Jonathan Yates

Gloucestershire Hospitals

NHS Foundation Trust

Legal Services Department
Cheltenham General Hospital
Sandford Road

Cheltenham

Gloucestershire

GL53 7AN

Tel: 0300 4223160

26 June 2019

Ms Katy Skerrett

HM Senior Coroner for Gloucestershire
Gloucestershire Coroner’s Court
Corinium Avenue

Barnwood

Gloucester

GL4 3DJ

Dear Ms Skerrett
Mr Jonathan Yates deceased

| am writing in reply to the letter dated 23 April 2019 from your Officer FC enclosing
the Regulation 28 Report to prevent future deaths. Thank you for agreeing to an extension of
time to respond.

The Trust has noted your outstanding concern as described in paragraph 5 of your Report,
namely, “how the nutritional status of a patient, particularly when nil by mouth, is
communicated effectively to staff caring for a patient during an admission.”

Assessment and management of nutritional status is a central element of caring for sick
patients. The Trust has an Adult Patient Nutrition policy to ensure that all patients receive
appropriate and timely nutrition support during their admission. The policy sets nutrition
quality standards, gives guidance on nutrition screening and the identification of patients at
risk of malnutrition.

However, the concern in this case arises from the failure on one occasion to use signage to
safely and effectively communicate Mr Yates’ nutritional status to the clinical team, rather
than the assessment and management of his nutritional needs.

Effective communication of nutritional status is a fundamental element of clinical practice,
and taught as part of professional training programmes. Within the Trust, communication of
the nutritional needs of a patient is achieved through written records, verbal communication
and the use of physical measures, and these follow the patient through their journey from
admission to discharge.

If the patient enters the Trust through the Emergency Department (ED), the medical and
nursing assessments will consider and record the nutritional needs of the patient at that early
presentation, and how they are to be delivered. These may be preliminary decisions,

intended to be reviewed later by the receiving medical teams if the patient is admitted to a
ward. For Mr Yates, it was recorded that his PEG feeding device was broken, needed repair,
and that he may be at risk of malnutrition until this was again functional.

Nutritional decisions made at this stage are available in the main ED medical record.
Specific comments or instructions for the patient can also be noted in the ED handover
document, used when admitted the patient to a ward, and for transferring key information to
the receiving clinical staff.

When the patient moves from ED onto a ward, the written handover is accompanied by a
verbal handover, between one qualified staff member to another.

If a patient is subject to an internal move from one ward to another, a specific internal
handover document is available and this again is accompanied by a verbal handover
between qualified staff

For any move between clinical areas, the medical records will accompany the patient and
can be referred to in handover discussions.

When a patient is admitted to a ward, a nursing admission procedure is carried out before
the patient is clerked (medically reviewed) by the doctor. If this is an internal move, the
handover to the new ward will include details of the nutritional status for the patient as a
specific handover item.

If this is a new admission for the patient, the Gloucester Patient Profile (GPP) document will
be used by the nurses to capture the condition and status of the patient on presentation to
that ward. This includes an opportunity for a specific detailed nutritional review and includes
a scoring tool which screens for the risk of malnutrition.

For new and internal transfer patients, the information passed to the receiving ward will form
part of the whole ward handover information which is delivered to all ward staff, three times
per day, at the beginning of each of the three shifts (early, late and night shifts). During these
handovers, any changes to nutritional status will be discussed, as will the maintenance of
existing nutritional care programmes.

Further detailed handovers are often conducted in allocated ward areas (ie bays, or single
side rooms) between the outgoing staff member for that shift, and the incoming colleague for
the next shift. On the admission of a surgical patient, the patient is assumed to be NBM until
this is confirmed or changed by a doctor. Any patient who is nil by mouth (NBM) should be
part of a robust safety handover.

On arrival on Ward 5b from ED, Mr Yates was known to be NBM, and the doctor was aware
of this. In addition, a member of the nursing staff consulted a doctor about Mr Yates’
continuing NBM status later that day, and this was confirmed.

As a practice development, and to increase the quality of handovers, the Trust has recently
introduced a pilot of the ‘safety huddle’ concept on selected wards. The aim of this daily
event is enable an effective dissemination of patient safety information to the whole ward
team, in a structured conversation. This looks in particular at patient needs in terms of falls
risks, social work requirements, communication with relatives together with identification of
the sickest patients and other immediate priorities such as nutritional status.

In the context of this case, ‘huddles’ will review and remind staff of the nutritional status of
all patients, with attention to patients that have a prescribed change to their oral intake eg if

a patient has been NBM awaiting surgery which is later cancelled, or until a doctor confirms
that the reason for being NBM before an investigation is no longer necessary.

Physical measures are available in clinical areas to communicate nutritional needs visually,
in the form of signs and markers. These are used to identify patients who have specific
nutritional regimes, including being NBM or who may be taking fluids only, or different dietary
preparations. The signs are placed close to the patient, usually above the head of the bed,
on the door of a side room, or both locations. Mr Yates had such a sign in his bed space
whilst in a bay, but when he was relocated to a side room, unfortunately, this was not moved
with him.

On review of the professional processes by which nutritional status is managed, the Trust is
satisfied that appropriate systems are available and in use to safely manage the nutritional
care of patients.

Regrettably, in Mr Yates’ case, human factors intervened in his care. The staff member who
moved Mr Yates from one bed location to another omitted to move the NBM sign and

replace in the usual position at the head of the bed or on the door, as was heard in evidence
at the inquest.

! hope this information is helpful.

Please do not hesitate to contact me if you require further information

Yours sincerely

www. gloshiospitais, rns.uk BEST CARE FOR EVERYONE