Norma Bruton

STRICTLY PRIVATE AND CONFIDENTIAL 
ADDRESSEE ONLY 

13th July 2023 

For the attention of Vanessa McKinlay 
Assistant Coroner for Birmingham and Solihull 
Birmingham Coroner’s Court 
Steelhouse Lane 
Birmingham 

Dear Ms McKinlay 

Inquest touching the death of Norma Winifred Bruton 
Response to Regulation 28 Report to prevent future deaths 

I write in response to the Regulation 28 Report made by you following the Inquest touching the 
death of Mrs Bruton which concluded on 18 May 2023. 

University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the 
concerns raised within your report to prevent future deaths, which relate to the falls risk assessment 
documents in particular prompts in relation to patients who may have chest drains or intravenous 
fusions in place. 

Falls risk assessment 
I note that during the Inquest you heard evidence that the falls risk assessment did not include a 
prompt for staff to assess the impact of any equipment that they may require, such as in Mrs 
Bruton’s case, a chest drain, and whilst it was included within the manual handling assessment, the 
information was not automatically fed into the falls risk assessment. 

To provide some background all patients admitted to UHB must be screened for their risk of falls.  
This includes a multifactorial risk assessment which identifies the patient’s individual risk factors for 
falling in hospital which can then be treated, managed or improved during their admission.  These 
can include cognitive impairment, continence needs, falls history, unsuitable footwear, 
comorbidities or medication that may increase risk of falling, postural instability or mobility/balance 
problems and vision impairment.  Combined with the falls risk assessment is a manual handling 
assessment that nursing staff are required to complete at the same time as the falls risk assessment. 
The manual handling form stipulates how a patient should mobilise in light of their falls risk factors. 
So the two, in practice, are considered alongside each other. The manual handling form is more 
detailed in regards to how patients can/should mobilise,  and there is a question as to whether the 
patient, when walking, requires assistance with drips or attachments and this is to be taken into 
consideration when completing the assessment.  In Mrs Bruton’s case she was assessed on 14 
October 2022 as not being at risk of falls and her manual handling assessment noted her to be 
independent.  The question around requiring assistance with drips or attachments when mobilising 
had not however been completed.  

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 The information recorded in the manual handling assessment has not been designed to 
automatically feed into the falls risk assessment as this was considered to be a duplication of 
information in the patient record.  The recommendation is that these assessments are looked at in 
combination not isolation.  

Our electronic records system (PICS) incorporates multiple assessments/records that when looked at 
in combination provides detailed guidance / overview of a patient’s status in regards to falls and 
mobility risk. Staff should therefore always refer to, and consider the following in combination; the 
falls risk assessment, the manual handling assessment (that provides a more detailed account of 
what mobility needs the patient has, such as attachments that may limit a person’s mobility, 
whether any specific mobility aids are required, and what level of supervision from staff is needed);  
also the Daily Care Plan, which details whether bed rails are required, any additional needs a person 
may have, and also demonstrates what their current needs are during that particular shift.  

Updates to falls risk assessment document 

We have considered the concerns you have raised within your report to prevent future deaths and 
we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow 
staff to select an appropriate option if a patient has any equipment, such as drains, in place.  This will 
then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will 
be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.   

There is a lead in time for the changes to be made to our PICS system, and we can confirm that this 
change is expected to take place on the 15th August 2023.  In the meantime whilst waiting for the 
programming work to be completed, the Lead Nurse for Falls Prevention has attended and 
highlighted at Divisional Preventing Harm Groups, which are attended by  ward managers, Matrons 
and Deputy Directors of Nursing, the importance of ensuring that attachments are recorded and 
considered as part of a person’s manual handling needs. This has also been discussed at the 
Operational Care Quality Group chaired by the Director of Nursing Quality, Safety and Innovation, 
and attended by all of the Divisional Deputy Directors of Nursing and Nursing Leads for patient harm 
groups.  We have also updated our Trust Inpatient Falls Procedure so that this is further emphasised. 

Based on the review of our falls risk assessment and the updates we are making to PICS, we are 
confident that the systems and processes that we have in place are sufficient to minimise and 
manage the risk of falls of our patients.   

I would like to assure you that the concerns raised within the Regulation 28 Report have been taken 
extremely seriously which I hope is demonstrated by our response above.  

Yours sincerely 

Chief Nurse 

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