths following an inquest
concerning the death of Barbara Johnson (30 April 2017)

Thank you for your letter of 21 March enclosing the Regulation 28 Report
(‘Report’) following the death of Barbara Johnson. Firstly, | would like to express
my deep condolences to Ms Johnson's family. | was sorry to read about Ms
Johnson's death.

The ‘Matter of Concer’ that you addressed to NHS England as well as to the
Department of Health and Social Care, and to Greater Manchester Mental Health
Trust, is as follows:

There was an apparent lack of training or instruction to nursing staff regarding
handovers between shifts. Other than that which is provided during the nursing
degree, there is no training or refresher training on the importance of handover
and what should be included in the handover information. There is a reliance
upon staff themselves to familiarise themselves with the handover policy at
Tameside [sic] General Hospital (available on the intranet) and to read the same.
In the present case, pertinent information (such as marked decrease in fluid
consumption and the patient presenting with slurred speech) was not handed
over. | was advised that there is no local or national policy requiring refresher
training (or any training following completion of the nursing degree) on the
importance of handover and what should be included in handover. This gave rise
to a concern.

We have liaised with NHS Improvement as NHS Improvement is the national
body responsible for overseeing foundation trusts and NHS trusts, as well as
independent providers that provide NHS-funded care.

We believe that best practice would be for individual organisations, including
mental health trusts, to have a policy/procedure on conducting handovers which
would include the key elements of handover. One of the key elements would be
information on physical healthcare. Many trusts are now adopting the SBAR
(Situation, Background, Assessment, Recommendation) process for handovers,
which provides a clear structure and ensures that not only is key information
communicated between staff, but also provides clarity on the how this
information should be responded to.

High quality care for all, now and for future generations

There are national-level resources to support this. For example, Improving the
physical health of adults with severe mental illness: essential actions, A report of
the Academy of Medical Royal Colleges and the Royal Colleges of General
Practitioners, Nursing, Pathologists, Psychiatrists, Physicians, the Royal
Pharmaceutical Society and Public Health England (October 201 6) says the
following:

Mental healthcare providers should ensure that...communicatian systems are
used for handover and medical emergencies, such as the SBAR system
(Situation, Background, Assessment, Recommendation) (p 12)

Communication and handover and systems should be used routinely to enable
Staff to communicate effectively about the physical health (and mental health
Status) of people with SMI [severe mental illness]. (p 31)

The report is available here: httos://www.rcn.ora.uk/-/media/royal-colleqe-of-

nursing/documents/news/2016/ohysical-and-mental-health-report-25-oct-
2016.pdf

The Care Quality Commission (CQC) have published a brief guide on physical
healthcare in mental health settings, which sets out the evidence that CQC
inspectors of mental health services will look for in order to ensure that providers
are meeting the physical health needs of people with mental illnesses in their
inpatient services, linked to CQC's inspection domains. The guide is available

here: httos://www.cac.org.uk/sites/default/files/20170612 briefquide-
physical healthcare mental health settings.odf

We would expect that training on a trust's handover policy would be part of the
induction process in all trusts and, although not covered in specific regular
training, would be picked up in other areas of training such as risk assessment
and management, which form part of core training for all mental health staff. |
suggest that you may wish to write to Health Education England, who are
responsible for overseeing the development, education and training of the
healthcare workforce in England.

Thank you for bringing these important patient safety issues to my attention and
please do not hesitate to contact me should you need any further information.

Yours sincerely,

>

ile

Professor Stephen Powis
National Medical Director
NHS England

High quality care for all, now and for future generations