Mary Lincoln

Dr 
Medical Director 
Trust Headquarters and Medical Education Centre 
Aberford Road 
Wakefield 
WF1 4DG 

Sent via email: 
Ms Lorraine Harris 
HM Assistant Coroner 
West Yorkshire (Eastern District) 
HM Coroner’s Service 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Ms Harris 

Re Inquest of Mary Ann LINCOLN (dcd) – 27.04.1936 to 21.05.2020 

I am responding on behalf of the Trust to the Regulation 28 Report to Prevent Future 
Deaths that you issued to The Mid Yorkshire Hospitals NHS Trust (MYHT) on 2 
August 2021 (notification received by MYHT on 17 August 2021).   

The Matters of Concerns raised in your report were: 

(1) During evidence it became apparent that there is no guidance or policy with regard 
to checks on patients overnight (who are not subject to NEWS, turning etc).  Mrs 
Lincoln was put in to bed at around 2130 and only checked once in the night despite 
being in hospital, having a history of falls and knowledge of the fact she needed the 
toilet overnight.  Although she had previously used the call buzzer she was also 
known  to  mobilise  herself.    She  was  not  discovered  until  0630,  and  then  only 
because someone noticed as they passed her door.  She had lain on the floor for 
some time, with an open fracture.  The hospital conducted a serious incident review 
in which it recommended the checks policy should be reviewed.  It appears it was 
reviewed  but  no  changes  were  made.    Evidence  had  been  heard  that  previous 
rounding checks were deemed inappropriate and therefore no further action was 
required.  Therefore there is no policy or guidance with regard to people who are 
vulnerable, a falls risk and known to get up in the night (for any reason) to be further 
assessed for checks overnight. 

Chairman – Keith Ramsay             

Chief Executive – Martin Barkley 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (2) There is a bedrails policy in place, the author of the SI report found that it appeared 
to  be  comprehensive.    During  evidence  however  the  staff  responsible  for 
implementing  its  use  were  either  unaware  of  it  (it  appears  it  is  not  circulated  to 
HCA’s), or find it confusing.  There is obviously a void between producing a policy 
and ensuring it is circulated and understood by all concerned.  

I  would  like  to  thank  you  for bringing  these  matters  to  MYHT’s  attention.   We  have 
reviewed our processes and are presently undertaking a number of actions.  

Frequency of Checks 
This matter of concern was received and discussed with the senior nursing team within 
the  corporate  division.    It  was  acknowledged  that  regular  checking  of  patients, 
vulnerable or not, is a Trust-wide issue applicable to all divisions who have in-patients. 

As part of the Trust’s serious incident investigation it was identified as an action that 
there  was  a  need  to  review  or  develop  guidance  for  nursing  staff  surrounding  the 
frequency of patient checks during a night shift.  One option considered at the time 
was whether this guidance should be included as part of the Standard Observations 
Policy  already  in  operation  at  the  Trust.    However,  following  discussions  with  the 
Matron  for  Quality  and  Patient  Safety,  it  was  felt  that  the  existing  policy  was  not  a 
suitable  vehicle  to  include  this  type  of  guidance,  as  the  policy’s  focus  is  on  vital 
observations and escalation. 

Reintroduction of an “intentional rounding observation tool” was also considered but 
as  this  tool  had  previously  been  discontinued  because  it  had  become  a  “tick-box” 
exercise,  it  was  considered  inappropriate  to  reintroduce  it  when  meaningful  (albeit 
quick) checks should occur. 

It  was  also  noted  that  a  patient  who  is  nursed  in  a  bay,  is  more  likely  to  have  an 
increased level of observation due to the likelihood that a member of staff will enter the 
bay to provide some level of care to another patient e.g. toileting, vital sign recording 
etc.  Equally,  a  patient  nursed  in  a  side  room  may  receive  a  lower  level  of  ad  hoc 
checking,  just  by  virtue  of  being  in  a  (single)  side  room  as  opposed  to  a  (multi-
occupancy) bay. 

In addition, it was recognised that a patient who has a level of vulnerability (falls risk, 
pressure ulcers, lacking capacity, DOLS) will have had an enhanced care assessment 
and  may  already  be  receiving  an  increased  number of  checks through  bay  tagging, 
cohort nursing or 1:1 care.  

There is also a level of nursing activity for all patients after the night shift team comes 
on duty including medication rounds, drinks, observations (formal), settling down for 
the night, and dimming of the lights.  This activity usually takes place between 19:30 
and 22:00hrs. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Regardless  of  this  activity,  it  is  accepted  that  staff  at  the  Trust  would  benefit  from 
written guidance around the frequency of checks expected to take place overnight.  

In response, the Assistant Director of Nursing, Division of Medicine will communicate 
to  all  divisions  via  a  Standard  Operating  Procedure  (SOP),  the  following  minimum 
standard of ad hoc checks and documentation expected between the hours of 22:00 
and 07:00.  

The SOP will include the following: 

  Patients who are cared for in side rooms (including patients assessed as high risk 
of falls, or with increased toileting needs etc.), should be visually checked hourly, 
as a minimum 

  Patients who are cared for in bays (including patients assessed as high risk of falls, 
or with increased toileting needs etc.), should be visually checked two hourly, as 
a minimum 

  Where there are no concerns regarding the patient, this must be documented on 

the electronic record on PPM+ as follows: 

  “Patient checked hourly overnight, no concerns”, or 

  “Patient checked two hourly overnight, no concerns”.  

  Any concerns regarding patients during the checks must be actioned and escalated 

appropriately as per normal practice, and documented within the records. 

  The  one  hourly  or  two  hourly  checks  are  in  addition  to  the  regular  vital  sign 

observations, medication rounds and any further care required overnight.  

Compliance 
The  Trust  recognises that  it  will take  a  period  of  time  to  implement  and  embed  this 
practice  in  all  wards  across  all  divisions.  It  is  proposed  that  this  SOP  will  be 
implemented  by  the  end  of  this  calendar  year;  however,  in  the  meantime, 
communication has been sent to Assistant Directors of Nursing across the Trust with 
the  above  guidance  to  disseminate  to  their  teams.  Once  introduced  into  a  ward, 
Divisional  Assistant  Directors  of  Nursing  and  their  teams  will  be  able  monitor 
compliance  through  the  monthly  Ward  Health  checks  as  these  ‘overnight  patient 
checks’  will  form  part  of  the  auditing  of  night-time  documentation,  to  demonstrate 
continued  learning.    Furthermore,  compliance  will  be  reported  through  the  Patient 
Safety  and  Clinical  Effectiveness  Group 
following 
implementation and any further concerns will be actioned accordingly.   PSCE is a sub-
committee of the Trust Board Quality Committee and is chaired by the Trust Medical 
Director.  PSCE  meets  monthly  and  has  clinical  representatives  from  each  of  the 
operational divisions and corporate functions. 

three  months 

(PSCE) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Falls/Bed Rails Policy 
The Trust has taken the following individual steps to share the learning from the serious 
incident  investigation  and  the  Coroner’s  Inquest  findings  and  recommendations, 
including providing opportunities for the Falls Policy to be accessed and understood 
involved by all staff using it.  Importantly, this has included highlighting individual staff 
responsibilities under the policy when assessing the use of bed rails.  

1)  The  Inquest  outcome,  including  issues  raised  by  the  Coroner  and/or  family  and 
lessons learned, was emailed widely throughout the Trust to senior management 
for dissemination to all appropriate staff. 

2)  Email communication was sent to Assistant Directors of Nursing across the Trust 
and  forwarded  to  their  respective  inpatient  areas  for Ward  Managers  to  discuss 
within their services the Trust’s bed rails assessment processes. 

3)  This  was  followed  up  by  discussions  at  Matrons  meetings  and  Ward  Manager 

meetings. 

4)  Learning from other Trusts in relation to bed rails management (identified through 
CQC  inspections)  was  circulated  by  MYHT’s  Falls  and  Quality  Practitioner  to  a 
number  of  high  level  groups  including  the  Patient  Safety  Improvement  Group, 
Nursing  Review  Group,  Patient  Safety  Panel  and  PSCE.    The  learning  was 
subsequently incorporated into an addendum  to the falls policy published in July 
2021. 

5)  In August 2021, the Gate 43 Newsletter featured a ‘learning from incidents’ section 
which included an anonymised summary of the events surrounding this particular 
incident and learning.  This also included the responsibilities of staff members when 
assessing a patient for bed rails. 

6)  This  particular  ‘learning  from  incidents’  will  be  highlighted  again  through  an 
upcoming  Patient  Safety  Bulletin  which  will  be  circulated  trust-wide  by  end  of 
October 2021. 

7)  In  addition  to  this  learning  being  shared  globally,  where  required,  individualised 
counselling  /  training  with  staff  members  will  be  undertaken  in  relation  to  the 
assessment and use of bed rails. 

I  trust  this  advice  is  helpful  and  provides  you  with  assurance  that  MYHT  has  taken 
appropriate steps to address these important matters of concern and we thank you for 
bring them to our attention. 

In closing, on behalf of The Mid Yorkshire Hospitals NHS Trust, I would also like to 
take  this  opportunity  to  once  again  offer  our  sincere  condolences  to  Mrs  Lincoln’s 
family in relation to her sad death. 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 Yours sincerely  

Dr 

Medical Director