Benjamin Clark

r.!1:1-1 
Northumbria Healthcare 
NHS  Foundation Trust 

Patient Services and Quality Improvement 

Northumbria House 
Unit 7/8 Silver Fox Way 
Cobalt Business Park 
Newcastle upon Tyne 
NE27 0QJ 

28 July 2021 

I  . 

Ms Carly Henley 
HM Assistant Coroner for Newcastle upon Tyne 
Lower Ground  Floor 
Block  1 
Civic Centre 
Barras Bridge 
NE18QH 

Dear Ms Henley 

INQUEST INTO THE DEATH OF BENJAMIN CLARK 
RESPONSE TO REGULATION 28 REPORT;  PREVENT FUTURE DEATHS RESPONSE 

We  write  in  response  to  your  Regulation  28  Report  dated  8  July  2021  following  your 
investigation  into  the  death  of  Benjamin  Clark.  This  response  has  been  prepared  by 
Northumbria  Healthcare  NHS  Foundation  Trust  (The  Trust)  and  addresses  the  concerns 
as set out by HM Assistant Coroner. 

The Trust will  respond to each of those concerns ih turn. 

Response 

The  Trust  is  committed  to  ensuring  that  lessons  are  learned  when  any  serious  incident 
occurs. At the time of the incident a Serious Incident (SI)  Investigation was undertaken and 
the Trust formed  an  action  plan.  Both the  SI  investigation and  action  plan were shared with 
HM  Senior Coroner in  advance of the inquest. 

During  the  inquest HM  Assistant Coroner heard  oral  evidence from  the Trust in  relation  to 
the measures and  steps that have been  implemented since this  incident in  order to  reduce 
and  mitigate the risk of any future incidents occurring. 

Matters accepted during the inquest by the Trust 

During the inquest the following was accepted  by the Trust: 

1. 

Mr  Clark  had  been  transferred  to  North  Tyneside  General  Hospital  (NTGH),  ward 
24,  as  a  level  3 falls  risk  (requiring  observations  in  line  of sight).  At the  time  of Mr 
Clark's  fall,  this  had  been  reduced  to  a  level  2  (observations  every  30-60  minutes) 
however, observations undertaken  had  in fact been  once every 2 hours. 

 2. 

3. 

4. 

5. 

The  change  from  level  3  to  level  2  had  not  been  documented  within  the  nursing 
records (as detailed  in  No.1  of HM  Coroner's matters of concern). 

There  was  evidence  that  the  Avoiding  Falls  Level  of  Observation  Assessment 
(AFLOAT)  tool  had  been  used  however,  this  was  not  contained  in  the  nursing 
documentation. 

Nursing records in this matter were poor and  not to the Trust expected standard. 

At the  time  of the  incident,  staff were  using  a standard  observation  chart which  did 
not stipulate timings for enhanced observations such  as  level 2 and above. 

· 

Evidence of change heard during the inquest 

HM  Assistant Coroner heard  evidence from  Matron 
the Trust have taken following this incident.  Matron 

  as to the  extensive  steps that 
 confirmed the following: 

.
1 . 

2. 

3. 

4. 

5. 

Since the  incident  involving  Mr Clark,  the  ward  at  NTGH  have  now  implemented  a 
new  observation  chart.  This  chart  determines  the  frequency  that  observations 
should  be  taken  on  the  front  of  the  chart.  The  reverse  of  the  chart  is  set  out 
differently. to  the  standard  observations  chart  to  allow  for  increased  frequency 
observations to  be  completed.  A copy  of this  observation  chart was  shared  with  the 
family  and  HM  Assistant  Coroner on  the  day  of the  inquest.  It  was  confirmed  that 
the  use  of this  chart was  a pilot and  is  well  used  within  NSECH  and  had  also  been 
adopted  by NTGH. 

Safety  huddles 'which  take  place  on  a daily basis  discuss  observations that are  set 
for patients and  include levels 2,  3 and  4 each  morning. 

Aside  from  the  observations  undertaken  for  Mr  Clark,  and  the  issues  relating  to 
frequency  of  observations  as  set  out  above,  all  appropriate  risk  assessments  in 
relation to falls were completed for him  in  a timely way. 

Discussions  are  ongoing  between  the  Matrons  withi'n  NTGH  in  order  to  place  the 
AFLOAT  risk  assessment  and  observation  chart  onto  the  electronic  care  record 
NerveCentre.  The  Trust can  confirm  that this will  be  done before the  end  of August 
· 
2021 . Notwithstanding this,  the documents are  in  use in  paper form. 

Once  the  documentation  is  placed  on  NerveCentre,  an  electronic  alert  will  be 
created  for observations and  will  alert staff via  a hand  held  electronic device that a 
particular  patient  observation 
for 
observations.  The  level  of  observation  set  by  a  Registered  Nurse  is  linked  to  the 
timed alert required for care  rounding. 

is  due,  ensuring  a  more  robust  regime 

The  Trust  notes  that  concerns  1-3  within  HM  Assistant  Coroner's  PFD  report  addresses 
those  concerns  at  the  time  of the  incident  but  does  not  appear  to  take  into  account  the 
extensive  steps that the  Trust spoke of during  the  inquest and  that have  already been  put 
in  place since this  incident. 

The Trust considers that the  measures that have already been  implemented  alongside the 
ongoing  discussions,  have  significantly  reduced  the  risk  of a  similar  incident  occurring  in 
future. 

 The  Trust  considers  that  in  such  circumstances,  a  PFD  report  is  disproportionate  and,  in 
accordance  with  paragraph  10(3)  of the  Chief  Coroner's  Guidance  No.5, 
a  concern  of a 
risk to life caused  by present or future circumstances is  no longer present. 

' 

Below is  set out the response to each of HM  Senior Coroner's concerns: 

Concern 1 

As  indicated  above,  the  Trust  accepted  that  Mr  Clark's  observations  were  downgraded 
without any notes "to justify this reassessment. 

Paragraphs  1  and  2  of  'Evidence  of  change  heard  during  the  inquest'  confirms  the 
measures  implemented  to  ensure  that  observations  are  discussed  within  teams  more 
frequently and  the frequency of observations is  clearly recorded within the patient record. 

Concern 2 

Paragraph· 1,  4 and  5 of 'Evidence of change heard during the inquest' confirms that a new 
observatio'n  sheet is already in  use which will  stipulate on  the front,  the level of observation 
assigned  and  the ·frequency of which  those observations should  be  undertaken. The Trust 
is  also  planning  to  further  enhance  this  system  by  implementing  a  system  of electronic 
alerts to notify staff when  an  observation is due. 

The  Trust  can  confirm  that  the  AFLOAT  risk  assessment  and  observation  chart  will  be 
placed  onto NerveCentre before the end  of August 2021. 

Concern 3 

the  AFLOAT  assessment  is  kept  on 

The  evidence  provided  to  HM  Assistant  Coroner was  that  the  AFLOAT tool  was  used  in 
both  hospitals  and 
the  ward.  The  AFLOAT 
assessment is a laminated chart,  kept on  all wards,  which  staff refer to for setting a level of 
observation,  prior to  adding  onto  NerveCentre.  The  evidence  heard  was  that the AFLOAT 
tool  had  not been  included within  Mr Clark's documentation.  The evidence did ·not suggest 
that only N~ECH  used this tool  in. writing. 

As  per paragraph 4,  AFLOAT is  in  use  in  paper form.  The Trust can  confirm  that' AFLOAT 
is  used  by  all  hospital  sites  within  the  Trust to  assist with  setting  the  level  of observation. •· 
However,  the  final  decision  is  at  the  nurse's  professional  judgement.  The  nurse  should 
document their rationale if they do not agree with the AFLOAT recomme'ndation. 

Matron 
 explicitly confirmed that a new observation  chart, as set out at paragraph  1 
of the  'Evidence  of change  heard during  the  inquest',  was  alrea · y  in  use  at  NTGH  as  a 
pilot.  The  "Increased  Care  Rounding"  paper  chart  is  freely  available  and  its  use  is 
encouraged  when  providing  Level  2  observations.  The  Trust  has  not  proceeded  past  the 
pilot  stage  because  an  electronic  version 
instead,  held  within 
NerveCentre. 

is  being  created 

The  assessment is  carried  out daily or more frequently  if there  is  a change  in  the  patient's 
condition.  AFLOAT  assessment will  be  on  NerveCentre  and  will  alarm  every 24  hours  so 
there ·is  a mandatory daily  review.  This  needs to  be  completed  by  a Registered  Nurse.  At 
the  end  of the  assessment,  the  nurse  can· either  accept  of decline  the  advised  level  of 
observation.  If declining, they are mandated to  provide rationale for their clinical judgement 

 -AFLOAT does  not convey a patient's falls  risk  (all  patients over 65  years of age and  those 
with  a  history  of falls  should  be  considered  at  risk  and  the  Trust  complies  with  this  in  its 
Falls  Risk Assessment document). AFLOAT conveys the level of observation that a patient 
should  receive  to  try  and  reduce  their  risk  of falls.  National  Institute  for  Health  and  Care 
Excellence  (NICE)  and  the  Royal  College  of  Physicians  (RCP)  are  very  clear  that  we 
should ·not use ri.sk  stratification tools. 

We· hope  that  the  information  provided  during  the  inquest  and  in  writing  offers  you  the 
necessary assurances that the Trust already have in  place effective measures,  which  they 
continue  to  review  to  develop  and  improve,  to  ensure  that  observations  are  appropriate 
and falls  risks are mitigated. 

Yours sincerely