Doris Smith

26th April 2023 

Private and Confidential 
Ms Sonia Hayes 
Area Coroner 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Ms Hayes, 

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations  2013,  dated  27th  February  2023,  which  was  issued  following  the  inquest  into  the 
death of Doris Smith. The Trust has provided a response in acknowledgement of your concerns. 

I would like to begin by extending my deepest condolences to Doris’s family. This has been an 
extremely difficult time for them and I hope that my response provides  Doris’s family, and you, 
with assurance that the Trust takes their loss seriously and has taken action to address the issue 
of concern raised in your report. 

1.  Essex Partnership NHS Foundation Trust staff:  

a.  delayed the completion of a falls risk assessment  
b.  completed  the  falls  risk  assessment  with  inaccurate  information  to 

assess Doris Smith’s risk and updates were also inaccurate  

c.  did  not  follow  the  advice  of  the  physiotherapist  that  would  have 
required  Doris  Smith  to  mobilise  only  with  assistance  of  staff  and 
whether her level of observations should have been changed. 

Since Doris was a patient with EPUT, the Trust have made a number of practice changes to 
improve the care provided to patients in relation to falls. These are detailed below:  

-  Within 24 hours of admission, the Guide To Action falls assessment is completed and 
staff  are  expected  to  update  the  falls  risk  assessment  whenever  there  has  been  a 
change in the patient’s clinical condition. This guide to action is an admission guide, 
which details the expected steps that the staff member takes when admitting a patient 
who is at risk of falls.  The falls risk assessment provides staff with questions that are 
designed to prompt them to implement safety measures appropriate to that patient. For 
example, the risk assessment prompts the staff member to assess the patient’s ability 
to transfer and mobilise and, if there are concerns, to review the height of the bed or 
chair and gives advice of how to prompt the patient to mobilise safely. 

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 -  The falls risk assessment is included in the local induction of all clinical ward staff band 
2 to band 7 and for the induction of temporary workers. Knowledge and understanding 
is  also  reviewed  in  the  probation  period  of  substantive  staff  members  through 
discussions, which usually concludes after the first six months of employment. This can 
be  extended  if  there  are  further  learning  requirements  or  concerns  for  practice. 
Furthermore,  the  admissions  checklist  (which  involves  consideration  of  falls  risk)  is 
audited weekly by Ward Managers with action taken to ensure these assessments are 
completed if they are incomplete. 

Clinical dashboards are available for all wards on the Trust intranet and provide details 
of any outstanding assessments for patients in all wards which appear as red. The falls 
risk assessment is part of the data included on these dashboards and the target for 
completion  is  within  24hrs.  The  dashboards  provide  live  information  on  the 
completeness of all relevant patient information and key performance indicators and is 
updated  every  15  minutes.  If  it  is  recognised  that  the  documents  have  not  been 
completed,  this  will  be  noted  by  the  Performance  Team  and  raised  with  the  clinical 
team to action. In addition, the Ward Clerk prints out the daily clinical dashboard which 
is  included  in the  handover  and this  is  monitored as part  of the  Matron’s  assurance 
audit.  Performance  is  also  discussed  in  the  Ward  Manager’s  meetings  and  monthly 
team meetings. If there is a capability issue, this would be identified and managed. 

In addition to the falls risk assessment and the admission checklist which aid the staff 
member  to  introduce  falls  reduction  interventions  and  strategies for  that  patient,  the 
Trust is currently engaged with Carradale futures in a project to produce two Standard 
Operating Procedures (SOP) that relate to the management of  inpatient falls. These 
are management of falls the inpatient setting and the management of a patient following 
a fall. 

The  SOP  for  falls  management  in  the  inpatient  setting  will  guide  staff  through  the 
process required when there is a concern about the risk of a fall, how to prevent a fall 
within  the  inpatient  setting  including  specific  information  on  expert  advice  from 
occupational therapy and physiotherapy teams, and the steps required to safeguard a 
patient’s safety when a patient does have a fall. This will include advice on how often 
the  patient  is  visualised  by  the  staff  member  throughout  the  course  of  the  shift.  For 
example, for a patient at high risk of falls and all safety measures are unable to fully 
mitigate  the  risk  of  a  patient  fall,  it  would  be  recommended  that  they  will  be  within 
eyesight of a staff member at all times. The staff member will be promoted to check the 
physical  observations  of  the  patient  specifically  where  there  are  postural  blood 
pressure differences and to ensure that the patient is clinically safe to mobilise. The 
purpose of these documents is to ensure that in a high pressured environment such as 
the  ward,  staff  may  not  have  capacity  to  review  an  entire  guideline  or  policy,  which 
maybe several pages in length in its entirety. The SOP take the key information for the 
policy, and will provide practical step by step actions to be taken to immediately improve 
the safety of the patient.  As part of the implementation plan, there will be a supporting 
training session delivered to staff on usage of the SOP. 

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 Following an event where a patient experiences a fall, the details of this are shared in 
written  communication  methods  such  as  emails,  along  with  handover  and  safety 
huddles. Safety huddles are attended by the multidisciplinary team and allow for prompt 
discussion to review the incident and identify risk, and review risk mitigations and the 
patient’s 
recommendations  are 
communicated with the wider team in handover and changes to care updated within 
the clinical records. This helps to support the culture for staff to feel confident to discuss 
safety  concerns  and  be  part  of  forming  actions  to  make  individual  and  ward-based 
improvements. 

level  of  observations.  Agreed  actions  and 

-  Falls  are  reported  on  Datix.  Local  investigation  of  the  incident  occurs  by  the  Datix 
handler,  which  is  usually  a  senior  clinician  assigned  to  review  actions  required  and 
learning  from  the  incident.  Datix  allows  incidents  to  be  clustered  to  ascertain  any 
themes or trends within the incidents which had been reported, so this can be analysed 
and understood by the care team. Ward Managers and Matrons have access to view 
the ward Datix dashboard to review any themes for learning. Analysis can be completed 
for an incident of a particular nature, a team/ward, or for an individual patient which can 
inform their care plan. Incident trends are established and discussed in safety huddles, 
team meetings, Ward Manager’s assurance meetings and the senior huddle and sit rep 
calls. 

-  Posters are displayed in patient bedrooms to clearly inform the patient and supporting 
staff  of  the  mobility  assistance  they  require,  and  includes  details  of  aids  they  may 
require for the  hearing  and  visual  needs.  The  posters  are  initiated  by  physiotherapy 
staff  and  updated  by  them  or  the  occupational  therapy  staff.  When  an  update  is 
completed, this is emailed to the team, updated within the clinical records, discussed 
at the safety huddle and handover. This ensures prompt and thorough communication 
sharing.  This  was  in  place  at  the  time  Doris  was  an  inpatient  and  remains  current 
practice. 

-  The Falls Champions Networks were re-launched in January 2023 as part of the Trust’s 
Physical Health Care meeting. Each ward have an identified registered member of staff 
who  attend  the  meeting  and  feedback  learning,  changes  in  policy  and  practice 
developments in their local team. The Champions will also support the implementation 
of  the  revised  falls  policy  once  approved  and  will  audit  clinical  records  to  ensure 
patient’s falls risk assessments are updated. 

2.  Neurological  observations  following  a  sustained  head  injury  were  not 

completed as required. 

-  Training for staff related to the understanding of neurological observations is covered 
in several mandatory training courses, including; Grab Bag, Preventing Falls in Hospital 
and Immediate Life Support. This covers theoretical components and the use of case 
studies and scenario based training to ensure embedding of knowledge in a practical 
sense. This training is completed by substantive and bank staff and currently includes 
non-registered staff members.  

3 

 
 
 
 
 
 
 
 -  There may be instances which occur whereby the patient declines neuro-observations 
being taken. In this scenario, the staff would be expected to record all of the observations 
they are able to complete and record these within the clinical records. Clinicians may 
also consider the risk of the patient, and whether additional engagement and supportive 
observations  would  be  required  to  support  and  monitor  the  patient.  Staff  would  be 
expected  to  escalate  this  non  concordance  to  the  clinical/  medical  doctor  if  they  are 
unable  to  complete  neurological  observations.  I  would  expect  that  a  medic  would 
clinically assess if this was safe based on an examination of the patient. If neurological 
observations are clinically required, all efforts must be made to do these observations 
using skills available to them. At the least, a patients Glasgow Coma Scale or AVPU 
score can be recorded.  

3.  Doris  Smith  had  falls  on  the  ward  and  her  level  of  observations  was  not 
reconsidered in light of advice from the physiotherapist after each fall.  

and 

6.  Lack  of  effective  communication  as  to  the  care  and  treatment  required  for 
Doris  Smith  between  Trust  staff  and  the  levels  of  observations  required  to 
keep her safe on the ward  

-  The  unit  physiotherapist  attends  the  daily  safety  huddle  to  ensure  effective 
communication  with  and  between  the  clinical  team.  Where  this  is  not  possible,  the 
physiotherapy assistant attends to provide a handover of assessments and plans and 
to  receive  updates  on  any  patients  requiring  physiotherapy  input.  During  these 
meetings,  the  physiotherapist  or  their  assistant  will  contribute  to  discussion  around 
requirement for observation and other risk mitigating interventions. Any changes to the 
patient’s  care  are  communicated  with  the  team  and  are  updated  within  the  clinical 
records, and the mobility poster displayed in their bed area where relevant. 

4.  The Trust Observation Policy is used in different therapeutic settings and is 
confusing as to the Levels of Observation required and the focus is on risk 
for mental health rather than physical healthcare issues that may arise.  

-  The  Trust  has  an  Engagement  and  Supportive  Observation  Policy  (CLP8)  which 
provides staff with the standards of expectation for how to engage with and supportively 
observe mental health patients. If defines this supportive observation as: ‘Supportive 
observation  calls  for  empathy  and  engagement  combined  with  readiness  to  act.  It 
provides  an  opportunity  for  staff  to  interact  with  the  patient  in  a  therapeutic  way. 
Supportive observation can increase understanding of the feelings and motivations of 
the patient to act in a particular way. It can also offer the patient support and guidance 
in how to deal with those feelings and thoughts.  

-  These  supportive  observations  are  a  different  nursing  skill  to  physical  health  care, 
physiological  observations  and  the  Trust  has  a  separate  clinical  guideline  for  these 

4 

 
 
 
 
 
 
 
 
 
 observations.  The  ‘Clinical  Guideline  on  the  Use  of  National  Early  Warning  Score 
System  (NEWS2)  (CG87)  provides  staff  with  a  framework  for  the  identification  and 
management of patients who are at risk of physiological deterioration. It has information 
on when physiological observations must be taken, when to complete a monitoring plan 
for physiological observations, how to record these observations and what to do if the 
metrics are abnormal.  

-  For  neurological  observations,  the  guideline  prompts  staff  to  monitor  the  level  of 
consciousness  and  assessment  of  new  or  pre-existing  confusion  as  a  minimum. 
Section 7.0 of the CG87 policy gives staff guidance on Neurological observations and 
the trigger system and clinical response required to NEWS2. It prompts staff on steps 
to  be  taken  following  a  fall  which  includes  a  full  assessment  and  recording  of  the 
patient’s neurological condition using the Glasgow Coma Scale (GCS). 

-  Appendix 2 of the CG87 Slips, Trips and Falls Policy, which is available to all staff on 
the intranet, is a Neurological Observation Chart. This prompts staff to complete a GCS 
on  admission  and  then  gives  minimum  frequency  of  neurological  observations  and 
NEWS post fall. Every 30 minutes for 2 hours, then 1 hourly for 4 hours, then 2 hourly 
for 24 hours. This is stored in the patient record.  The SOP for post fall will also ensure 
that staff are prompted to complete this.  

5.  Quality of record keeping:  

a.  The  Trust  medical  records  recording  system  is  electronic  and 
evidence was  heard  that the window on  the screen  used  for  staff  to 
type their records is very small and difficult to use.  

b.  There were significant examples of cut and paste including out-of-date 

information recorded in the medical records.  

-  Within the clinical records, Paris, there is a function to expand text boxes for clinicians 
to  type  information  within,  and  text  can  be  made  larger  on  the  screen for  this  to  be 
readable for the clinician. This technique will be re-circulated to staff in May’s edition of 
the Lessons Identified Newsletter or 5 Key Messages. 

-  A recent Trust-wide audit on record keeping was completed to review patient records 
for all clinical teams and the report finalised in April 2023. It was a retrospective audit 
looking at information recorded for the most recent contact with the patient to obtain 
assurance  the  records  meet  procedure  regarding  health  and  social  care  records. 
Clinical teams carried out the audit on their own records and submitted the information 
for analysis by the Clinical Audit Team. One of the findings from the report raised an 
issue of copying and pasting in records for teams in the Mental Health Inpatient and 
Urgent Care group. Discussions with the teams are being held to agree next steps to 
reduce copying and pasting with one suggestion is to use a current assurance process 
to review some records using the clinical dashboard as part of monitoring. Namely the 
Matron’s  Assurance,  this  is  where  matrons  will  complete  an  inspection  of  their 
wards/units to review key areas are meeting standards. Where standards are not met 

5 

 
 
 
 
 
 
 
 the i.e. assurance has not been obtained matrons will address with the ward/unit team, 
discuss the issues and develop an improvement plan as necessary. 

- 

In  addition,  EPUT’s  Lessons  Team  produced  a  short  animated  video  with  record 
keeping tips included, and this was cascaded across the organisation on 25th January 
2023. The tips included the accuracy and purpose of maintaining adequate records. 
On  1st  February,  the  Lessons  Team  hosted  a  live  learning  event  entitled  “Learning 
Matters:  Your  Monthly  Insight”. The topic  of discussion focussed  on  record keeping, 
themes of good practice and also the legalities around medical records. 

-  On 10th  March  2023,  EPUT’s  Lessons Team released  a  Safety  Learning Alert,  which 
focussed on copying and pasting within clinical records. The Alert noted that copying 
and pasting had been evident in records within recent inquests, and provided examples 
of where this had been completed. Learning themes were included within the alert, and 
actions were set for managers to ensure the key learning had been disseminated and 
actions  had  been  taken  to  address  the  concerns  raised.  The  final  action  is  due  for 
completion in May 2023. I have attached a copy of the Safety Learning Alert. 

I hope that I have provided you with robust assurance that the Trust has taken steps to address 
the issues of concern in your report, that we are continuing to take action to strengthen the care 
provided to our patients, and that patient safety is the Trust’s top priority. 

Yours sincerely, 

Chief Executive 
Essex Partnership University NHS Foundation Trust 

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