Cecilia Edwards

Dr 

Executive Medical Director  
Whittington Health NHS Trust  
Whittington Hospital  
Magdala Avenue  
London  
N19 5NF 

15/04/2021 

HM Coroner Mary Hassell 
Senior Coroner  
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London N1C 4PP  

Dear Senior Coroner Hassell,  

Re: Regulation 28 Prevention of Future Deaths (PFD)  

I  am  writing  to  respond  to  the  Regulation  28  Prevention  of  Future  Deaths  (PFD)  report  for  Ms 
Cecilia Edwards on behalf of the District Nursing service at Whittington Health NHS Trust.  

Matter of Concern 1 - On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a 
category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability 
nurse.  However, no such referral was made, either by the attending nurse; the district nurses who 
visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co-
ordinator until 22 September 2020.  

Whittington  Health  has  reviewed  the  process  for  referral  to  the  Tissue  Viability  Nursing  service 
(TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made 
based on clinical need and categorisation, and not purely based on categorisation alone. The new 
guidance will undertake regular audit practice to monitor compliance. The guidance will be formally 
ratified in August 2021, following consultation with staff.  

In  addition,  Whittington  District  Nursing  service  is  working  towards  the  digitalisation  of  clinical 
notes, and the streamlining of documentation to mitigate the risk of key information being missed. 

At  the  time  of  the  incident  there  were  three  different  places  where  patient  information  was 
documented; the home notes (on paper kept in the home), eCommunity (the service’s nurse visits 
allocation  software)  and  RiO  (the  electronic  patient  record  keeping  system  used  by  most 
community services in the Trust.)  Since January 2021, a new  version of eCommunity has been 
introduced  which  removes  the  capability  to  record  clinical  notes.  Additionally,  the  service  will  be 
moving toward single documentation of the clinical patient information on the community electronic 
records  from  September  of  this  year.  Therefore,  removing  the  risk  of  documenting  the  same 
information in multiple places this includes patient assessments and care plans.   

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 Matter  of  Concern  2  -  60%  of  the  district  nurses  who  visited  Cecilia  Edwards  were  agency 
nurses. This is obviously undesirable in itself, although I recognise that it may be very difficult to 
address.  That  notwithstanding,  the  district  nurse  team  manager  giving  evidence  in  court  agreed 
with  Ms  Edwards’  niece  (herself  a  former  district  nurse  and  health  visitor,  and  her  auntie’s 
longstanding advocate) that clear protocols would raise standards, make mistakes less likely and 
bring the agency staff in as part of the organisation. Ultimately this would improve patient care.  

Due to the COVID-19 pandemic acute period (Late February – April 2020), there were significant 
staffing  shortages  across  the  District  Nursing  service.  During  this  time  Whittington  Health 
benefited  from  having  regular  temporary  staff  (bank  and  agency)  which  enabled  the  service  to 
continue  providing  care  to  patients  who  were  housebound.  The  Trust  recognises  however,  that 
when using agency staff, it is critical that there is continuity of care.  

Through the improvements to the patient documentation there is a key strand of work in relation to 
improving continuity of care for all patients and ensuring that allocation of staff to patients includes 
this and that staff recognise the importance of getting to know their patients and families. This roll-
out  of  the  digitalisation  patient  records  and  visits  allocation  programme  has  involved  all  staff, 
permanent and temporary.  

In  addition,  the  daily  handover  process  has  been  revised  to  ensure  that  all  teams  across  the 
service  have  allocated  time  to  attend,  including  temporary  staff.  Handover  also  now  includes  a 
specific  item  for  pressure  ulcer  management.  The  District  Nursing  Leads  (senior  nurses)  are 
monitoring handover on a regular basis to ensure the changes are embedded.  

Work is also ongoing to recruit to the District Nursing service, both for substantive roles and on the 
Bank, both locally and internationally. The Trust actively works with agency staff who are regular 
workers to consider joining the organisation as permanent employees and they are offered several 
flexible options to meet their personal circumstances. Vacancies are monitored through the Trust 
divisional reporting structure and at the Trust workforce committee. 

Matter of Concern 3 - The district nurses who visited Cecilia Edwards needed the assistance of 
the  two  carers to  turn her and  attend  to  all  her nursing  needs,  but  sometimes  when  they  visited 
there were no carers present and so the nursing care given was incomplete. The carers attended 
at set hours four times a day, and so it seems that the onus was on the nursing team to arrange 
the twice weekly visits appropriately. Sometimes, individual nurses would ring individual carers to 
make arrangements, but there was no organisational system to ensure that nurse and carer visits 
coincided as a matter of routine.  

There are robust arrangements established with local social care agencies and the District Nursing 
service.  However,  in  this  case  there  was  a  private  carer  arrangement,  funded  and  organised  by 
the  family.  This  requires  an  individualised  approach  by  the  service  to  co-ordinate  the  care  with 
families to meet specific requirements of the patient. The service has reviewed how it works with 
families  in  these  circumstances  and  going forward  there  will be  a  discussion  with  the family  and 
the nurse caring for the patient on this. The plan of care and working together will be agreed with 
the family and service and will be clearly documented in the electronic patient record care plan.  

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 This  will  be  monitored  on  a  regular  basis  by  the  senior  nurses  and  included  in  future  case  note 
audits and caseload reviews. 

I hope this information provides you with assurance of the actions the Trust has taken and 
continues to take to ensure that the Regulation is met.  

Please do not hesitate to contact me if you would like any further information.  

Yours sincerely  

Dr 
Executive Medical Director  
Whittington Health NHS Trust 

Cc:  

Chief Executive, Whittington Health  

Chief Nurse and Director of Allied Health Professionals, Whittington Health  

 Chief Operating Officer, Whittington Health  
, Inspector, Care Quality Commission 

, Interim Assistant Director of Quality, North Central London CCG 
, Associate Director of Quality Governance, Whittington Health 

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