Alan Jones

f Q XY GIG Bwrdd lechyd Prifysgol

“Ge Aneurin Bevan
7 N HS University Health Board

Our ref: FP Direct Line: fF 13 April 2021

Ms Caroline Saunders

HM Senior Coroner for Gwent
Room 204W

The Civic Centre

Godfrey Road

Newport

NP20 4UR

Dear Ms Saunders

Re: Aneurin Bevan University Health Board response to Regulation 28
Report received following the inquest touching on the death of
Mr Alan Jones, DOB 22/06/1926

Thank you for your report dated 16 February 2021, which was received by the
Health Board on 19 February 2021. Information has been provided by

Executive Director Therapies & Health Science and the Executive
Director of Nursing.

Further to your report, the information presented below is intended to describe
the action taken / being taken by the Aneurin Bevan University Health Board to
mitigate the risk of future deaths.

Matter of Concern - Multidisciplinary Care

The Health Board fully accepts that protecting hospital patients from falls and
the related harm is the responsibility of the entire multidisciplinary team, both
registered and non-registered staff. This is extensively supported by the
evidence base and national guidance, which the Health Board both endorses
and works to incorporate in its approach to protecting patients whilst in
hospital. It is clear from the death of Mr Jones, and other serious incidents
where hospital patients have fallen, that the Health Board has scope for
improvement and can take further action to strengthen the multidisciplinary
approach.

Pencadlys Headquarters

Ysbyty Sant Cadog St Cadoc’s Hospital
Ffordd Y Lodj Lodge Road

Caerllion Caerleon

Casnewydd Newport

De Cymru NP18 3XQ South Wales NP18 3XxQ

Ff6n: 01633 234234
Tel No: 01633 234234

Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd lechyd Prifysgol Aneurin Bevan
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Health Board

Ms Caroline Saunders 2 13 April 2021

Your concerns as set out in the Regulation 28 notice, rightly point to the care
planning that follows from the initial multifactorial assessment when a patient
arrives on a ward or their circumstances change. To be effective in reducing
falls and protecting patients from related harm, the care plan must be
multidisciplinary, which the Health Board has recognised in revising its Falls
Policy for Hospital Adult Inpatients. The entire policy has been reviewed
through this lens, to make clear the responsibilities of all professions and
disciplines that can contribute to the care of a hospital patient. The policy
makes clear the expectation of joint multidisciplinary assessment and care
planning. The policy revisions have been completed and are awaiting
ratification by the Health Board’s Clinical Standards and Policy Group before
publication. It will be ratified by end of April, when the supported
implementation will commence. Once ratified, a copy of the policy can

be provided.

The Health Board recognises that publishing a revised policy will not in itself
enable the required change in emphasis towards multidisciplinary care
planning and so a policy implementation plan is being developed. The policy
implementation plan will be overseen and monitored by the Falls & Bone
Health Steering Group, which is both multidisciplinary in its membership and
also diverse in representing all divisions across the Health Board. The Falls

& Bone Health Steering Group reports to the Health Board’s Quality and Patient
Safety Committee (a formal committee of the Board). The implementation
plan will largely focus on training, targeting the multidisciplinary team and will
be delivered both through online learning but also, importantly, through face
to face training on the wards. Informing the training will be learning taken
directly from serious incident investigations involving hospital falls, using
actual case studies. The training will be evaluated and compliance will be
monitored, including multidisciplinary participation.

To further support awareness of the multidisciplinary requirements set out in
the revised policy, a Health Board wide communications campaign will be
developed and launched to coincide with the publication of the policy.

The Falls & Bone Health Steering Group has also developed an action plan for
reducing inpatient falls (enclosed). This action plan includes a wide range of
action beyond the revision of the policy. A key action in the plan is introducing
‘Falls Prevention Collaboratives’, which utilise quality improvement
methodologies which support identification of specific areas for focus alongside
thematic reviews. The ‘Collaboratives’ follow a similar approach adopted by
the Health Board to successfully reduce pressure damage in hospital; they are
delivered at ward level with full multidisciplinary participation. Wards and
teams that will participate in the collaborative have already been selected and
work is underway.

Learning from incidents is key to ward level improvement and preventing
future harm and this needs to happen involving the entire multidisciplinary
team. The Health Board has established robust arrangements for investigating
injurious falls in hospital. All hospital falls resulting in a long bone fracture,

Ms Caroline Saunders 3 13 April 2021

and classified as severe harm, are investigated and presented to the Falls
Review Panel, which is multidisciplinary in membership. Hospital falls classified
as catastrophic harm are subject to an Executive led investigation, again
involving the entire multidisciplinary team. In response to the need to ensure
multidisciplinary participation in patient care planning to prevent falls, then it is
essential that accountability sits with the multidisciplinary team and that they
are all involved in the incident investigations. It is true that in the recent past
that the Health Board investigation of falls and reporting (whether to the falls
review panel, to Exec led investigations and even to the Coroner inquests) has
fallen largely to nursing colleagues. This deliberate change to engage the
multidisciplinary team in the investigations and subsequent reporting of
findings is a key change being adopted by the Health Board.

In direct response to the Coroner’s concerns about multidisciplinary care, the
Falls & Bone Health Steering Group will be actively reviewing and monitoring
completion of the actions described, with a clear expectation that
multidisciplinary participation and ownership of falls prevention care plans can
be evidenced.

Matter of Concern — 1:1 Supervision

Clear processes are in place within the Health Board to escalate any staffing
deficits within the planned roster and/or any requests for additional staffing
requirements. At the time of Mr Jones’ fall the Health Board had in place a
Nurse Staffing Escalation Policy which articulates everyone responsibility, from
Ward to Board, in maintaining appropriate nurse staffing levels and sets out
clear actions if there is a deviation from what is required. In addition, daily site
meetings occur to manage nurse staffing levels, consider any deficits, manage
and identify any potential risks and escalate any supplementary requirements
to the Resource Bank. There is clear evidence, by way of ‘Healthroster’, to
indicate there was a recognition and identified need to increase nurse staffing
levels to manage enhanced care on many occasions throughout Mr Jones's
admission. This requirement had been escalated and acted upon by the Ward
Manager, Senior Nurse and Assistant Divisional Nurse - as per Nurse Staffing
Escalation Policy. Additional shifts had been created and sent to the Resource
Bank. All reasonable steps had been taken to manage the known staffing
deficits (as required by the Nurse Staffing Levels Wales Act). Despite this not
all temporary staffing requests were able to be filled.

Ward 4/1 is deemed a Nurse Staffing Levels (Wales) Act 2016 (NSLWA) s25B
ward and as such undergoes an in-depth bi-annual review and re-calculation to
determine acuity, dependency and nurse staffing requirements following the
All Wales Bi-Annual Acuity Audit. A review, assessment and recalculation of
ward 4/1 took place in September 2019. All quality metrics aligned to the
NSLWA were considered, to include falls. The bi-annual review involved the full
engagement and contribution of the Divisional Nurse, Senior Nurse, Ward
Sister, finance and Human Resources to ensure the ward establishment was fit
for purpose and aligned to patient acuity. It is to be noted that ward 4/1 had

Ms Caroline Saunders 4 13 April 2021

previously identified a need for an increase in Health Care Support Worker's to
support enhanced care by night and as a consequence the substantive HCSW
workforce was increased to support this requirement.

In 2019, on the backdrop of significant vacancies, circa 350 Whole Time
Equivalent (WTE), it was imperative that the Health Board considered new
roles and responsibilities for acute wards, promoting the principle of the
‘Prudent Registered Nurse’ with emphasis on appropriate and safe delegation
practices. The core care team model was introduced as a result of a
collaborative approach between Divisional and Corporate Nursing together with
Workforce and Organisational Development. Ward 4/1 was identified as an
ideal ward to embed this new model due to the dependency of the patients
cared for, hence the recalculation undertaken in September 2019 incorporated
the core care team model. The core care team comprised of several different
roles, to include:

e Band 4 Assistant Practitioner
e Roster Creators
e Ward Assistants

The implementation and embedding of this new model has since been
evaluated and presented to the Executive Team. The overall evaluation was
deemed positive.

By way of assurance the Health Board has in place the following to review and
maintain nurse staffing levels:

e Biannual review of nurse staffing levels on all s25B adult medical and
surgical acute wards.

e A sequence of nurse staffing reviews in other areas/specialties, which
include:

Assessment areas: ED, AMU, SAU
Coronary Care

High Care Respiratory

Critical Care

Theatres

Community Hospitals

e A NSLWA Operating Framework and Staffing Escalation Process, the purpose
of which is to standardise and inform staff groups of their responsibilities
also of processes and procedures for ensuring appropriate and carefully
considered nurse staffing in all areas.

Ms Caroline Saunders > 13 April 2021

e A weekly reporting and escalation process by means of the Executive Safety
Huddle by which nurse staffing deficits are reported. A comprehensive report
is shared, which includes any incidents resulting in harm which may have
been attributed to nurse staffing levels.

The establishment of Registered Nurse and HCSW pools on each acute site to
support deployment of staff - taking all reasonable steps to ensure planned
rosters were maintained on a backdrop of significant absenteeism and
fluctuation in capacity required to manage the pandemic.

The recruitment strategies deployed within Aneurin Bevan University Health
Board to address the vacancy factor has placed the Health Board in a far more
positive position than some 18 months ago. March 2021 reports a vacancy
factor of 165.45WTE Registered Nurse vacancies - with a projected forecast of
121.32WTE vacancies by August 2021.

In addition to the extensive work on RN recruitment the Health Board has also
supported a significant increase in the substantive HCSW workforce across all
specialities. An additional 145WTE HCSW’s have been employed since July
2020, providing continuity in care and improved patient experience.

Other matters not included in Regulation 28 report

I would like to respond to two other matters that you raised during the Inquest
that were not found to have contributed to Mr Jones’ death and therefore not
contained in your Regulation 28 report but outlined in a separate letter dated
15 February 2021. I will respond to each in turn:

Performance of neurological observations following Mr Jones’ seven
falls

You have specifically asked that we review the Serious Concerns Report
performed after the death of Mr Jones and to confirm (with reference to the
records) whether the neurological observations were requested post fall and
performed according to the Health Board protocol.

On review of the Serious Incident report there are three falls incidents which
make reference to a request for neurological observations, which accords with
the Health Board protocol. These specific three falls are detailed below. On all
three occasions immediate observations were undertaken by staff at the time
of the falls and recorded.

Regarding the fall that occurred on 13" November 2020, the clinical review
which forms part of the ‘Immediate Assessment following an Inpatient Fall’
included a request for neurological observations. From the time of the fall, the
required observations were undertaken hourly until 10.04 on the day Mr Jones
passed away. This information was recorded in the Care Flow System (a
system where observations are recorded).

Ms Caroline Saunders 6 13 April 2021

The falls which occurred on the 29" October and the 9t" November also detail a
request for neurological observations as part of the post fall clinical review. On
both occasions the clinical records on our Care Flow System show no evidence
that the required observations were undertaken.

It is clear that, despite the request from the ‘Immediate Assessment following
an Inpatient Fall’ for neurological observations, on two of the occasions, this
was not completed fully as required.

I am sorry that the Serious Concerns Report we prepared in response to Mr
Jones’ seven falls did not make this explicit and clear. To ensure that internal
serious incident investigations are both thorough and accurate the Health
Board will in future seek additional clarity and documented evidence for
statements related to care and treatment, including assessments and
observations.

Notification of the Health and Safety Executive

We have reviewed the falls and subsequent death of Mr Jones, referring to the
incident record and Serious Concerns Report and conclude that this incident
meets the criteria of RIDDOR and therefore should have been reported to the
HSE for failings in providing and applying adequate fall prevention measures,
including close supervision to a patient in a confused mental state. I can
confirm that the death of Mr Jones has been reported to the Health & Safety
Executive since the Inquest and your letter.

To enable the Health Board to meet the requirements of RIDDOR a dashboard
has been developed within the Datix Incident Reporting system to allow
visibility of any falls resulting in significant harm. We have also reviewed the
Standard Operating Procedure for RIDDOR and incorporated a new section on
reporting patient falls. In addition, our Health Board’s Head of Health and
Safety will be participating in a newly established All-Wales task and finish
group to look at the reporting of patient safety RIDDOR’s to ensure that we
have a consistent approach across NHS Wales.

I hope that this additional information in relation to these two matters is
helpful in terms of clarification but also as an update on how we are improving
and strengthening in these specific areas.

I trust that this information addresses the concerns raised in your report,
however please do not hesitate to contact me should you require any further
information.

Ms Caroline Saunders 7 13 April 2021

Yours sincerely

Chief Executive/Prif Weithredwr

Encs ABUHB Inpatient Falls Action Plan (updated 6" April 2021)