Mellin Beard

INHS |

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Karen James

Chief Executive Officer
Silver Springs
Fountain Street
Ashton-under-Lyne
Lancashire

OL6 9RW

Telephone: 0161 922 6002

1 July 2019

Mr Christopher Morris

HM Area Coroner

Manchester South Coroner's Court
1 Mount Tabor Street

Stockport

SK1 3AG

Dear Mr Morris,

Regulation 28: Report to prevent future deaths, following the Inquest touching upon the death
of Mr. Mellin Beard

| am writing in respect of your letter dated 17 May 2019, and enclosure in the form of a Regulation 28
Report issued following the Inquest touching upon the death of Mr. Mellin Beard, which concluded on
24 April 2019. | hope to be able to address the concerns raised in your report and set out below my
response.

Concern 1:

A member of the Trust's community nursing team gave evidence to the effect that it was ‘common’ not
to receive timely referrals in respect of patients who were discharged from hospital and required
community nursing services. Whilst it was apparent from the evidence before the court as a whole
that this concern does not relate solely to patients who have been receiving in-patient care at
Tameside General Hospital, and that some improvements have been made with the introduction of an
e-discharge system, it is a matter of particular concern that this problem continues to subsist at the
Trust in particular due to the integrated care model as between acute and community services the
organisation purports to espouse.

Upon consideration and investigation into your particular concern detailed above, we have discovered
that whilst you heard evidence that the referral to District Nurses was only made by the acute hospital
staff following a telephone call from District Nurses to the hospital, this is in fact not what has been
recorded in the patient's notes. We apologise for any confusion caused however the patient's notes
make it clear that attempts were made to send the referral to District Nurses by staff on the Ward on
29 August, the day of Mr. Beard’s discharge. Unfortunately, there were technical problems with the
fax machines and the referral could not be sent through. The intention was to re-send the referral the
following day, on 30 August. It appears that on 30 August, District Nurses contacted the Ward to
request the referral prior to it being sent out by Ward staff. A referral was then promptly sent. Given

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GG confident Chief Executive - Karen j : Matters J

NHS

Tameside and Glossop

Integrated Care
NHS Foundation Trust

the sequence of events above, the referral to District Nurses for Mr Beard was a delayed referral, as
the Ward staff would have continued to re-send the referral to District Nurses as planned, and that the
telephone call from District Nurses occurred before this took place. As above, we do apologise for
any confusion on this point at the Inquest. Our witness who gave evidence in this respect was simply
recounting their experience of the transaction between District Nurses and Acute staff and was not
attempting to mislead the Coroner is any way.

Notwithstanding the above, due to your concern, the Trust has made enquiries into whether missed
referrals are ‘common’ as was suggested to you at the Inquest. Firstly, | would like to respectfully
outline the difference between a missed referral and a missed visit as a missed referral does not
necessarily mean a patient has not received a visit they should have had. As the Trust operates a
triage system for all referrals to District Nurses, it may be appropriate that a patient may not been
seen by a District Nurse for several days after receipt of a referral, if their need does not require it.

Secondly, | would like to share information regarding what practices the Trust has that ensure patient
care is handed over smoothly between District Nurses and Acute Services. The District Nurses have
a clear process when a patient is transferred to Acute services, which includes preparing a Transfer of
Care document, which provides the Acute service with all the necessary detail of their involvement.
This document helps District Nurses track their patients and update their cases. Further, District
Nurses discuss patients who have been admitted to hospital in their daily Safety Huddles and there is
a board or book used by the different teams in which they also keep track of patients who are
admitted to hospital. The tracking of patients helps District Nurses to ensure patients are successfully
handed over. Additionally, when a patient is discharged from hospital, if they require further care by
District Nurses, a referral is completed and submitted to District Nurses by Acute services. This
communication between District Nurses and Acute services helps to ensure patient care is handed
over smoothly and no care is missed.

As mentioned above, we have made enquiries to assist you in understanding more fully if missed
referrals are ‘common’. A meeting took place at the beginning of June with the Trust's entire group of
District Nursing Team Leads and their Matron at which a discussion was had regarding the regularity
of missed referrals. The consensus was very much that this was not a ‘common’ or regular
occurrence from their professional experience. A review of ail incidents detailing a missed referral
from March 2018 to March 2019 was completed. This review found that a total of eight missed
referrals were identified in this twelve month period. A rate of 0.67 missed referrals per month is not
considered to be ‘common’ by the Trust. Enquiries were also made with the Trust’s Single Point of
Contact [SPOC], which is a Trust service that receives and triages all referrals to District Nurses trust-
wide. Missed referrals were not deemed to be ‘common’ by this service either.

Whilst we hope we can provide you with assurance that missed referrals are not ‘common’ between
Trust services, we would also like to assure you that we are aware that they do occur and take these
incidents very seriously when they do, to learn and prevent reoccurrence.

The first course of action when a missed referral is identified is for SPOC to determine what the
referral was for and who it was from. They then triage the referral to ensure that any urgent care is
provided. The Trust's priority is to ensure that patients receive the care they need as quickly as
possible.

Further, whenever a missed referral is identified by any member of staff, they have a responsibility to
raise a clinical incident report so that the matter can be investigated. District Nurses have

continuously reinforced the importance of a robust incident-reporting culture so as to ensure further
incidents can be prevented and appropriate learning and training can take place to keep patients safe.

[ac|w] disability Everyone
EG) confident Chief Executive ~ Karen f - “Matters f

INHS|

Tameside and Glossop

Integrated Care
NHS Foundation Trust

In addition to reviewing individual incidents, which are raised when a missed referral is identified,
these incidents are tracked by relevant services and any trends or themes are looked for to ensure
these are quickly identified and addressed. Any trends or themes that are identified are highlighted to
the relevant divisions in their regular divisional meetings so that appropriate steps can be taken to
address them in a timely manner.

As part of our investigation into your concern, discussions have been held with the Head of Nursing
Community Adults, the Service Director and Lead Nurse of the Trust's Intermediate Tier Services, and
the Team Lead for SPOC in relation to ongoing improvements in the District Nursing referral process.
| am happy to inform you that we will be moving onto an electronic portal for all referrals to District
Nurses made within the Trust. Once this has been running for a while, we will investigate the potential
for non-Trust agencies to also use this portal for referrals, as we receive a high number of referrals
from care homes.

Given we are still working towards moving onto the electronic system, we have taken steps to tighten
our processes in the meantime and are currently working through our strategy for the removal of all
fax machines and the migration to electronic communication systems.

We hope to have provided you with assurances that missed referrals between the Acute services and
the District Nursing Service are not in fact ‘common’ and that when missed referrals do occur, the
Trust pro-actively addresses any learning that can be drawn from it.

Concern 2:

The Ward Manager of Ward 31 confirmed in her evidence that, at the time of the care provided to Mr
Beard, there was only one permanent substantive registered nurse working on the ward, with the vast
majority of shifts being fulfilled by agency workers. Whilst the Ward Manager gave evidence of
significant improvements to recruitment and retention of nursing staff on the ward, and of additional
actions her and her team have introduced to promote consistency amongst agency staff, it is a matter
of concern that there is still significant reliance on agency nurses (with the financial and continuity of
care implications which can arise from that) within the Trust.

In order to address your concern above, the Trust wishes to offer you information and assurances
around our recruitment processes and why it is necessary at times to use Agency and Bank nursing
staff.

Recruitment and employee retention are high priorities for the Trust, reflecting the National position
and priorities for Nursing. We understand the importance of having an adequate level of substantive
staff to ensure patient safety, continuity of care and to avoid the financial burden that can be caused
by being under-staffed. | am happy to be able to assure you that the Trust is very proactive when it
comes to employee recruitment, including the recruitment of registered nursing staff, whose numbers
were the cause of your concern in this Inquest.

The Trust is an active partner in the Greater Manchester-wide Nursing Leadership Workforce and
Recruitment work. We run ‘Recruitment Open Days’, which have increased in frequency and are now
occurring each quarter. To prepare for these days and to ensure high attendance numbers, the Trust
advertises these events on Social Media and websites such as NHSJobs, Linkedin, Indeed, and the
Trust's recruitment website, TRAC, which is a system that is used by close to 90% of ail Trusts.
During these Open Days prospective employees meet with teams they are interested in joining and
have a tour of the site to see what the working environment is like. We make every effort to engage
them and support them from the start on what is hopefully a long career with the Trust. | am happy to

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NHS

Tameside and Glossop
Integrated Care
NHS Foundation Trust

report that our most recent Open Day, which took piace in June 2019, saw five registered nursing
posts filled with another two candidates awaiting interviews.

In addition to open days, we work with other Trusts across Greater Manchester and advertise job
opportunities on recruitment websites and through NHSJobs and our own TRAC system. We also use
Social Media on occasions where we are trying to fill a particularly difficult job posting. These methods
have been successful for the Trust to date, and we will continue to use them.

We are also attending college job fairs and university open days in the Greater Manchester area to
discuss employment opportunities with the Trust.

| am also able to assure you that we do a lot of work to recruit newly qualified nursing staff. Our
recruitment team works in connection with our Preceptorship Team, who are responsible for the
training and education of our trainee nurses, to ensure the transition from trainee to qualified is a
smooth process and involves securing a permanent post with the Trust. Since September 2018 we
have retained 39 newly qualified nurses, which is an improvement from our position in September
2017, when we retained 32 newly qualified nurses. We expect these figures to continue to rise given
the work being done by our teams.

In addition, since 2016 the Trust has been working to improve our registered nurse retention rate. At
that time, the Trust was contacted by NHS Improvement who offered targeted support to improve our
retention rate for registered nurses, as the Trust was in the lower quartile of performance. Since then,
the Trust has managed this issue via a Recruitment and Retention Action Plan, with outcomes being
reviewed by the Executive Management Team and the Workforce Committee. Although our
invalvement in this support programme has now finished, we continue to measure performance and
associated outcomes.

The Trust focused specifically on improving retention within Nursing and Midwifery services, which
included taking the follawing steps:

Strengthening the Exit Interview process, with earlier notification/intervention;
Offering career development conversations with a Senior Nurse or Midwife;
Launching an Internal Transfer process to enable sideward moves;

Reducing time for fill for vacancies, aided by TRAC recruitment database;
Improving e-roster forecasting of future rosters, so staff can plan ahead better;
Starting on-boarding sessions, to engage with staff who have joined the Trust;
Strengthening staff recognition with ‘Who's Your Hero’ scheme;

Introducing the e-card system scheme to aid recognition and gratitude amongst staff;
Mapping training opportunities to clinical roles via a Clinical Skills Matrix;
Designing and delivering a Preceptorship programme for newly qualified Nurses;
Trialing of alternative roles such as the Registered Nurse Associate;
Acclimatisation programme developed for Assistant Practitioners new to role.

| can confirm that over the last 12 months there has been an overall trend of improvement noted in
the registered nurse profession within the Trust. The turnover target was achieved in 2019 and our
overall picture for staff turnover, including nursing staff, is now in the best quartile, which indicates our
retention efforts have been successful.

Although we have seen success in the past 12 months, we wilt continue to closely monitor retention

performance and take pro-active steps to ensure future success in this area. | hope to have assured
you of the ongoing efforts made by the Trust to recruit and retain registered nursing staff.
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AaB confident Chief Executive — Karen James Matters f/
EMPLOYER Chalr ~ Jane McCall Ei y in|

NHS

Tameside and Glossop
Integrated Care
NHS Foundation Trust

| would like to also assure you that the Trust's use of Agency registered staff has seen a downward
trend from August 2018 to May 2019. We hope to see this continue given the improvements made so
far in our recruitment efforts. And whilst we appreciate that it is preferable to employ substantive
registered nurses, so that patients have continuity of care and stability in the Trust's finances, we are
acutely aware of the need to use Bank and Agency staff at times, to ensure our patients’ safety is
secure.

As you may know, Bank staff are employees of the Trust who take on shifts in other areas of the
Trust, when the need arises. These employees are familiar with Trust policies and Procedures and
can therefore facilitate a consistent treatment environment for patients, even if they are not always on
their usual Ward. Further, efforts are made to ensure that when Agency staff are used, the same
individuals are used consistently in the same areas. Again, this is to ensure continuity of care and to
ensure that these individuals are familiar with the way the Trust operates.

We acknowledge that ideally, the Trust would not have cause to use Bank and Agency staff to fill
vacancies that arise, however we also recognise that at present the use of these individuals is
essential to the effective and safe running of the Trust. And as such, we ensure that there are
processes in place to ensure any Bank or Agency staff member completes a full local induction and
the Trust's expectations of their performance are communicated to them.

Although the need to use Bank and Agency staff still exists for the Trust, | can assure you that we are
making every effort to improve and develop our recruitment and retention processes to ensure as
many registered nurses are employed by the Trust as possible.

| hope to have addressed the concerns and should you have any queries arising from the content of
this letter or require further information or clarification, please do not hesitate to contact me.

Yours sincerely

nO

Karen James
Chief Executive Officer

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