John Preece

From the Chief Executive and Registrar

Nursing &
Midwifery
Council

Andrew Barkley

HM Senior Coroner

South Wales Central Coroner Area
Coroner's Office

Courthouse Street

Pontypridd

CF37 1JW

7 March 2019
Dear Sir
RE: The Late John Preece — Regulation 28 Prevention of Future Deaths Report

1 am writing to respond to your report to Prevent Future Deaths made under paragraph
7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, and to explain the action we’ve taken or
propose to take in relation to the issues you've raised.

Firstly, | would like to offer my sincere condolences to Mr Preece’s family, and to assure
you and them that we take the concerns you have raised very seriously. To help you
understand the actions we have taken to address your concerns in this case, it may be
helpful if | first explain our regulatory role in setting and maintaining standards for
registered nurses.

Our statutory functions and objectives

We are a statutory body created by the Health Act 1999 and governed by a number of
pieces of secondary legislation. Our functions are set out in Article 3(2) of the Nursing
and Midwifery Order 2001 (‘the Order’):

The principal functions of the Council shall be to establish from time to time standards of
education, training and conduct and performance for nurses, midwives and nursing
associates and to ensure the maintenance of those standards.

Our approach to regulation is necessarily circumscribed by our legislation. It also
reflects what the Professional Standards Authority (“PSA”) has described as “right touch
regulation”.

23 Portland Place, London W1B 1PZ
T 020 7637 7181

www.nmc.org.uk

We are the professional regulatory body for nurses and midwives in the UK. Our role
is to protect patients and the public through efficient and effective regulation.
Registered charity in England and Wales (1091434) and in Scotland (SC038362}

Page 1 of 4

Our Education and Training Standards

In order to begin their professional life as a registered nurse, each nurse must obtain a
qualification’ which has been approved by us as demonstrating that the nurse has met
our standards of proficiency for nurses (‘proficiency standards’). Our proficiency
standards are the standards we consider necessary for safe and effective practice as a
nurse at the point of entry to our nursing register. We also set standards for providers of
nursing programmes (‘education standards’), which are the standards of education and
training we consider are needed to achieve our proficiency standards.

We ensure, through our statutory quality assurance processes, that we only approve
education institutions and nursing programmes which meet our standards.

In 2016 we identified education for nurses and midwives as a key priority, and
embarked on a programme of change designed to ensure that our standards remained
contemporary and fit for purpose to protect the public. Between June and September
2017 we conducted a full public consultation on our proposed new standards, during
which we heard from over 2000 individuals and many organisations. Our new standards
were approved by our Council in March 2018, and since 29 January 2019 it has been
necessary for all education providers to seek approval against these new standards if
they wish to continue offering approved nursing programmes. Links to our new nursing
proficiency standards and our new education standards may be found here:

https://www.nmce.org.uk/standards.
Nurses joining our register

Reading our new proficiency standards, you will see that they are clearly designed to
ensure that all nurses applying to join our register are able to provide holistic, people-
centred care in a context of continual change including challenging environments,
different models of care delivery, shifting demographics and evolving technologies.
They specify the knowledge, skills and attributes that all nurses, whatever their area of
specialism, must demonstrate when caring for people of all ages and backgrounds,
They are designed to ensure that they are able to care for people with complex mental,
physical, cognitive and behavioural care needs in a variety of care settings.

In particular, you will see that the proficiency standards state that at the point of
registration, registered nurses must be able to safely demonstrate that they can use
evidence-based approaches to take histories, observe, recognise and assess people of
all ages, and use evidence-based best practice approaches to undertake, respond to
and interpret neurological observations and assessments, and identify and respond to
signs of deterioration.

1 The law on Mutual Recognition of Professional Qualifications applies to nurses applying to join our
register from the EU.

2 See in particular our Proficiency Standards: Platform 3 “Assessing needs and planning care” and
Platform 6 “Improving safety and quality of care"

Page 2 of 4

Professional standards for registered nurses

Once nurses are registered, they are required to uphold throughout their careers the
professional standards contained within ‘the Code: Professional standards of practice
and behaviour for nurses, midwives and nursing associates’ (NMC 2018)
https:/Awww.nmce.org.uk/standards/code. The Code contains (amongst others)
requirements that nurses maintain the knowledge and skills they need for safe and
effective practice, complete the necessary training to carry out a new role, and raise
concerns immediately if they are asked to practise beyond their role, experience and
training.

In order to maintain their registration, every nurse must ‘revalidate’ their registration
every three years to ensure that they practise safely and effectively and keep their skills
up to date. The revalidation process requires them to demonstrate that they have
practised for at least 450 hours, obtained at least 35 hours of CPD, reflected on their
practice, including their adherence to the Code, and obtained five pieces of practice
related feedback.

Our Fitness to Practise process and our Employer Link Service

In appropriate circumstances, we enforce the standards set out in the Code through our
fitness to practise proceedings. Depending on the seriousness of the case, our fitness
to practise (FtP) proceedings can result in us providing advice or a warning, accepting
undertakings, imposing a caution or a conditions of practice order or suspending or
removing a nurse from our register.

We also expect employers to recruit and train their nursing staff appropriately and to
support their staff in upholding the standards in the Code, and we reinforce this through
regular meetings between members of our Employer Link Service and employers
across the UK. Where an issue comes to our attention relating to the provision of safe
nursing care, we may advise employers to take appropriate action, or if appropriate,
take action ourselves. Where the issue falls outside our remit (for example because it
relates to a systemic problem) we refer the issue to the appropriate regulatory body.

Specific action we are taking in this case

You have asked us to provide details of action we have taken or propose to take in
relation to the concerns you have raised.

With regard to your concern that the nurses in question may not have been trained in
some basic areas during their nursing training, we are not in a position to confirm the
specific details of any particular individual's original nursing training. However, | hope
that | have reassured you that we are doing everything we can through our new
standards and assurance processes to ensure that nurses entering our register and
maintaining their registered practice are properly trained in managing falls and
conducting observations, no matter what their area of specialism, the age or
background of the person they are caring for, or the context in which they are providing
care.

Page 3 of 4

Also, for data protection reasons, we are unable to comment publicly on whether we are
taking any regulatory action in relation to the fitness to practise of any of the nurses
involved. However, | can confirm that we are aware of their identities, and that we will
pursue any regulatory concerns which it is appropriate for us to take, through our fitness
to practise procedures. Outcomes of our fitness to practise proceedings are published
on our website, and any restrictions we impose on any nurses’ fitness to practise are
reflected on our public register.

We note that you have also written to the Cardiff and Vale University Health Board.
They will no doubt explain in their response the relevant training, if any, which nurses in
this unit had received, and any relevant steps they are taking to learn from this tragic
incident. | can confirm that we will be drawing the concerns you have raised to the
attention of the Healthcare Inspectorate Wales, so that they aware of the issues (if they
are not already) and can take any appropriate action.

| hope that this letter reassures you that we are doing everything we can to address the
concerns you've raised, within the scope of our statutory remit. Sf you have any further
questions concerning this case or the action we have taken, please do not hesitate to
get in touch.

Yours sincerely

Andrea Sutcliffe ~
Chief Executive and Registrar

Page 4 of 4

GIG | Bwrdd techyd Prifysgol Ysbyty Athrofaol Cymru
Yiany | Caerdydd a‘r Fro University Hospital of Wales
ofjo iE . UHB Headquarters
NHS | Cardiff and vate Heath Park q Pare Y Mynydd Bychan
waAIT=S | University Health Board — Cardiff, CFl4 4xW Caerdydd, CF14 4XW

Eich cyt/Your ref:

Eln cyf/Our ref: LR-Jb-03-7330

Welsh Health Telephone Network:

Direct Line/Llinell uniangychot: 02920 745681

Len Richards
Chief Executive

11 March 2019

Mr Andrew Barkley

Her Majesty's Senior Coroner
South Wales Central Coroner Area
Coroner's Office

The Old Courthouse

Courthouse Street

Pontypridd

CF37 1JW

Dear Mr Barkley
Touching upon the death of the late Mr John Preece

Thank you for your letter which we received on 16 January 2019. The University
Health Board (UHB) has reviewed the points raised within the Regulation 28 report
with relates to the very sad death of Mr Preece. Our response has been informed by
key clinical staff within Mental Health Clinical Board.

We recognise that this will have been a very difficult time for Mr Preece’s family and
would like to offer out most sincere condolences. The matter has been fully
investigated and there is a comprehensive improvement plan in place which is being
monitored by the Clinical Board.

For ease of reference, | will respond to each of the matters of concern you have
raised in turn.

1. There was a clear lack of understanding and basic knowledge of falls
management in both trained and support workers in circumstances in
which it should have been obvious that Mr Preece sustained a head injury.
The evidence clearly revealed that there was knowledge of a head injury
following his seizure and fall. Even if that were not the case a head injury
should have been suspected.

Mental Health Clinical Board run a bespoke falls training programme which has been
developed by the Practice Nurse Educators within the Mental Health Services for
Older People (MHSOP) Directorate. The sessions specifically include training on
falls risk management (to identify measures to reduce the risk of a patient falling),
post falls management, responding to an unwitnessed or witnessed fall and
performing neuro observations. This training is delivered on a rolling programme and
so far, approximately 75% of nurses (both qualified and unqualified) within MHSOF M0, is

Bored Lechyo Prifyspot Caerdydd a'r Fro yw envy gwethredol Bwyrdd Lechys! Leo! Prityego! Caerdyde a’r Fro.
Cavdit and Vate Univenity eahh Bosra the operational name of Cardiff and Vale Universky Local Health Gourd! i AO

and Adult Mental Health have attended this training. 37 out of 42 nurses working on
St Barrac's ward have completed this training and arrangements are in place for the
outstanding 5 nurses to attend training soon.

The UHB has recently opened a falls simulation training suite in the University
Hospital of Wales (UHW) and there are plans for a further suite to be sited in
University Hospital Llandough. All qualified and support staff are encouraged to
attend simulation workshops on falls prevention management and post fall care. The
training covers the management of an unwitnessed fall including how to respond to a
head injury.

One of the Nurse Advisors for Standards and Professional Practice is currently
working a day a week with nursing staff in MHSOP reviewing patients who have
been assessed to be at high risk of falling. The purpose of this work is to try and
identify other preventative measures to further reduce the risk of falling.

2. There was a clear lack of knowledge amongst all staff, both registered
nurses and support workers as to how to conduct neuro observations
despite the evidence showing that guidance in the form of health board
policy and also a “wall chart” was available to be consulted.

Training on neuro observations is included in the bespoke Mental Health training
programme and also in the UHB wide falls simulation training.

A new neuro observation chart was introduced in August 2018 and it is now UHB
policy that only registered nurses perform this task.

3. There was no forward planning for the continued observations of Mr
Preece throughout the day on 9‘" September 2015 and as a result he was
simply put to bed and not closely monitored as the circumstances
required.

There are clear escalation processes in place and our internal investigation identified
that 2 nurses did not follow this process. They were managed by UHB disciplinary
procedures and have now been referred to the Nursing and Midwifery Council for
further investigation.

4. The evidence revealed that none of the registered nursing staff were
trained either during their basic nurse training or subsequently upon
employment within the health board, on how to conduct neuro
observations and that together with a failure to appreciate an obvious head
Injury meant that not only observations conducted but that no medical
assistance was sought for at least 10 hours.

In 2015 undergraduate nurse training did not cover how to perform neuro
observations but this task has now been added to the curriculum and as mentioned
above, training on how to perform neuro observations is now included in falls training
within the UHB.

Me

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Cardiff and Vale University Heattn Board is the operational name of Cardiff and Vale University Locat Heath Board Says

5. Evidence given at the inquest showed that the health board had
considered the introduction of the NEWS scoring system (National Early
Warning System) for the Mental Health Directorate but felt unable to
introduce it as the mental health unit did not sit within/alongside a district
general hospital. The obvious concern being that against a background of
poor training and poor management medically unwell mental health
patients are at risk.

St Barruc ward is part of Barry Hospital which is not attached to one of the UHB's
main hospital sites. Barry Hospital is a community hospital with in-patient wards and
other community out-patient services.

MHSOP Directorate are not able to guarantee the level of medical cover at Barry
Hospital (there is no 24 hour medical cover) hence it has not been possible for the
NEWS monitoring system to be implemented there in the same way as it has been
implemented in the district general hospitals where medical staff are available on-site
at all times. MHSOP have therefore introduced an escalation policy specifically for
St Barruc ward covering in and out of hours. This policy gives nursing staff guidance
on who to contact for medical advice and who to escalate any concerns to.

NEWS is used across MHSOP wards based in University Hospital Llandough to
assist nurses and medical staff in determining the degree of illness of a patient and
again there are clear escalation policies in place, if nurses identify a patient whose
NEWS score is deteriorating or if they have general concems.

| hope that the information set out in this letter provides you with the assurance that
the Health Board has fully considered the issues raised as a consequence of the
inquest into Mr Preece'’s death, and has taken appropriate action in response.

Yours sincerely

thehucke

Len Richards
Chief Executive

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