Michael Yemm

Adult Social Services 
County Hall 
Martineau Lane 
NORWICH  
NR1 2DH 

Tel: 

Please ask for: 
. 
Direct dial: 
Our ref:  

Yvonne Blake 
Area Coroner 
Carrow House 
301 King Street 
Norwich 
NR1 2TN 

11 March 2021 

Dear Yvonne 

I understand how busy your department is at present and have attempted to contact 
you several times by telephone. I had wanted to discuss this matter with you before 
putting it in writing, but given the difficulties with the telephone system I wanted to ask if 
you would be able to telephone me so we can discuss it further. My number is 

.   

I am writing to express some concerns and to request your review of the evidence 
regarding the inquest held for Mr Michael Yemm on Tuesday 2 February 2021. 

You will be aware that a Regulation 28 report to prevent future deaths has been issued 
to Norfolk County Council. However, I note that Norfolk County Council was not asked 
to provide a report for the Coroner about our involvement with Mr Yemm, nor to 
contribute to the inquest in any way.  

There are a number of points I would like to raise with you regarding this matter from 
the perspective of Norfolk County Council’s Adult Social Services Department, and to 
ask that you would re-examine the evidence using the information received by Adult 
Social Services from the Norfolk and Norwich University Hospital (NNUH). 

You may be aware that in March 2020, the Department of Health and Social Care 
published guidance requiring hospitals and local authorities to work together to 
implement new Discharge to Assess (D2A) arrangements.   

COVID-19 Discharge Service Requirements (March 2020, HM Government/NHS) 
Hospital Discharge Service: Policy and Operating Model (August 2020, HM 
Government/NHS) 

D2A is a concept whereby patients are transferred from acute hospital at the point 
where they no longer require acute hospital care through one of three pathways; either 

Page 1 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
                               
        
 
 
                             
 
       
 
 
 
 
 
 
 
 
 
 
 
 
 
 at home with support (pathway 1), in community based sub-acute bed with 
rehabilitation and reablement (pathway 2) or in a care home sub-acute bed with 
recovery and complex assessment (pathway 3). Thereafter any further health or social 
care assessments are delivered outside of the acute hospital environment. There is a 
focus on the hospital’s integrated discharge team who work with the ward to assess 
and define health care needs in order to identify which pathway it is most appropriate. 
At the point of discharge, care is fully funded by the NHS. 

1)  Mr Yemm was placed into a totally unsuitable and unsafe residential 

setting 

On 24 May 2020, Adult Social Services was contacted by a member of the 
ward staff at Langley Ward, NNUH, advising that Mr Yemm required ‘Support 
following hospital discharge. Unplanned admission to NNUH. Short term 24 
hour residential support required while delirium resolving.’ Mr Yemm 
had been placed on D2A pathway 2. Norfolk County Council is not able to 
place people in nursing home care without a nursing needs assessment 
carried out by a health professional. We were advised by health professionals 
that nursing care was not needed at this time and residential placement was 
sourced at Melton House, in line with the hospital’s assessment. 

As you are aware this placement broke down and Mr Yemm was readmitted 
to NNUH on 26 July 2020 following a fall. On 4 August a referral was 
received by Adult Social Services advising that Mr Yemm was now on the 
Discharge to Assess pathway 3 and required enhanced nursing care. It was 
noted at this point that Mr Yemm’s delirium had resolved which raises a 
question about why a lower level of care had been requested by the hospital 
in May. 

A total of 31 nursing homes were contacted but none considered that they 
would be able to meet Mr Yemm’s needs. 

On 2 September 2020, on receipt of Mrs Yemm’s letter, the CCG agreed to 
fund a bed in a neurological unit. I suggest the need for a neurological 
specialist bed was evident prior to the initial discharge, as the behaviours 
were apparent at this point and an issue on the initial discharge. 

2)  Mrs Yemm wrote to the Director of Adult Social Services asking for help 
in finding a suitable placement and did not receive the courtesy of a 
reply 

A letter has been identified which Mrs Yemm shared with the community 
response team social worker. The community response team social worker 
shared this with her senior managers and at that point the meeting was called 
with the CCG on 2 September 2020. 

Mrs Yemm’s letter was not escalated to 
the community response team and as a consequence, the matter was 
escalated appropriately and led to action by the CCG for an appropriate 
placement to be sourced and funded. 

 as it was received by 

This case highlights a known issue where people with highly agitated behavioural 
needs due to dementia or other health conditions, whose needs are outside of the 
ability of registered dementia nursing homes to care for the needs being displayed. This 
is evidenced in that 31 homes were contacted and yet no placement was available 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 because the nursing homes were unable to meet Mr Yemm’s level of need. Until the 
CCG agrees to fund a specialist neurological placement, adult social care is not able to 
source a placement with a higher level of care. It was not until Mrs Yemm complained 
that her husband’s needs were assessed for specialist provision by healthcare services. 

I would be grateful if you would give this matter your attention and consider reviewing 
the evidence taking account of information shared by Norfolk County Council. It would 
be most helpful if you would be able to contact me by telephone to discuss this further. 

Kind regards 

Director of Community Social Work 

Page 3 of 3

yath the care we wart i
for those we love the most N#S Foundation Test

Our Vision 5 > . .
ro. To prow every patient Norfolk and Norwich University Hospitals NHS

Legal Services Department
Norfolk & Norwich University Hospitals
NHS Foundation Trust

Private & Confidential Norwich Research Park
Ms Y Blak 1 Colney Lane
Ss ake Norwich NR4 7UY

Area Coroner

Carrow House direct “i
301 Kings Street

Norwich
NR1 2TN

9 April 2021
Dear Ms Blake
Response to Regulation 28 report —- Death of Michael Yemm

| am writing in response to the above Regulation 28 report (Report) that | received on
10 February 2021. | hope that this letter and the accompanying documents will
satisfy you and Mr Yemm’s family that the matters of concern raised in the Report
have been carefully considered by the Trust and appropriate action has been or is
being taken.

The Report raises three matters of concern. The Trust’s response in relation to each
one is set out below.

1. The care home placement

Mr Yemm was admitted to the Trust on 24 May 2020 and discharged on 17 June
2020 to Melton House Care Home. Mr Yemm was discharged on a D2A3 (Discharge
to Access) = for a short term community bed for the assessment of his long

term needs. was involved in the discharge planning arrangements. It was
initially hoped Mr Yemm could be discharged home with a package of care.
However, his increased needs and falls risk meant a short term community bed was
the most appropriate option. requested a bed close to home. A referral
was raised on 10 June 2020 suggesting a “Residential/Nursing home’. The
placement at Melton House was sourced by Social Services and confirmed on 15
June 2020.

Mr Yemm was readmitted on 18 June 2020 from Melton House following a fall.
Concerns were raised by Mr Yemm’s Community Care Nurse about the suitability of
Melton House due to a lack of adequate supervision. A new D2A3 discharge referral
was raised on 23 June 2020. The referral states: “Please assess for short term bed.
Wife wishes to be involved in planning as feels Morton House [sic] was unsuitable.” It
was subsequently agreed that Mr Yemm could be discharged back to Melton House
but with 1:1 supervision funding for 2 weeks. This was to allow time for the needs

{

assessment to be undertaken. Social Services has confirmed the 1:1 supervision
was provided but is unable to provide any information about arrangements beyond
the initial two week period.

Mr Yemm was readmitted again on 26 July 2020 from Melton House following
another fall and with a urinary tract infection. Melton House informed the Trust it was
unable to meet Mr Yemm’s needs. A further D2A3 discharge referral was therefore
made on 29 July 2020. The referral states that: “He is unable to return to Melton
House as they are unable to manage his falls risks and unable to manage his
diabetes.” Unfortunately, Mr Yemm deteriorated and a new fast track referral was
completed on 16 September 2020. This referral stated that: “patient was in
residential care, they are no-longer able to meet his needs so requires a new
placement’. Sadly, however, Mr Yemm passed away in hospital.

2. The hospital discharge despite being told they couldn’t send him back, and
just leaving him there

The Report states that:

“The hospital dropped Mr Yemm off back at the care home without any warning after
being informed that they could not have him back. He was also discharged on insulin
which the home could not administer as they do not have trained nursing staff.”

It also states that:

“After his second admission the manager of the care home told the hospital that they
would not accept him back as his needs could not be met by them. Despite this
without notifying the care home, Mr Yemm was dropped off by hospital transport and
the home had no option but to keep him as he was left there. They did manage to
obtain extra help, but his care needs increased, and he was again admitted to
hospital.”

Mr Yemm was started on insulin during the May 2020 admission. A District Nurse
referral was made on discharge as Mr Yemm was unable to manage his own
injections. On 17 June 2020 a “verbal handover’ was given to Melton House
including confirmation that the District Nurse referral had been completed in respect
of Mr Yemm’s “insulin administration’ .

After Mr Yemm’s admission on 18 June 2020, the Manager of Melton House was
informed during discussions between 24 and 26 June 2020, that Mr Yemm was on
long acting insulin and that the District Nurse would administer his regular doses. It
was also confirmed that 1:1 supervision had been requested and approved by Social
Services. Both Mand Melton House agreed the discharge to Melton House
on this basis.

Mr Yemm’s discharge was delayed pending the return of his Covid-19 swab test
results. — Melton House were notified that the discharge had been
moved to 27 June 2020 and transport was arranged for 12:00 hours. The Trust does
not have its own non-emergency transport facilities, and all such transport is
arranged via ERS Medical.

3. The in-patient fall and care of dementia patients

2

Mr Yemm’s fall on 3 September 2020 has been the subject of a Serious Incident (SI)
investigation. | confirm that work has been undertaken in accordance with the actions
recommended in the SI Action Plan attached to the SI Report (see attached). The
relevant teams have also been notified of your concerns so they can ensure these
are covered by the work being carried cut.

The relevant issues identified in the Action Plan are referenced below, together with
details of the associated actions that have been undertaken:

The patient was not referred to the Dementia Specialist Team

There are a number of actions being taken to address this issue:

1. Ward Manager, has issued a reminder (see attached email)

to all ward staff requiring them to ensure they are familiar/up to date with (i)
the “Memory Matters” page on the Trust intranet which contains a range of
educational resources; and (ii) Dementia awareness and DOLS training, both
of which can be accessed via the Trust’s online training facility (ESR).

2. Ward Manager ME has met with and organised ward based education
sessions with the Dementia Support Team (DST) (see attached emails).
Some ward based sessions have already been delivered via the Clinical
Educator and this is ongoing. Arrangements are also being made for ward
staff to spend a day with the DST.

oy Funding is being sought for the implementation of a ward based Dementia
Support Worker post. Regular support is being provided to the ward by the
DST in the meantime.

The Fails Risk and Safety Sides assessments are not adequate and require
review

The Falls Risk and Safety Sides assessments are under reviewas part of an ongoin
project. MG b2s been working i | _—_e
Deputy Chief Nurse on the project. A NICE compliant Falls Risk assessment has
been trialled and a final draft has been put together (see attached). The assessments
and the associated policy are currently at the final adjustment/review stage. It will
then be a question of implementing the roll out of the documents. These presently
form part of a risk assessment booklet which means complete roll out is dependent
on other risk assessment documents being reviewed. There is no final completion
date at the moment. Alongside the change in risk assessments, it is planned that
there will be an education package to support staff through the changes and to
recognise the multifactorial elements of falls prevention.

The patient had a prolonged stay in hospital due to delay in acquiring a
suitable placement

The SI findings have been shared with the complex discharge team.

| confirm that in addition the following steps have been taken to ensure that learning
is shared as a result of the SI findings:

|

1) The SI learning was shared at the Endocrinology Clinical Governance meeting for
January 2021 (see attached slides). It was also shared in the Team Medicine
Newsletter for February 2021 (see attached) and with the Governance leads vig
Divisional Governance in January 2021 (Agenda attached).

2) Award newsletter was sent to all staff (see attached).

| hope that this information provides you with the assurances you require that the
Trust has implemented changes in practice and put in place training to ensure that
the risk of future deaths from similar circumstances will not occur again.

Yours sincerely

{chit Executive Us & C oh ¢ f We (Vw

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