Evelyn Ross

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

24 July 2020 

Your Ref: 313783 
Our Ref: PFD-1219888 

Ms Alison Patricia Mutch 
HM Senior Coroner, Manchester South 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport SK1 3AG 

Dear Ms Mutch,  

Thank you for your letter of 27 April 2020 to Matt Hancock about the death of Evelyn Ross.  
I am replying as Minister with responsibility for patient safety. 

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Ross’s 
death and I extend my sincere condolences to Mrs Ross’s family and loved ones on their 
loss.  It is important that we take the learnings from Mrs Ross’s death so that people 
continue to receive the highest quality care from the NHS.    

Your report raises several matters of concern relating to the care received by Mrs Ross 
while at the Trafford General Hospital.  I am advised that the Manchester University NHS 
Foundation Trust has provided a detailed response in relation to these concerns.  I 
understand this includes information about the improvement in nurse staffing levels; the 
Trust’s hospital discharge, falls management and clinical record policies; and 
arrangements for the review of patients by consultants in the Care of the Elderly.  

My response will focus on the actions being taken at a national level that are relevant to 
the concerns you have raised about the nursing workforce, falls prevention and delayed 
transfers of care.    

Individual NHS Trusts are responsible for the number and type of staff they employ and 
they must ensure that there are sufficient staff and that those staff are trained and 
competent to carry out their duties.  This applies equally to the usage of agency staff, 
which is a local decision for individual employers.  

At a national level, it is acknowledged that whilst the deployment of a flexible workforce is 
an important element of efficiently running the NHS, recruitment agencies are expensive, 
and it is crucial that we continue to reduce unnecessary expenditure on agency staff in the 
NHS.  In 2015, the then Secretary of State, Jeremy Hunt, announced the introduction of 
several measures to reduce agency spend, including price caps, procurement frameworks 
and expenditure ceilings. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We recognise that to fully eliminate unnecessary agency spending, the Department and 
the NHS need to support trusts in developing a viable alternative source of flexible staffing 
in the form of in-house Staff Banks.  Having reduced the rate of agency spending, we are 
now entering a new phase of work, focusing on the creation and improvement of staff 
banks, wherein existing NHS staff, who choose to work flexibly, can do so through an NHS 
owned bank, as opposed to a privately-owned agency.  In the context of staff shortages in 
the NHS, in-house staff banks, and especially collaborative banks, create a larger pool of 
flexible staff, ensuring better quality and continuity of care, and reducing unnecessary 
agency spending by avoiding expensive commission.  

In terms of the health and care workforce overall, Health Education England (HEE) 
provides leadership for the education and training system at a national level.  HEE ensures 
that the workforce has the right skills, behaviours and training, and is available in the right 
numbers. 

The NHS published the Interim People Plan1 in June 2019 that sets out the long-term 
vision and immediate actions to meet the challenges of workforce supply, reform, culture 
and leadership.  Publication of the final NHS People Plan has been deferred so that the 
NHS is able to devote its full operational effort to the COVID-19 response.  However, when 
published, the final NHS People Plan will set out further actions to secure the NHS staff we 
need in the future. 

Ensuring the NHS has the staff it needs, especially our nursing staff who are the absolute 
bedrock of the NHS and care system is, and will remain, a priority for the Government.  
We are making progress on this and at a national level we have seen an increase of 
19,398 (6.9per cent) since March 2010 in the number of nurses and health visitors to 
March 2020 

However, we of course accept we need to do more and that is why on 18 December 2019, 
the Government announced a commitment to deliver 50,000 more nurses in our NHS by 
2025.  We will do this through a combination of investing in and diversifying our training 
pipeline, as well as recruiting and retaining more nurses in the NHS.   

This Government has already taken steps to deliver this commitment through our recently 
announced financial support package for eligible students.  Eligible pre-registration 
nursing, midwifery and most allied health professional students on courses at English 
universities from September 2020 will benefit from grants of at least £5,000 per academic 
year.  There will be up to £3,000 additional funding for some students to help with 
childcare costs or who choose to study in regions or specialisms struggling to recruit, 
including with priority given to shortage groups that are key to delivering the NHS Long 
Term Plan2.  None of this funding will have to be paid back.  

In relation to the delay experienced by Mrs Ross who, you explain in your report, was 
clinically ready to leave hospital but could not until care arrangements were in place, we 
are clear that no one should stay in hospital longer than necessary.  Doing so removes 

1 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf 

2 https://www.longtermplan.nhs.uk/ 

 
 
 
 
 
  
 
 
 
 
 
 people’s dignity, reduces their quality of life, leads to poorer health and care outcomes and 
is more expensive for the taxpayer.  For older people in particular, longer stays in hospital 
can lead to worse health outcomes and can increase their long-term care needs.  We 
know that for people aged 80 years and over, ten days in a hospital bed equates to ten 
years of muscle wasting.  

Despite the NHS being busier than ever before, with hospital admissions rising by 18 per 
cent from 2009/10, the majority of patients are discharged quickly.  The average length of 
stay has fallen from 5.6 days in 2009/10 to 5.0 days in 2018/19.  The NHS and social care 
services have been working hard to reduce delays and free up beds and since February 
2017, 1,798 beds per day have been freed up nationally by reducing NHS and social care 
delays.   

It is the responsibility of the NHS and its local partners, including social service 
departments, to ensure that no patient remains in a hospital bed for longer than clinically 
necessary and that any ongoing care and support can begin promptly. Discharge 
arrangements from hospital should start before a patient is ready for discharge and the 
hospital should involve local social services at the earliest opportunity to plan post-
discharge care and avoid delays. 

The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be 
focused on primary and community care.  This includes a national roll-out of support for 
care home residents so more can be looked after where they live.  The NHS also aims to 
place therapy and social work teams at the beginning of the acute hospital pathway, 
setting an expectation that patients will have an agreed clinical care plan within 14 hours of 
admission, including an expected date of discharge. 

During the COVID-19 pandemic, we are supporting health and care organisations to 
ensure we have the capacity to meet the needs of people affected by the virus.  The 
COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to 
reduce the friction surrounding funding decisions and assessments and focus on getting 
people out of hospital with the right support as soon as they are medically fit.  We have 
made £1.3 billion funding available via the NHS to help patients who no longer need 
urgent treatment to get home from hospital safely and quickly.  This funding will cover the 
follow-on care costs for adults in social care, and people in need of additional support, 
when they are out of hospital and back in their homes, community or care settings, during 
the pandemic. 

Finally, with regard to falls prevention, the National Institute for Health and Care 
Excellence (NICE) has published a clinical guideline on Falls in older people: assessing 
risk and prevention (CG1613) that includes guidance on preventing falls in older people 
during a hospital stay.  The guideline says:  

1.2.2.1 Ensure that aspects of the inpatient environment (including flooring, lighting, 
furniture and fittings such as hand holds) that could affect patients' risk of falling are 
systematically identified and addressed 

3 https://www.nice.org.uk/guidance/cg161 

 
 
 
 
  
  
 
 
 
 
 
 This recommendation would apply to wards, toilets and other parts of the hospital.  The 
guideline recommends that for patients at risk of falling in hospital, an assessment of the 
patient’s individual risk factors should be conducted and where necessary, appropriate 
intervention put in place.  NHS trusts are expected to take account of NICE guidelines 
when planning care.   

I hope this response is helpful.  Thank you for bringing these concerns to my attention.   

NADINE DORRIES

Joint Group Medical Directors’ Office 
Trust Headquarters 
Room 218, Cobbett House 
Oxford Road 
M13 9WL 

Tel:  

Email:  

@mft.nhs.uk  

Sent via email to:  

/  
manchestersouthcoroners@stockport.gov.uk  

22 June 2020 

Ms Alison Mutch OBE 
HM Senior Coroner 
Manchester South 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Ms Mutch 

Mrs Evelyn ROSS (deceased) 

I am writing on behalf of Sir 
 in response to your Regulation 28 Report sent to 
Manchester University NHS Trust (‘the Trust’) on 27 April 2020.  Your report related to the death 
of Mrs Evelyn Ross at Trafford General Hospital on 23 September 2019 and whose Inquest was 
held on 13 March 2020.  We would like to express our condolences to the family of Mrs Ross for 
their loss. 

Trafford General Hospital is part of the Trust’s Wythenshawe, Trafford, Withington and Altrincham 
(WTWA) site. 

I  understand  that  you  concluded  that  Mrs  Ross  died  following  complications  from  surgery 
contributed to by a fractured neck of femur and anticoagulation.  After hearing the evidence at 
Inquest, you have raised the following matters of concern. 

1.  The  Inquest  was  told  that  the  ward  in  question  had  been  short  staffed  for  a  number  of 
months.  As a result, there was a reliance on agency staff and less experienced staff.  The 
Trust was now seeking to resolve the issue, but it was still not fully resolved.  It reflected a 
wider issue of a national shortage of nurses. 

2.  The Inquest was told that whilst Mrs Ross was medically fit for discharge prior to 01 July 
she had not been discharged because of delays in arranging a suitable care package to 
support her in the community. 

3.  During the course of the Inquest the documentation relied on by the Trust was lacking in 
detail  and  meant  that  it  was  difficult  to  understand  her  condition  at  key  points  or  to 
understand the rationale for decisions. 

4.  The Inquest heard that the Trust had not followed their own falls risk policy in relation to 

Mrs Ross. 

5.  There did not appear to be a clear system of regular orthogeriatric consultant reviews of 
Mrs Ross.  This meant that there was no escalation of her condition to a consultant when 
she began to show signs of deterioration. 

I have sought to address each of your matters of concern in turn below. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  The Inquest was told that the ward in question had been short staffed for a number 
of months.  As a result, there was a reliance on agency staff and less experienced 
staff.    The  Trust  was  now  seeking  to  resolve  the  issue,  but  it  was  still  not  fully 
resolved.  It reflected a wider issue of a national shortage of nurses. 

Recruitment of nursing staff both registered and unregistered has in the past proven an 
ongoing  challenge  for  a  period  of  time  at  Trafford  General  Hospital  however,  some 
significant positive progress has been made in this regard. 

Since April 2019, a number of International Recruitment (IR) Registered Nurses have been 
recruited  to  wards  at  Trafford  General  Hospital  in  addition  to  successful  domestic 
recruitment to Registered Nursing posts across Trafford General Hospital.  A substantive 
appointment was made for a new Ward Manager that joined the team in January 2020, in 
addition  four  experienced  Band  6  Registered  Nurses  have  been  appointed  to  Ward  6 
specifically.    A  Band  3  Patient  Flow  Coordinator  role  has  also  been  developed  and 
successfully appointed to on Ward 6. 

The Trust has an established process in place to review nursing workforce establishments 
and  skill  mix  for  all  wards.    This  utilises  an  evidence-based  triangulated  approach  to 
determine nurse staffing levels and  skill mix, that reflect patient acuity and dependency 
requirements to inform workforce planning.  The Safer Nursing Care Tool (SNCT) is utilised 
to gather patient acuity and dependency data over a four-week period.  Ward 6 completed 
data  collection  periods  in  March,  June  and  September  2019  and  January  2020.    The 
outcome of this data collection was utilised to inform the establishment review process, 
which  was  completed  for  Ward  6  in  March  2020.    Further  workforce  redesign  is  being 
progressed collaboratively with Therapy Leads for Ward 6, to reflect the requirements of 
the  rehabilitation  service  at  Trafford  General  Hospital.    Roles  for  Nursing  Associates, 
Trainee  Nursing  Associates  and  Aspirant  Nurses  are  currently  being  utilised  and 
incorporated into the wider workforce planning across Trafford General Hospital services. 

In March 2020, ward establishments at Trafford General Hospital were reviewed, this was 
completed  for  Ward  6.    The  outcome  confirmed  the  requirement  for  additional  Nursing 
Assistants,  which  has  gone  through  an  approval  process  and  these  posts  are  currently 
being  actively  recruited  to.    Ward  6  is  currently  fully  recruited  to  the  required  nursing 
establishment  for  Registered  Nurses  and  has  no  vacancies.    The  Senior  Nursing 
Leadership  team  at  Trafford  General  Hospital  continuously  monitor  staffing  levels,  and 
redeploy staff as required to ensure safe staffing levels are maintained. 

Prior to Mrs Ross’ admission, in April 2019 a new Head of Nursing commenced at Trafford 
General Hospital, who has undertaken and completed a review of the nursing leadership 
structure.    These  include changes  to  areas  of  responsibility  and  line management,  and 
further appointments made to the post of Lead Nurse in addition to four Matron posts.  To 
further  strengthen  the  Senior  Nursing  Leadership  team  at  Trafford  General  Hospital,  a 
Matron for Quality Improvement and Patient Safety has been appointed on a  12-month 
secondment.  This has established a new experienced Senior Nursing Leadership team at 
Trafford  General  Hospital,  supporting  a  robust  professional  governance  structure, 
providing  clear  lines  of  assurance  and  accountability  directly  to  the  WTWA  Director  of 
Nursing. 

Induction for new recruits is provided on the Trafford General Hospital site, and the Head 
of Nursing now supports this with the welcome and introduction session.  This provides an 
additional  opportunity  for  staff  to  engage  with  Senior  Nurses  who  give  feedback  and 
provide ongoing support. 

Ward Managers’ roles have been realigned to allow for increased clinical time (15 hours’ 
management time and 22.5 hours’ clinical time per week) and therefore also provide more 
visible clinical professional leadership for ward teams, patients and visitors. 

Page 2 of 9 

 
 
 
 
 
 
 
 As  detailed  in  the  witness  evidence  of  Matron 
,  due  to  deployment  of  NHS 
Professionals temporary staff at Trafford General Hospital to supplement substantive staff 
levels, a local induction has been developed for each clinical area.  This is to ensure that 
staff who are unfamiliar with the ward are given an overview of the expectations, their roles 
and responsibilities. 

A review of the skill mix and roles and a Training Needs Analysis for the Out of Hours team 
has also been undertaken.  This is to ensure that the clinical contribution is  maximised, 
and the correct level of professional leadership is provided to teams at Trafford General 
Hospital in the out of hours period. 

The Matrons, Lead Nurse and Bed Managers meet three times a day to plan deployment 
of staff and highlight any concerns that require escalation across the site to support the 
ward nursing teams.  Senior nursing colleagues have reiterated to all nursing staff the clear 
process of escalation of any concerns, if they require any additional support from the Senior 
Nursing Leadership team. 

Extensive  work  has  been  undertaken  at  Trafford  General  Hospital  under  the  new 
leadership team in respect of recruitment of substantive staff; and notable improvement in 
staffing levels have been made.  Unfortunately, nurse recruitment and workforce supply 
continue to be an issue of national concern across the NHS.  The Trust however continues 
to  focus  efforts  on  ensuring  the  recruitment  and  retention  of  staff  in  accordance  with 
patients’ clinical need. 

2.  The Inquest was told that whilst Mrs Ross was medically fit for discharge prior to 01 
July she had not been discharged because of delays in arranging a suitable care 
package to support her in the community. 

As  detailed  in  the  evidence  you  heard  at  Inquest,  whilst  Mrs  Ross  has  been  deemed 
medically  fit  for  discharge,  she  required  a  review  by  the  Mental  Health  Liaison  Service 
Rapid Assessment Interface and Discharge (RAID) team, and a package of care to enable 
discharge from hospital to take place.  I understand that on 24 June 2019 Mrs Ross was 
referred to Ascot House, a service provided by Trafford Council, which is an intermediate 
care community assessment centre for older adults that also provides rehabilitation.  Mrs 
Ross was however declined admission by Ascot House due to additional care needs.  The 
necessary notification (Section 5) was submitted by the Trust to Social Services on 01 July 
2019, as the indicator that Mrs Ross was medically fit for discharge from hospital to the 
relevant Social Services provision; to trigger the response from Social Services to ensure 
services were set up and in place to allow for discharge from hospital. 

In line with usual practice in secondary care, patient discharges from hospital are in some 
cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions 
by  other  bodies  such  as  Local  Authorities;  for  instance  assessments  in  respect  of  any 
ongoing package of care required in the community, as well as other bodies in the Social 
Care sector.  It is the Trust’s responsibility to undertake such liaison where applicable to 
ensure arrangements are in place so that the Trust can effect a safe patient discharge to 
the community.  Given the Trust’s dependence on other parties in respect of this, delays 
can  occur,  and  this  is  unfortunately  an  NHS-wide  issue  not  unique  to  our  Trust.    Safe 
discharge requires teamwork across many people and organisations. 

In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local 
‘Discharge  Policy  for  Adult  Inpatients  (excluding  Children  and  Maternity)’,  implemented 
May 2019, a copy of which is enclosed (Appendix 1).  At the Trust’s WTWA site this policy 
is overseen by the Integrated Discharge team.  The policy is applicable to all Trust staff 
who are involved in the assessment, planning and monitoring of patient discharges.  It also 
applies  to  staff  from  other  health/social  care  organisations  involved  in  the  discharge 

Page 3 of 9 

 
 
 
 
 
 
 
 
 process.    The  purpose  of  the  policy  is  to  support  a  well-organisation,  safe  and  timely 
discharge for all adult patients. 

The  discharge  policy  acknowledges  that  the  planning  of  patient  discharge  should  be  a 
process and not an isolated event, and hospital discharge plans should be established at 
the earliest opportunity in order to ‘identify factors that may impact on efficient discharge’ 
(DH  2010).    To  ensure  a  safe  hospital  discharge  to  an  appropriate  setting,  the  Trust 
discharge policy requires that a discharge plan should be well-defined, comprehensive and 
agreed  by  the  patient  or  their  carer.    The  discharge  policy  also  requires  effective 
communication  at  every  stage  of  the  discharge  process  between  the  Multidisciplinary 
Teams  (MDT)  and  the  patient  or  carer/s,  identifying  factors  that  may  impact  on  their 
discharge and ensuring that each review and update has been discussed and conveyed 
to all associated parties.  Therefore, where discharge is on hold, for instance pending In-
reach Psychiatric or Social Services assessment of the patient; the patient, their carers 
where relevant and families are kept informed at each and every appropriate stage. 

Weekly  length  of  stay  meetings  are  held  with  the  MDT  where  all  patients  planned  for 
discharge are reviewed.  This is documented in the Electronic Patient Record (EPR) to aid 
effective  communication  between  professionals,  patients  and  their  families.    MDT  daily 
board rounds are held in each ward, to review patients’ estimated date of discharge and to 
ensure that the ‘SAFER’ standards are applied.  The SAFER patient flow requirements re 
that senior reviews are undertaken for all patients before midday by a clinician able to make 
management and discharge decisions, all patients will have an expected date of discharge 
and  clinical  criteria  for  discharge  set  by  assuming  ideal  recovery  and  assuming  no 
unnecessary waiting.  The flow of patients is to commence at the earliest opportunity, early 
discharge is effected where possible, appropriate and safe, and there is a systematic MDT 
review of patients with extended lengths of stay (over seven days), with a clear objective 
of promptly discharging patients where they are medically fit for discharge and discharge 
from hospital can be safely effected. 

As stated above, a Patient Flow Coordinator role has been developed and successfully 
appointed  to  Ward  6  at  Trafford  General  Hospital.    In  addition,  the  Hospital  Discharge 
Service  is  available  and  responsible  for  supporting  wards  in  the  discharge  process  of 
patients, and their input is routinely sought for instance in respect of patients who require 
special  considerations  or  who  may  have  complex  support  needs  on  discharge.    The 
discharge service will assist the ward staff to plan and identify the supporting needs of the 
patient for discharge. 

The Trust discharge policy requires that timely referrals are made to other specialist teams 
or services as necessary to formulate comprehensive diagnostic, treatment and discharge 
plans.  The Ward Manager is responsible for ensuring that an effective discharge planning 
process  operates  on  the  ward  and  is  required  to  attend  the  length  of  stay  meetings  to 
discuss any discharge issues.  The Ward Manager is also required in accordance with the 
policy  to  inform  the  Ward  Matron  of  any  issues  which  are  impacting  on  the  effective 
discharge of patients from their ward. 

Whilst some patient discharges are classed as ‘simple discharges’, some cases given the 
nature of issues involved may be classed as ‘complex discharges’, in line with the policy.  
The  nature  of  the  discharge  will  have  a  bearing  on  the  process  of  discharge  planning.  
Complex  discharges  are  defined  as  patients  who  will  be  discharged  either  home,  to 
intermediate  care,  or  to  a  nursing  or  residential  care  home,  and/or  who  have  complex 
ongoing health and social care needs, which require detailed assessment, planning, and 
delivery by the MDT and multi-agency working; these are patients whose length of stay in 
hospital is more difficult to predict. 

In  respect  of  the  specific  reviews  awaited  in  Mrs  Ross’  case,  given  that  as  highlighted 
above both In-reach Liaison team review was mandated and an assessment/rehabilitation 

Page 4 of 9 

 
 
 
 
 
 
 centre  placement  was  declined  by  the  Local  Authority;  in  order  for  the  clinical  team  to 
progress her discharge, as I am sure you will appreciate, there was a limitation on further 
actions the Trust was able to take to address this issue, due to its dependence on actions 
by In-reach, Social Care and other bodies. 

Mrs  Ross’  discharge was  complex,  and  I  am assured  that  all meetings and  reviews  for 
discharge could be safely effected. 

The Trust’s discharge policy highlights the need to minimise unnecessary delays in the 
discharge process and ensure length of stay is determined by clinical need.  Unfortunately, 
in  Mrs  Ross’  case,  whilst  discharge  plans  were  being  arranged,  her  clinical  condition 
changed such that she was no longer deemed medically fit for discharge and required a 
prolonged hospital admission to tend to her acute care needs. 

3.  During  the  course  of  the  Inquest  the  documentation  relied  on  by  the  Trust  was 
lacking in detail and meant that it was difficult to understand her condition at key 
points or to understand the rationale for decisions. 

I am sorry to learn that you consider the Trust’s clinical notes lacked in detail and apologise 
if the evidence you heard was not able to reflect the progression of Mrs Ross’ condition 
and the clinical decision-making around this.  I confirm these concerns have been raised 
with the relevant members of the clinical team involved in Mrs Ross’ care and the Inquest. 

The Nursing and Midwifery Council’s ‘The Code:  Professional standards of practice and 
behaviour for nurses, midwives and nursing associations’ (2018) and the General Medical 
Council’s ‘Good Medical Practice’ (2013) set out the expected professional standards and 
responsibilities around clinical record keeping.  Suffice to say, all Trust clinical staff are of 
course required to adhere to these fundamental tenets. 

Additionally,  the  Trust  has  its  own  local  policy  in  respect  of  clinical  documentation  and 
record-keeping,  which  sets  out  the  core  clinical  standards  required  for  record  keeping 
along with best practice guidelines relating to paper and electronic records. 

The Trust’s health records management policy also emphasises that health records are 
essential for delivering quality and safety of care and highlights the legal obligations and 
responsibilities  of  individual  staff  members  to  comply  with  the  requirements  of  health 
records legislation. 

Training is provided to all clinical staff in respect of documentation in clinical records.  As 
part  of  the  mandatory  induction  of  all  staff,  Trust  training  is  provided  in  respect  of 
Information Governance, which covers accurate and clear record keeping.   This is also 
covered in the mandatory training updates which all staff are required to undertake every 
two  years.    All  staff  also  receive  a  local  induction  in  their  own  area  of  work  which 
comprehensively covers all areas of documentation and records keeping relevant to the 
individual staff member’s role.  The Trust retains records of all staff training undertaken 
Trust-wide, including mandatory training. 

Ward 6 Nurses have now completed extensive competency-based assessments relating 
to all aspects of nursing care, and standards of documentation have been reviewed and 
signed off by a Senior Nurse. 

The monitoring of performance in maintaining professional standards in respect of good 
clinical record keeping is undertaken by way of regular audits of clinical records.  At Trafford 
General Hospital ward-specific documentation audits are undertaken monthly by the senior 
team on the ward and periodical/spot-check audits are completed by the Matron for Quality 
Improvement and Patient Experience, to provide a real time understanding of compliance.  
Any  areas  of  non-compliance  identified  via  audit  are  discussed  with  staff  proactively  to 

Page 5 of 9 

 
 
 
 
 
 
 
 
 
 
 promote  shared  learning  and  address  any  omissions  in  the  required  standard  of  care 
around clinical documentation. 

As of April 2020, the Matron for Quality Improvement and Patient Experience’s compliance 
audit for falls risk assessment completion and falls care plan implementation was 90%.  
Hot Topic Sessions covering falls risk reduction and management have been launched in 
June  2020.    So  far  this  month  across  Trafford  General  Hospital  30  members  of  staff, 
including six members of staff from Ward 6, have attended the training, with several further 
sessions to take place this month to capture further staff. 

4.  The  Inquest  heard  that  the  Trust  had  not  followed  their  own  falls  risk  policy  in 

relation to Mrs Ross. 

As  detailed  in  the  nursing  witness  evidence  you  heard  at  the  Inquest,  Mrs  Ross  was 
identified as presenting as a falls risk, and the ward staff discussed with Mrs Ross’ daughter 
and son on 31 May 2019 the decision to move her to a bay tagged area so that she was 
visible at all times.  during the weekly risk assessment updates however, whilst it was noted 
that  Mrs  Ross  was  still  deemed  to  be  a  falls  risk,  reviews  of  the  care  plan  were  not 
completed every 24 hours as required.  Mrs Ross however did continue to receive regular 
observations, she was nursed in a cohort bay, and she was mobile with a zimmer frame 
and  the  assistance  of  one  person.    Falls  risk  reduction  measures  were  in  place  in 
accordance with falls care plan actions. 

When  a  nursing  review  of  Mrs  Ross’  care  was  undertaken  prior  to  the  Inquest,  it  was 
identified that the individualised additional interventions section of the falls care plan were 
not  reviewed  every  24  hours.    It  was  noted  however  that  at  the  time  there  was  a 
discrepancy  in  the  Trust  falls  policy  which  did  not  specifically  refer  to  a  requirement  to 
undertake  this,  and  document  this  review  every  24  hours.    Subsequently,  the  Falls 
Specialist Nurse was made aware of the discrepancy in the falls policy.  This amendment 
to the policy has been incorporated with further updates to the policy (to reduce the need 
for  multiple  policy  revisions  being  shared  with  staff  intermittently,  and  to  provide  one 
comprehensive update).  These changes are due to be ratified by the Trust’s Professional 
Board following which the updates will be presented to the Manchester Falls Collaboration 
and disseminated across the Trust. 

As  part  of  the  Monthly  Matron  Review  proforma,  a  sample  of  patient  assessments  are 
audited to monitor the ongoing completion of Falls Risk Assessments.  Results of these 
audits are highlighted at the Monthly Matron Confirm and Challenge meetings with Ward 
Managers. 

Training  is  provided  to  all  clinical  staff  in  respect  of  falls  management.    The  current 
compliance rate for Ward 6 staff for falls e-learning training is 83%.  This compliance rate 
will increase once staff members who are currently absent due to sick leave return to work 
and are able to complete the training. 

Prior to Mrs Ross’ admission, the Trust had recently, in April 2019, implemented a new 
Trust-wide  updated  Falls  Management  Policy  and  I  enclose  a  copy  of  this  for  your 
information (Appendix 2).  I am very sorry to hear that there was evidence that aspects of 
the falls policy were not adhered to in Mrs Ross’ case. 

I confirm that a clinical walk round was completed at Trafford General Hospital prior to the 
implementation of the new policy.  This included the Specialist Falls Nurse and a Matron 
attending each of the clinical areas and wards, promoting the new documentation.  The 
Specialist  Falls  Nurse  and  Clinical  Educator  completed  further  sessions  delivering  the 
revised paperwork and launching the policy.  The implementation of the new policy was 
also published in the Trust-wide communications news brief.  It was disseminated at Ward 
Manager meetings and Ward Managers were tasked with cascading the policy and new 

Page 6 of 9 

 
 
 
 
 
 
 
 
 paperwork to staff at the daily safety huddles.  From May 2019, falls education sessions 
were held at Trafford General Hospital, enabling staff to ask questions about the new policy 
and paperwork and talk through the new algorithm.  Face to face training and support has 
continued  in  addition  to  the  provision  of  interactive  e-learning  training  around  falls, 
mandatory for all clinical staff and required to be completed every three years. 

Trust-wide  audit  work  is  undertaken  to  ensure  compliance  with  policies  such  as  that  in 
respect of falls management in order to measure the effectiveness of the new policy.  There 
is  also  a  programme  of  annual  Ward  Accreditation  in  place,  which  includes  review  of 
standards of documentation, including completion of falls risk assessments and adherence 
to the policy. 

Specifically, in relation to falls risk assessments, the updated falls policy includes a new 
risk assessment tool, which was launched at Trafford General Hospital in April 2019.  There 
are weekly audits of falls risk assessments in ‘hot spot’ areas, which assess completion 
and accuracy.  Audits are ongoing and subject to scrutiny by the Trust’s Leadership team. 

In April 2019, Trafford General Hospital launched a new electronic patient record system 
called Chameleon, onto which all inpatient risk assessments including falls assessments 
are entered. 

In addition to the updated policy prior to Mrs Ross’ admission, in March 2019 the Trust 
established a multidisciplinary Task and Finish Group dedicated to addressing the issue of 
inpatient falls at Trafford General Hospital.  This initiative was led by the Head of Nursing 
for the WTWA Division of Medicine.  The team developed an overarching Action Plan for 
Trafford General Hospital as well as a specific Action Plan for Ward 6.  The Task and Finish 
Group  met  fortnightly  to  guide,  progress  and  document  the  actions  taken.    The  Group 
comprised 
the  site  Head  of  Nursing,  Lead  Nurse,  Matrons,  Ward  Managers, 
Physiotherapist,  a  governance  manager  and  clinicians.    The  Task  and  Finish  Group 
oversaw the implementation of actions identified in the Action Plans and this work has been 
incorporated  into  the  work  streams  of  the  WTWA  Falls  Task  and  Finish  Group.    Each 
individual Ward Manager has been provided with a checklist to support falls risk reduction, 
as well as falls reduction and management prompts. 

In order to strengthen its governance, accountability and assurance framework, in January 
2020 the Trust established a Quality and Patient Safety Group at Trafford General Hospital 
to lead the development and implementation of an overarching quality improvement and 
transformation  programme.    The  Group  is  chaired  by  the  WTWA  Deputy  Chief 
Executive/Director  of  Finance  in  order  to  oversee  the  delivery  of  Trafford  General 
Hospital’s Quality Improvement and Transformation Programme and Quality and Patient 
Safety  objectives.    The  Group  reports  directly  to  the  WTWA  Quality  and Patient  Safety 
committee, in addition to the Hospital Management Board.  The Group has patient safety 
and quality improvement objectives, aiming to have a measurable impact by way of positive 
outcomes for patients, carers and their families.  The Group’s progress is monitored and 
measured against agreed key performance indicators.  The single overarching quality and 
patient safety improvement plan developed for Trafford General Hospital includes actions 
relevant  to  all  wards  and  departments,  as  well  as specific  actions  relevant  to  individual 
areas.  Key lines of responsibility have been identified to ensure progress.  The Group has 
resumed meetings monthly from June 2020, after usual business was paused by necessity 
due to the Trust’s emergency response to the COVID-19 pandemic. 

In addition, a Quality and Patient Experience Matron post has been seconded to Trafford 
General Hospital for 12 months, in order to prioritise and monitor patient feedback, incident 
themes,  training  and  supporting  the  implementation  of  ward-specific  Improving  Quality 
Programme (IQP) projects.  The Matron has for instance overseen the development of the 
above-referenced Training Needs Analysis document specific to staff on Ward 6 at Trafford 
General Hospital, to identify and prioritise ongoing staff training and development.   IQP 

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 projects are identified throughout the year as part of the Trust’s commitment to continuous 
improvement. 

The Manchester Falls Collaborative has an overarching work programme, underpinned by 
hospital-level  falls  work  plans.    The  WTWA  site  has  a  Falls  Work  Plan  in  place  for  the 
period 2019-2022, which Trafford General Hospital is monitored via the monthly Quality 
and Patient Safety Committee. 

Falls resulting in patient harm are presented to the monthly Falls Accountability meeting.  
Thematic  analysis  is  considered  in  order  to  establish  learning  arising  out  of  patient 
incidents in respect of falls and to implement preventative measures to improve patient 
safety. 

In addition to thematic analysis of falls resulting in patient harr across the WTWA site, the 
Trafford  General  Hospital  Senior  Nursing  team  hold  weekly  Harm-Free  Care  meetings 
where each Ward Manager presents their ward’s patient falls from the previous week.  This 
process  provides  assurance  that  all  falls,  including  falls  resulting  in  no  harm,  are 
investigated and managed appropriately.  For the WTWA site, the majority of all falls have 
been found to have been unavoidable from January – April 2020.  If a fall is found to have 
been avoidable, actions and lesson learning are discussed at ward level with all staff.  The 
outcome  of  the  Harm-Free  Care  meeting  is  recorded  onto  the  Trust’s  Ulysses  risk 
management system for ongoing monitoring of compliance with required clinical standards. 

Work is underway with the WTWA Falls Specialist Nurse, Matron for Quality Improvement 
and Patient Experience at Trafford General Hospital and the Practice-based Educator team 
to implement an additional condensed training package at Trafford General Hospital, using 
the  ‘Hot  Topic’  awareness  scheme  for  falls  in  June  2020.    This  supplementary  training 
commenced on 16 May 2020 at the Wythenshawe Hospital site and comprises discussion 
of  Trust  falls  policy  and  risk  assessments,  background  information  on  falls  such  as 
prevalence and the human cost of falls, risk factors in relation to falls, practical falls risk 
reduction measures, and post-fall care including an in-depth run through of the post-fall 
algorithm, completing a post-fall action record and incident reporting.  It is intended that 
this additional training package will be rolled out at Trafford General Hospital following on 
from  work  already  embedded  by  the  Matron  for  Quality  Improvement  and  Patient 
Experience. 

A number of initiatives are already in place at Trafford General Hospital to ensure oversight 
of falls across the hospital including Matrons/Lead Nurse completing their enhanced care 
reviews three times per week as per policy, live documentation audits, relaunching the Bay 
Tagging initiative on hot spot areas and firmly challenging staff who do not adhere to policy, 
quality improvement projects in relation to intentional rounding and increased daily senior 
nursing on clinical areas to ensure correct adherence to Enhanced Observations of Care 
Policy and proper use of falls sensor equipment. 

In addition to these assurance processes, senior nursing teams across WTWA are being 
asked  to  relaunch  both  the  Staff  Competency  Checklist  for  the  Risk  Reduction  and 
Management of Inpatient Falls, and the Falls Risk Reduction and Management Prompts, 
to ensure staff feels comfortable and confident in falls risk assessment and care planning; 
and that additional training needs are highlighted appropriately.  This process also allows 
for staff managing individuals involved in falls incidents to consider their competency level 
and ensure guided reflection is appropriately provided. 

The Trust’s WTWA site continues to progress with the harmonisation and streamlining of 
all falls management processes and procedures.  The Trust is committed to providing har 
free care for patients identified to be at risk of falling.  The Trust leads the multi-agency 
Manchester Falls Collaborative, which enables learning and evidence-based best practice 
to be shared and is committed to ensuring delivery of its falls work programmes. 

Page 8 of 9 

 
 
 
 
 
 
 
 5.  There  did  not  appear  to  be  a  clear  system  of  regular  orthogeriatric  consultant 
reviews of Mrs Ross.  This meant that there was no escalation of her condition to a 
consultant when she began to show signs of deterioration. 

The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily 
at the morning Board Rounds and all patients are discussed and followed up to Consultant 
level as needed.  If clinical concerns are raised in respect of an individual patient’s case, a 
member of the Senior Medical team (Consultant or Registrar) will review the patient. 

In respect of review of specific patients, as detailed in the Consultant witness evidence that 
you  heard  at  the  Inquest,  Consultant  reviews  of  individual  patients  take  place  at  twice-
weekly MDT meetings, which are led by the Consultant in Care of the Elderly.  At each 
MDT meeting, half the patients on the ward are discussed under their named Consultant.  
In addition to this, any unwell patients or concerns of the clinical team regarding any ward 
patient  are  discussed  i.e.  irrespective  of  whether  the  MDT  is  being  led  by  the  patient’s 
named Consultant. 

The junior doctors and clinicians who undertake the daily patient assessments/reviews are 
aware  of  the  requirement  to  escalate  to  Consultant  level  in  respect  of  specific  clinical 
factors  or  potential  areas  of  concern.    Consultants  are  contactable  by  telephone  in  the 
event that junior doctors on the ward have any concerns about patients.  In the absence of 
one of the two leading Consultants for Ward 6, the other Consultant provides cover for 
patients.  If a Consultant is not available on-site due to other commitments, such as clinical 
commitments  at  one  of  the  Trust’s  other  hospitals,  the  on-call  team  as  well  as  the 
Consultant of the week is immediately available to review any unwell patient. 

Having  undertaken  a  comprehensive  review  of  the  entries  in  Mrs  Ross’  clinical  notes,  the 
Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case 
there were in fact regular Consultant reviews, in line with required standards, and there was no 
issue in respect of junior doctor escalation, which as documented in the clinical notes took place 
as required.  I apologise if the evidence you heard at the Inquest did not accurately convey this. 

We hope that the above provides you and Mrs Ross’ family with assurance in respect of the matters 
of concern you had raised.  The Trust is committed to ensuring patient safety is our priority.  If you 
require any further information, please do not hesitate to contact us. 

Yours sincerely 

Miss 
Joint Group Medical Director 

Encl. 

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

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