Roger Southwick

Chief Executive 
Tameside and Glossop Integrated 
Care NHS Foundation Trust 
Fountain Street 
Ashton under Lyne 
Lancashire 
OL6 9RW 

11 July 2023 

Strictly Private and Confidential 

HM Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
Cheshire, SK1 3AG 

Dear Mr Briggs, 

9th 

I am writing further to the inquest regarding the death of Mr Roger Southwick (who died 
November  2022)  which  concluded  on  10th  March  2023  and  the  subsequent 
on 
Regulation 28 Notice issued to the Trust. I hope to set out below my response in terms of 
what we are already doing and what we plan to do in relation to your concerns. 

You expressed concerns regarding the falls risk assessments, specifically the inaccurate 
falls  risks  assessment  and  the  failure  to  record  and  act  on  family  concerns  regarding 
mobility by re-assessing falls risks. 

All  patients  being  cared  for  on  a  ward  in  the  hospital  are  discussed  at  the  daily  ward 
safety  huddles by  the consultant(s),  nurse(s) and  allied  health  professionals  involved  in 
their  care  and  treatment.  Those  patients  who  are  at  greater  risk  of  falls  are  identified 
clearly during this discussion and a “falling leaf” symbol is also applied to the electronic 
white  board  to  provide a  visual  cue  to  staff.  Nursing staff  are  aware  that  those  patients 
identified as a falls risk must have a falls risk assessment in place. 

In 2022 the Trust held a “Falls Risk Summit” chaired by the Executive Director of Nursing, 
which  brought  together  members  of  the  multidisciplinary  team  from  across  the 
organisation. The summit enabled a focussed review of falls data, themes, learning and 
each Clinical Division supported the development of a Trust wide action plan to improve 
the processes, education and resources for falls prevention. Progress on this action plan 
is monitored via the Safer Care Group. The learning and actions taken in response to this 
Regulation  28  Notice  will  also  be  monitored  via  the  Safer  Care  Group.  The  Safer  care 
Group feeds into the Patient safety Board and ultimately into the Trust Service, Quality, 
Assurance and Governance Group. 

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 The requirement of when and how complete a falls risk assessment is clearly described 
in the Trust’s Slips, and Falls Policy, which is accessible to all staff in the Trust (attached 
for your information). There has been a focused piece of work undertaken on the Acute 
Medical  Unit  in  relation  to  falls  risk  assessment  and  the  accuracy  of  this.  During  the 
inquest  of  Mr  Southwick,  the  falls  proforma  was  not  completed  in  line  with  Trust  policy 
following a fall. This proforma has been recirculated within the Acute Medical Unit team 
with  emphasis on  the  importance  of  the  accuracy  of  this  document.  As  such  a  monthly 
audit has been implemented and is completed by the ward link nurse for falls. 
This focused piece of work has been discussed at a number of forums including: 

  The  Patient  and  Staff  Quality  and  Safety  Forum  (PASQAF)  and  Confidential 
Enquiry  into  Peri-Operative  Deaths  (CEPOD)  which  occur  bi-monthly.  PASQAF 
CEPOD  are  multidisciplinary  meetings  and  allow  for  continuous  oversight  and 
learning to be shared across the Trust. 

  Safer Care Group –The Safer Care Group was created to lead the development, 
implementation  and  monitoring  of  work  within  the  Safer  Care  portfolio  which 
includes falls. The Group is chaired by one of the trusts Deputy Chief Nurses and 
the  patient  safety  clinical  lead.  This  group  reports  into  Service  Quality  and 
Governance  (SQAG)  via  the  Patient  Safety  Programme  Board.  The  group 
monitors performance, training and audit in relation to harm prevention across the 
Integrated  Care  Foundation  Trust.  It  measures  compliance  against  key  targets 
taking responsibility for identification of  gaps and develops improvement plans to 
address and action these. Oversight of divisional work is monitored via this group, 
with key update reports including a summary of training compliance, audit results, 
action  plan  updates,  learning  from  incidents  and  any  quality  improvement  work 
being delivered. 

The purpose of these forums is to initiate discussion, shared learning and improvement in 
regards to learning and reflective practices in the future. 

The Trust also has a Quality Assurance  Round, this  is an audit  which  is undertaken by 
each ward manager on a monthly basis. Amongst the metrics reviewed and monitored is 
that  of  falls  risk  assessments  in  line  with  Trust  Policy.  Each  audit  requires  the  ward 
manager to review a minimum of three sets of notes to identify that the risk assessments 
have  been  completed;  on  admission  and  every  seven  days  thereafter.  The  audit  also 
includes  three  sets  of  notes  to  be  reviewed  to  ensure  that  patients  have  individualised 
falls care plans if required. 

To  share  the  learning  further  the  Trust  has  introduced  a  separate  Standard  Operating 
Procedure  (SOP)  to  ensure  a  consistent  approach  to  care  following  an  inpatient  fall.  I 
have  attached  the  checklist  and  SOP  for  your  information.  The  process  will  have  daily 
oversight  at  the  Trust  Safety  Huddle  and  will  be  overseen  by  the  Divisional  Heads  of 
Nursing. 

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 The  Trust  have  reviewed  the  Falls  prevention  policy  and  have  identified  further 
improvement to the policy which will now include the assessment of the patient to include 
changes from their ‘baseline’ mobility, this will facilitate a holistic patient and relative/carer 
approach to assessing mobility and any acute changes. 

To provide additional oversight and learning of falls incidents the Trust now also operate 
a scrutiny process which comprises of the following: 

 

Incident  Review  Group  (IRG)  which  is  held  twice  a  week  and  reviews  incidents 
recorded across the Trust and provides a consistent approach to the investigation and 
grading  of  similar  incidents.  IRG  supports  the  provision  of  72-hour  reviews  for 
potential serious incidents ensuring that the appropriate level of investigation is being 
undertaken  and  the  appropriate  recording  of  harm  is  being  undertaken.  IRG  reports 
into  the Serious  Incident  Review Group,  which  has  Executive  attendance. The focus 
of  IRG  is  immediate  sharing  of  learning  and  also  to  identify  any  immediate  risks  or 
celebration of good practice. 

  Serious Incident Review Group (SIRG). The Serious Incident Review Group is held on 
a  weekly  basis  and  supports  robust  governance  systems  relating  to  the  declaration, 
investigation, completion and learning from serious incident investigations declared in 
line  with  the  Serious  Incident  Framework  (2015).  SIRG  has  replaced  the  current 
Executive  Scrutiny  Panel  and  reports  into  the  Service,  Quality  Assurance  and 
Governance Group (SQAG). SIRG has Executive oversight and receives and reviews 
all  incidents  where  a  patient(s)  is  suspected  to  have  come  to  significant  harm,  or 
where a never event is suspected; determine the agreed level/ type of investigation to 
be  completed  and  where  relevant,  to  agree external  reporting  to  commissioning and 
regulatory bodies. SIRG is a multi-disciplinary meeting chaired by the Executive Chief 
Nurse and Executive Medical Director and ensures that there has been a holistic MDT 
approach  to  managing  the  incident,  in  relation  to  falls  this  can  include  physical  and 
acute  medical  presentation  of  the  patient,  Medication  and  pharmaceutical  review, 
nutritional status and mental health capacity  of the patient triangulating this with the 
details of the incident. 

  Safer  Care  Assurance  Panel  has  been  created  to  review  falls  and  pressures  ulcer 
incidents, which caused moderate harm. Chaired by a Deputy Director of  Nursing or 
Head of  Nursing, this forum reviews Root Causes Analyses (RCAs) to identify areas 
of good practice and any missed opportunities or lapses in care to ensure learning can 
be gained and future harms prevented. 

The above scrutiny process ensures the Trust to have oversight of incidents, particularly 
those relating to falls, on a regular basis where learning can be shared. This also feeds 
into the Trust Wide Learning Forum  which has  been  created to share  learning from the 
panel  and  deliver  education  to  prevent  future  harm(s)  occurring.  All  Heads  of  Nursing, 
Matrons and Ward Managers are invited to attend. Areas focussed on to date in relation 
to falls prevention include: 

  The importance of recording lying and standing blood pressure (BP) in preventing 

falls 

  Medicines and the risk of falls 
  PJ Paralysis and why it is important for patients to keep mobile to prevent falls 

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 The Trust are continually improving the falls prevention work. The Trust held a ‘Focus on 
Falls  Week’  in  September  2022  and  this  is  now  an  annual  event.  The  Trust  strive  to 
improve  the  experience  and  outcomes  for  patients  by  avoidance,  where  possible,  of 
patients falling and/or reducing the number of falls occurring whilst in our care. 

I  hope  this  response  has  provided  assurance  that  the  Trust  has  taken  your  comments 
and  concerns  seriously  and  action  taken  to  minimise  the  risk  of  such  event  occurring 
again.  Should  you  require  any further information, please do not  hesitate to contact me 
through the Legal Services Team on 

Yours sincerely, 

Chief Executive 

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