Joan Howard

NHS}

Sheffield Teaching Hospitals

NHS Foundation Trust

Chief Executive's Office
Clocktower

Northern General Hospital
Herries Road
SHEFFIELD

$5 7AU

Pot
4 April 2020
Office of H.M Coroner
The Medico-Legal Centre
Watery Street
Sheffield
S3 7ES

Dear Ms Coombs
Prevention of Future Deaths Report — Joan Howard

| write to formally respond to your Prevention of Future Deaths (PFD) Report dated 10 February
2020, following the very sad death of Mrs Joan Howard. | wanted to say at the outset how
saddened | am by Mrs Howard’s death and how sincerely sorry | am for the undoubted distress
and upset this has caused her family. | fully appreciate your and the family’s concerns that a basic
element of Mrs Howard’s care — managing her dysphagia diet — was not properly implemented
despite her needs being clearly documented and her family advocating for her. | truly hope that
we can learn from this and take actions to ensure as far as is possible that nothing similar
happens again.

As you are aware from etter to you of 20 March 2020, we are assured that the
further information (concerning a Trainee Clinical Support Worker) that came to light following the
inquest is consistent with your findings and conclusions. The learning and actions that we are now
taking are comprehensive and the member of staff concerned has received appropriate training
along with on-going support.

Our review of the issues raised by this case, along with consideration of the PFD Report, has
involved six senior members of staff and external expertise, commissioned from a Human Factors
specialist. The senior staff involved comprised the Deputy Chief Nurse, the Head of Speech and
Language Therapy (SLT), the Nurse Director Lead for Nutrition and Hydration, the Catering
Manager, the Deputy Head of Learning and Development, and the Lead Nurse for Technology
and Innovation. As a result of their discussions, we have agreed actions to address the specific
steps you have requested we take. Some of these actions have already been completed and
others will be completed as soon as is practicable, in the context of the current situation nationally
in relation to COVID-19 and our response to this.

The steps you request relate to three issues — Training, Standard Operating Procedure (SOP),
and Information regarding dietary needs. My response below describes the actions we have
agreed to address each of these three areas.

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Training

By way of background, the Head of SLT explained at the inquest that the International Dysphagia
Diet Standardisation Initiative (IDDSI) was implemented across the Trust by October 2018, ahead
of the national target date of April 2019. Training was undertaken across all relevant care groups
through a cascade approach involving matrons, educators and ward staff. In addition, training was
provided as part of certain key courses, for example the Prepare to Care course for Trainee
Clinical Support Workers, and the Newly Qualified Registered Nurse Preceptorship training.
Training was supported by ward-based posters and information.

It is accepted that this approach did not make IDDSI training mandatory, nor could we be sure that
every member of staff involved in mealtime procedures (including, for example, housekeepers)
had received training in IDDSI through the cascade mechanism. We recognise the need for all
staff engaged in mealtime duties to receive training in IDDSI and this will be achieved as outlined
below:

e IDDSI training will be added to Job Specific Essential Training (JSET), making it necessary
training for all hospital and intermediate care based registered nurses, clinical support workers
(CSW), trainee nursing associates, and housekeepers involved in mealtime procedures. Plans
to include IDDSI training in JSET have been submitted to our Professional Education Group
(PEG) for ratification. PEG is chaired by the Deputy Chief Nurse and, once JSET proposals
have been approved, the target is to achieve 85% compliance by April 2021. Compliance will
be monitored through staff annual appraisals and at the point of recruitment within the care
groups, with oversight provided by PEG.

e IDDSI training will no longer be delivered by cascade, but through an e-learning package
entitled ‘Meal Service Safety’. This approach will ensure consistency, appropriate levels of
understanding, and refresher training. The training package will consist of three elements:
IDDSI, the Standard Operating Procedure (SOP) which was shared at the inquest and has
since been updated (copy attached), and guidance on handling hot food. The training will
ensure staff are familiar with IDDSI principles and terminology, and all stages in the SOP.
There will be specific focus on the ‘Safety Pause’ which has now been labelled the ‘Mealtime
Safety Huddle’ as this is a concept with which nurses are already familiar. The e-learning will
also include guidance on handling hot food which, although not an issue in the serious incident,
is important in maintaining staff safety. The training programme has already been finalised and
is awaiting a final decision from PEG in relation to the target audience so that it can then be put
in place by 30" April 2020. Compliance figures will be monitored through PEG.

e Compliance with IDDSI, including the SOP, will be monitored through two existing audits which
will be expanded to include IDDSI compliance. The first audit is the biannual Hydration and
Nutrition Assurance Toolkit (HANAT). This has been updated to include specific questions in
relation to the SOP and will be reviewed again by the Nutrition Steering Group prior to the next
audit to include questions in relation to handling of hot food. The second audit is the annual
‘Power of 3’ audit of meal service, which has been updated to include audit of IDDSI, SOP
compliance, and handling of hot food. This audit is undertaken by representatives from
catering, dietetics, and senior nursing and involves the completion of an audit of meal service
on one ward in each of the care groups annually.

e Inrelation to trainees and students, Trainee CSWs receive their training through our Prepare to
Care programme. This includes a nutrition module which covers aspects of nutrition including
swallowing, dysphagia and mixing drink thickeners. The training does not currently cover
IDDSI, however the new e-learning package will now be mandated as part of the Prepare to
Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include
CSWs, along with other staff involved in mealtimes, to support safe mealtime service.

e Student nurses receive formal training through the universities and this includes teaching
regarding dysphagia, swallowing, thickening, and SALT. They also spend 50% of their
experience in practice and this will include practical training and supervision when caring for
patients with dysphagia. Both Sheffield Hallam University and the University of Sheffield cover
these elements within their student nurse training programmes, however the University of
Sheffield training programme also incorporates IDDSI training. Consistency in student nurse
training is therefore an issue which will need further discussion and we will give this matter
appropriate consideration as soon as is practicable.

e Regarding bank and agency staff working within the Trust, these staff are recruited through
NHS Professionals, and many are existing STH staff working additional hours over their
contracted hours. These staff will have received their training as part of their substantive role.
For non-STH employees, IDDS! does not form part of the mandatory training provided by NHS
Professionals and this is therefore an issue which we will consider further as soon as
practicable. In the interim, the additional measures now in place through the SOP and the
Mealtime Safety Huddles, which are the responsibility of Trust Registered Nurses, will provide a
further safety barrier at mealtimes.

Standard Operating Procedure (SOP) for Ward Meal Service

Following the inquest, the SOP (attached) has been updated to include a description of the
purpose and approach to the mealtime safety huddle. It has also been updated so that reference
is made to specialist advice on patient fluid consistency and special dietary requirements in
relation to snack boxes and light bites. The updated SOP is a key component of the e-learning
package. It has been shared with matrons, included in the Catering Folder on each ward, and is
available to order through the Trust's Xerox ‘print on demand’ process. Compliance with the
SOP will be audited as described above.

Obtaining and utilising information regarding dietary needs
e Capture of Information on Admission

There is a process for assessment of a patient's dietary and other needs on admission. For
patients admitted directly to wards and assessment units this is by use of a bespoke clinical data
capture form (an e-form), which is based on national guidelines, in the electronic patient record. It
is recognised that information may accompany the patient into hospital, but that patients and their
families are also good sources of accurate information, which staff should access in completing
this form. In the Emergency Department (ED) patients’ nutritional needs and risks are
documented on hourly rounding charts and communicated in verbal handover between shifts.

e Transfer of Information

In order to improve the systematic communication of this information as patients are transferred
around the hospital, following this incident our process for safe patient transfer known as ‘Ticket
to Ride’ is being reviewed and updated to include dietary requirements. This includes
documentation of any issues in relation to dysphagia. ‘Ticket to Ride’ forms part of our policy on
the safe transfer of patients and the changes we are now making will ensure that key information
about dietary needs is formally documented and is not dependent upon verbal handover when a
patient moves from one area of the hospital to another.

e Information on the Ward/Clinical area

Work has now been completed to incorporate the national IDDS! descriptors into the Electronic
Whiteboard (EWB). This work had already been planned, but was expedited as a result of this
incident. As a consequence, patients’ eating and drinking requirements, food texture and fluid
consistency are now recorded on EWB. This is a visible prompt to all ward staff (not just nurses)
about the patient's individual requirements. This information then automatically populates the
multi-disciplinary handover sheet that is printed from the EWB for ward staff to refer to. The EWB
is recognised as a prime Multi-Disciplinary Team handover and effective communication tool
within the Trust.

In relation to patients who are transferred from the ward temporarily, for example for an outpatient
appointment or tests elsewhere within the Trust, it is accepted that inpatients remain the
responsibility of the host ward in many aspects of their care, including nutrition and hydration. In
addition, the outpatient or diagnostic area is able to access information from the EWB, to confirm
or clarify the patient's eating and drinking requirements. Our Patient Transfer Policy clarifies that
the host ward must ensure up to date information about the patient is communicated to the
receiving area to enable the immediate needs of the patient to be met on arrival.

For those patients who are admitted to hospital already requiring texture modified diets in the
community, the ward teams can now record the information straight onto the EWB and the correct
diet signage can be placed above the patient's bed immediately. The SOP prompts staff to ensure
that swallowing assessment detail is placed above the patient's bed, and wards will now be
provided with a supply of signage and related patient information forms so that temporary signage
will not be required. Signage is also available to order through the Xerox ‘print on demand’ service
and can be downloaded from the Trust intranet site. Signage now also includes a description of
the IDDSI levels alongside the level of diet the patient is on, so that this information is clearly
visible and easily accessible for staff ‘at a glance’.

Compliance with all stages of the SOP, including the issue of communication within the ward area,
will be subject to audit as described above.

Having outlined the actions we have agreed to take in response to this incident and to the PFD
Report, | hope that | have been able to convey how seriously we have viewed this matter. Whilst
we will be unable to implement all these changes in the near future, given the urgency of the
situation in relation to COVID-19, we are absolutely committed to learning from Mrs Howard's
death and implementing the remaining actions at the earliest opportunity.

Finally, | hope that my response has addressed the concerns and actions you identified in your
PFD Report and please contact me if you have any queries or points of clarification.

Yours sincerely
Chief Executive

Enc.

Standard Operating Procedure

Ward Meal Service — All Mealtimes
(The registered nurse in charge is responsible for overseeing the implementation of the SOP at ward level)

Take the patient’s meal request in advance to allow for choice and variety of food. Clearly identify and record on the whiteboard (handover sheet) patients
‘nil by mouth’, any special dietary, therapeutic needs including IDDSI, allergies or intolerances and ensure that SALT assessment information is at the bedside.

Prepare the patient for mealtime i.e. offer/assist with elimination and hand hygiene needs as required, assist with hand hygiene. Position the patient
comfortably for eating i.e. helping them to sit up, assist to sit out of bed or go to the dining area if applicable. Check that any medication required with a patient
meal is available and administer prior to meal service.

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Ensure the table area is clutter free, clean and easily accessible to the patient. Ensure the correct cutlery and napkin or feeding aids are provided. Protect
patient meal times wherever possible, minimising interruptions.

v

Plan the meal service so that all staff can assist and ensure staff wash their hands and wear green aprons. Ensure the availability and correct use of utensils for
the food to be served. Ensure all meals are served on a tray and at a maximum of two meals ata time.

v

Any shortfalls in food should be addressed in a timely a manner as possible and the Catering Department contacted. Any patients who miss meals should be
offered a snack box or light bite. These should contain foods which address the specific dietary requirements of the individual eg modified diets and fluids.

v

Position the food trolley centrally in the ward or move around the ward to minimise the distance from the food trolley to the patients. The temperature of the
meals should be checked at the beginning and throughout the service. Handle hot items safely to reduce the risk of burns.
The Nurse in Charge is responsible for a Meal Time Huddle* before service to ensure all those serving are aware of the patients who are on special diets /
fluids / nil by mouth (*see reverse)

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Presentation of food should be as attractive as possible and portion size should be considered and second portions offered. Drinking water must be available at
all times with fruit juice offered at every mealtime. All drinks should be made to the consistency of fluid which is safe for the individual to drink based on IDDSI
recommendations on the e-whiteboard and on the signage above the patient’s bed.

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Assistance with eating/drinking must be provided with plenty of time allowed for patients to eat each course.

Meal waste should be disposed of in the green bucket, taking care not to place any foreign objects into the bucket.

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Assistance with eating/drinking must be provided with plenty of time allowed for patients to eat each course.

PD10401 V3 Issue Date March 2020

lealtime Huddle

The mealtime huddle is an important safety huddle. It must take place by the meal trolley before any food is provided to patients and
involve those who will be involved in meal service.

It should be led by a staff member nominated by the Registered Nurse in charge and who is aware of the special dietary requirements of
the patients.

The leader of the huddle must highlight the patients who:

+ Are ona special diet, including those with swallowing difficulties

+ Are Nil By Mouth

+ Are on restricted fluids or special fluids — including thickened fluids
* Will require assistance with feeding

* Require additional monitoring of diet/fluid intake (for example those on food charts)