Hazel Wiltshire

fl!1#~1 

King's College Hospital 
NHS Foundation Trust 

Chief Executive 
King's College Hospital 
Denmark Hill 
London SE5 9RS 

28th October 2021 

HM Coroner Landau 
South London Coroner's Court 
2nd  Floor,  Davis House 
Robert Street 
Croydon 
CR01QQ 

Dear HM Coroner Landau 

Re:  Inquest of Hazel Fleur Wiltshire 

I write in relation to the regulation 28 report to prevent future deaths dated  1st September 
2021  in connection with the inquest of Hazel Fleur Wiltshire. 

We are very sorry that Mrs Wiltshire died in these circumstances at the Princess Royal 
University Hospital. We have apologised to her family for the failings in our care and we 
have offered them our sincere condolences. 

In your report you have identified the following concerns: 

•  The matron who gave evidence was not aware of obtaining data on response times 

from the call bell system and had not introduced any other system to monitor response 
times. 

•  Staffing levels were inadequate due to higher dependency ofpatients with Covid. 

I 

heard that one patient had to soil herself in her hand as no one was available to assist 
her with her toileting needs.  Mrs Wiltshire phoned home on occasion to ask her 
family to call the ward because they were not responding to her call bell.  The family 
could hear other patients on the ward crying out for help. 

•  Although Mrs Wiltshire was at risk of falls,  no risk assessments were completed on any 
of the three wards in which she stayed.  This suggests a systemic problem across the 
hospita/ that requires remedial action. 

Thank you for highlighting these points and giving us an opportunity to respond and to 
update you on the improvements we have made to ensure that patients are consistently 
receiving high quality care at King's College Hospital. 

Response times from the call bell system 

The current call bell system at the PRUH is approximately 20 years old and is due for 
replacement. Unfortunately it does not automatically generate reports on response times. 
The replacement plans are now being progressed and we expect this to take place in 2022. 
A project group has been identified including nursing representation to ensure this is 
implemented in a way that most benefits our patients. The upgraded system will enable 
reporting of response times. 

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 Prior to the implementation of the upgraded call bell system, we have re-introduced local 
Quality Audits led by the Matrons at the PRUH, alongside intentional quality rounding 
checks, which look specifically at documentation including. 
launching Executive Quality walk-rounds across the hospital sites. 

In November 2021  we are also 

We will also be including an audit of response time to call bells in our monthly ward audit 
cycle through the Perfect Ward app. The audit will include response times, checks to the call 
bell functionality prior to admission of a new patient and checks to see if call bells are within 
reach of patients whilst in bed. If any bells are found to faulty, they will be reported to Estates 
immediately and an incident report form will be competed. The Heads of Nursing and 
Director of Nursing will be completing these audits alongside the ward teams.  The wards 
and care groups will monitor the audit results via the Perfect Ward reports and 
improvements made accordingly. These results will be monitored locally whilst also being 
shared at Nursing and Midwifery Board monthly as a standing agenda item. This information 
will then be cascaded to all nursing and midwifery staff as well as patient safety and 
experience colleagues in feeder committee meetings on a regular basis. 

Staffing and continence care 

Mrs Wiltshire's admission coincided with the height of the second COVID-19 wave when the 
PRUH site was at capacity. At the time of the admissions there were 273 patients in general 
and acute beds,  157 patients through the Emergency Department and 19 patients in the 
Intensive Care Unit (ICU).  I would stress that we are not trying to excuse the failings in our 
care, but in recognising the impact of the pandemic on staffing, and the way in which care 
was delivered in extremis, is an important context when considering how to prevent future 
deaths in similar situations.  Covid-19 patients were often higher dependency, meaning that 
more staff were required to care for them on acute wards. This was in the context of staffing 
challenges made worse by staff sickness and requirements for self-isolation.  A review of 
staffing rates at the PRUH in January shows that the average fill rate for day staff was 86. 7% 
(the lowest rate recorded for day staffing at the PRUH site in the last 12 months) and the 
average fill rate for night shift staff was 91.6% (also the lowest rate recorded for night staffing 
at the PRUH site in the last 12 months). Although we experienced more stretched nurse to 
patient ratios during the pandemic as we were in extremis I want to provide assurance that 
daily staffing calls took place, led by senior nursing staff at the PRUH/SS, to mitigate risks 
and ensure ratios were as safe as possible. Throughout the waves of COVID-19 our 
recruitment and retention activity did continue although since wave 2 we have increased this 
work which is happening alongside HR colleagues across all sites to ensure we have robust 
plans to attract, develop and retain our current and future workforce. 

At the time of her fall in hospital Mrs Wiltshire was Covid-19 positive and therefore. was being 
cared for in a side room for infection, prevention and control reasons.  In order to attend to 
her, the nursing team were required to don (put on) and doff (take off) personal protective 
equipment before entering and when leaving side rooms. Whilst it is not possible to be 
specific in Mrs Wiltshire's case (as there are no specific records of when the call bell was 
activated) this may have been a factor in delaying the team attending to her as quickly as 
they would have liked. With additional training during the waves of COVID-19 and increased 
familiarity of donning and doffing it is probable that this activity has now become a quicker 
task to complete. 

· 

The story which you have heard about another patient who was not supported with her 
continence needs is distressing and deeply regrettable.  If you have further details about this 
case, then I would be grateful if you could share these details to enable us to apologise to 
the patient and their family, and to ensure we can investigate and learn from what happened. 

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Pioneering better health for all 

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 We recognise that falls in  hospital are often connected with patients using the bathroom or 
trying to get to the bathroom.  We are working to ensure that our continence care is pro-
active, e.g. patients assisted to the bathroom before they go to sleep and early in the 
morning. Our Practice Development, Clinical Safety and Bowel and Bladder Clinical Nurse 
Specialist T earns are currently working collaboratively to share learnings from poor practice, 
like you describe, in order to raise awareness and show case best practice. We are 
ensuring, in line with our Trust wide competency matrix and training needs analysis, that our 
senior nurses and practice development nurses have the appropriate skills and knowledge to 
provide gold standard continence care to all our patients and will role model this at all times. 
Continence care is also part of our rolling annual 'Topic of the Month' programme with the 
Practice Development Nurses who will deliver specific bite-size teaching co-produced with 
the Bowel and Bladder CNS Team. This will be audited the following  month and fed back so 
we can follow a continuous cycle of improvement. 

Falls risk assessments 

The absence of a documented falls risk assessment for Mrs Wiltshire prior to her fall was not 
acceptable.  In the Serious Incident investigation carried out by Trust it was identified that 
there had been at least 3 missed opportunities on different wards to complete the falls risk 
assessment. 

The Falls Team routinely review falls data,  including completion of risk assessments, and 
this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical 
update (described in more detail below.}  We are currently working with Epic (the new 
Electronic Patient Record  which is currently being developed for the Trust} to input learning 
from  patient safety incidents and to ensure that the system can be used for live monitoring of 
risk assessment compliance to drive Trust and local improvement. The falls team are also 
reviewing working with the Business Intelligence Unit (BIU} to move to a more automated 
approach using the current patients' electronic health records in the interim. 

The Practice Development Nurses are now supporting with falls training and promoting best 
practice across the PRUH wards. We also have named staff from each ward at the PRUH 
who will be the Falls Champions and are working closely with our Falls Practitioner Team. 
Falls refresher training sessions, delivered by the Falls team, have also been included as 
part of the annual clinical update (commenced in April 2021), which Band 5,  6 and 7PRUH 
nursing staff have been attending Feedback from these sessions has been very positive. 

In September 2021, the Trust ran a number of events to mark Falls Awareness Week which 
focussed on falls prevention. This occurred alongside Falls being the Topic of the Month for 
September 2021  which also included further training and bite-size teaching which is currently 
being evaluated and feedback shared with the teams. The PRUH are also doing some 
focussed work on falls prevention, led by the Site Director of Nursing, who chairs an 
operational falls meeting. This has focussed on collaborative working across professions to 
identify risks and common themes in relation to falls prevention with a clear action plan and 
deliverables from this working group. Since April 2021  the number of falls have reduced 
significantly, and work continues to further reduce the number of falls and lessen the impact 
on our patients. 

The Trust's Harm Free Care Forum, was reconvened following Wave 2 of the pandemic. 
This is a forum which champions falls prevention and helps to focus on the implementation 
of actions arising from trends and themes in falls incidents. The main purpose of the forum  is 
to review recent incidents and share what went wrong, why and the learning from this to 
ensure we are creating a good safety culture in the Trust. 
I trust that this response provides you with an assurance that the Trust have taken this 
seriously and are actively working to ensure we mitigate the risks of falls to all patients in our 

An Academic Health Sciences Centre for London 

Pioneering better health for all 

I  KING'S  HEALTH  PARTNERS 

 care. We do recognise the severe impact that a fall can have any patient, but particularly for 
our frail and elderly patients. 

Yours sincerely, 

Chief Executive 

An Academic Health Sciences Centre for London 

Pioneering better health for all 

I t  1•11  •·H MKING'S  HEALTH  PARTNERS