John Pearce

INHS|

Central and

North West London
NHS Foundation Trust

Executive Office
Tel: 020 3214 5760

24 April 2019

Mr Edwin Buckett

Assistant Coroner Inner North London
Poplar Coroner’s Court

127, Poplar High Street

London E14 0AE

Dear Mr Buckett,

RE: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS FOLLOWING
THE INQUEST OF MR JOHN WILLIAM PEARCE

| write in response to the Regulation 28 Report issued on 25 February 2019 following
the inquest into the death of Mr John William Pearce.

Central and North West London NHS Foundation Trust (CNWL) deeply regret the
death of Mr Pearce and apologise for any failings in the care we provided.

The Regulation 28 report identified four concerns which | have identified in bold
below followed by the Trust response:

“There was no clear instruction, protocol or system which assists nursing staff
in dealing with elderly patients who suffer from open wounds which worsen
over time, as to when the emergency services should be contacted. It is clear
that the staff were following a Tissue Viability Nurse care plan, but no-one
appeared to recognise the severity of the injury and the fact that tendons and
bone were exposed”

CNWL has a Lower Limb and Leg Ulcer Management Policy which was published in
October 2018 and gives detailed instructions on the management of lower limb
wounds, including traumatic non healing wounds as seen in this case. The purpose
of the policy is to standardise lower limb and leg ulcer management strategies
across the Trust in accordance with NICE (2016), Best Practice Statement (2016)
and RCN (2006) guidance.

Trust Headquarters, 350 Euston Road, London NW1 3AX
Telephone: 020 3214 5700
www.cnwi.nhs.uk

Be SS os Wellbeing for life

 =POwnye') PARTNERSHIP London Milton Keynes | Kent | Surrey | Hampshire

It is completely unacceptable that this policy was not consistently adhered to by the
staff involved in Mr Pearce’s care. In response to this, the Divisional Director of
Nursing and the Inner London Lead Nurse met with the team involved in this
gentleman’s care on 19 March 2019 to discuss the findings of the PFD, reiterate the
policy and assess any further support required in ensuring the above policy is
followed in the future.

In the meeting on 19 March, the policy was discussed in detail alongside
reinforcement of individual roles and responsibilities for escalating any deterioration
in a patient’s condition. This included reiteration of the role of emergency services
and the need outlined in this policy which requires the attendance on every third visit
by a qualified nurse or senior nurse; ensuring a thorough re-assessment is
undertaken and any risk factors which may contribute to delayed healing are
identified early and appropriately managed in line with the policy.

A further follow up meeting is planned with the team on 3 May 2019 to assess how
the team have embedded learning from this incident to date including their local
processes for ensuring that at handovers, deteriorating patients are identified in a
systematic manner.

All of our district nurses complete annual refresher training on wound care
management. There is a competency framework in place for health care assistants
and district nurse team leaders are responsible for ensuring that their staff are
competent. In light of these findings, the Lead Nurse will oversee a programme for
reassessment of competence and this will be completed for all staff by 1 June 2019.

In addition, a Trust-wide clinical message will be cascaded out to all community
nursing teams reminding them of the policy requirements, consent and capacity and
escalation processes.

There were insufficient attendances on Mr. Pearce by the District nurse Team
when it appeared to be decided that he would be visited at more frequent
intervals”

Whittington NHS Trust currently provide the specialist tissue viability service for
complex wounds to Camden residents and were directly involved in the care
delivered to Mr Pearce. As the specialist service, they advise our district nursing
teams on the wound care plan and frequency of visits. We are therefore sharing, and
working together, with the Whittington NHS Trust in the learning from this case.

Where a patient is clinically assessed and the condition of any wound is noted to be
significantly deteriorating, we fully acknowledge that the capacity and best interest of
the patient must be clearly assessed on each occasion and the records must
evidence that this has occurred.

Where the clinical advice indicates an enhanced level of visits, the decision to
reduce the level of visits should only be taken following evidence that the potential
consequences for the patients’ well-being have been detailed in full to the patient
and the risk to the patient discussed with those involved in the patients care.

Through the meetings already underway and being planned we have reinforced the
requirement for all involved parties — in this case our district nursing service, the GP
and the Whittington NHS Trust to consider better how to ensure the care continues
to be delivered in the best interest of the patient and the required frequencies of
attendances.

As above, the requirement of the policy that every third visit should be undertaken by
a qualified nurse or senior nurse; ensuring a thorough re-assessment is undertaken
and any risk factors which may contribute to delayed healing are identified has also
been further reinforced with the team.

“Too much emphasis was placed on Mr Pearce’s own view that he did not like
hospitals and did not want to go there, even though he was noted to be an
individual who had difficulty expressing himself”

This case has highlighted the difficulties of safely managing patients who decline
care against clinical advice. In cases where health workers believe the patient is
making unwise decisions against hospital admission and more frequent visits in
his/her own home, we provide specific safeguarding advice and will now consider
how best to adapt our existing Mental Capacity Act (MCA) training to support the
application of the MCA, and best interests need to be made on each occasion when
the patient is declining appropriate clinical care.

Where there is continued refusal but capacity is still observed and recorded, we will
ensure there is further escalation. The requirement of the CNWL Lower Limb Policy
referred to above that every third visit should be undertaken by a qualified nurse or
senior nurse must be followed.

We are tightening our process for ensuring that there is formal and regular mental
capacity assessment at the point that treatment decisions of consequence are being
made and recorded accurately in our clinical records.

We already run regular peer reviews across community services. As part of this
process, we will also now ensure that on each peer review, a sample of notes is
audited to assess completeness and accuracy of documentation.

On 10 April, the CNWL Trust Deputy lead for safeguarding adults and MCA met with
the team to follow up how community staff should be making their assessment of
capacity and consideration of best interests when seeing patients in their home
environment. The actions to be taken where the health of patients is observed to be
deteriorating and how that risk should be effectively managed, has been reinforced.

During May our Safeguarding Adults lead will also be providing additional bespoke
training for capacity and best interest in community settings including supporting
clinicians with necessary documentation.

As identified above, the learning from this case will be shared across the Trust as
part of our “clinical message of the week” process during the next month. The case
will also be shared at a planned learning event with staff, GP and colleagues from
Whittington Health on 9 May 2019.

CNWL operates a Trust-wide Pressure ulcer board and, during June, this forum will
also be used to cascade learning around escalation of deteriorating wounds,
capacity and best interest assessments.

“There was no clear evidence that photographs taken of the wound were
shared with other agencies or the deceased’s GP, such that another view
could be taken of those wounds so as to consider whether the emergency
services should become involved as a matter of urgency”

Photographic evidence was regularly taken and consent to photography was
recorded with all photographs being uploaded to the clinical recording system
(Systmone). The process already in place ensures that any photographs can be
reviewed by the Whittington NHS Trust who currently provides the specialist tissue
viability service to Camden residents and were involved in the care delivered. As
mentioned above, we are working with the Whittington to address the learning from
this case and are due to meet with them on 9" may as highlighted above.

Due to the GPs using a different recording system (EMIS), the GP would not
automatically be able to access the photographs. We recognise that it is not practical
or necessary to share all photographs of wounds automatically with every GP. As
part of the escalation where a patient’s condition is seen to be deteriorating, the
requirement for sharing information, including photographs, is expected and would
take place via secure email. This has been reinforced to our staff as part of the
meeting in March and will be again reinforced at the follow up session in May.

The ability to share photographs of deteriorating wounds with both the specialist
service and the GP will provides a further level of scrutiny to decision making
regarding the need or otherwise of involvement of emergency services.

CNWL has a deteriorating patient policy which identifies actions staff need to take to
identify when patients clinical condition changes. The policy requires that staff in
adult services use the National Early Warning Score (NEWS2) tool which directs
staff to seek emergency help. CNWL will re-train members of the team in the use of
this tool by the end of May 2019.

The Lead Nurse will oversee a 3 month action plan to ensure that the improvements
required, as outlined above, are embedded in this team. She will be required to
formally report back, at the end of the 3 month period to the Divisional Board as part
of our assurance process.

| hope this provides you with sufficient assurance that the Trust is taking decisive
action to improve care for patients in the community with this type of injury. If you
have any questions or comments, please do contact me directly on the details

above.

Yours sincerely,

Claire Murdoch
Chief Executive