Carol Clements

25 July 2023 

Private & Confidential 
Assistant Coroner Rebecca Ollivere 
Birmingham & Solihull Coroners Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

Chief Executive Officer 
Trust Headquarters 
3 Priestley Wharf 
Holt Street 
Birmingham Science Park 
Aston 
Birmingham 
B7 4BN 

Dear Ms Ollivere 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
INQUEST: CAROL ANN CLEMENTS (DECEASED) 

www.bhamcommunity.nhs.uk 

Thank you for your Regulation 28 Report to Prevent Future Deaths dated 30 May 2023. 
May I take this opportunity at the outset to express my condolences to the family of the late 
Carol Ann Clements. I was sorry to hear about the fall that was experienced by Mrs 
Clements in one of our in-patient facilities. 

Following receipt of the Regulation 28 Report, the Trust held a Round Table Meeting 
chaired by the Trust’s Chief of Nursing and Therapies to review the matters of concern you 
have raised. At the meeting, key stakeholders from both divisional and corporate services 
reflected deeply on the matters of concern, how these could be addressed, how improved 
care could be delivered across our inpatient services and how any potential barriers to this 
might be addressed.  

An in-depth action plan has been created around improvement to our falls assessment 
training, our enhanced supervision training, and how we audit falls risk assessments, led by 
the Divisional Director of Nursing and Therapies for the Adult & Specialist Rehabilitation 
(A&SR) Division. This will set out both the Trust wide and divisional actions required to 
address your concerns, along with agreed action owners and timescales for delivery. This 
action plan will be submitted to the Chief of Nursing and Therapies for approval by 25 July 
2023. 

 
 
 
 
 
                                              
                                                     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 Once approved, the delivery of the action plan will be monitored monthly via the Adults & 
Specialist Rehabilitation Inpatient Quality & Safety Committee and the Adults &Specialist 
Rehabilitation Divisional Quality & Safety Board, with any required escalations going to the 
Trust’s Quality & Safety Executive and the Trust-wide Falls Prevention Strategy Group 
chaired by the Trust’s Director of Therapies and Chief Allied Health Professional. 

In terms of the Matters of Concern: 

1.  “Enhanced Supervision Levels training is not included on mandatory training programmes. 

Whilst some training sessions have been delivered by the trust to current staff members 
following this incident, I am concerned that new staff members joining will not be suitably 
trained in this area.” 

Mandatory training is Trust-wide and covers general training required by all staff, whereas 
Essential to Role training is focused on the specific training required by each member of 
staff in the roles which they perform.  

The Adult & Specialist Rehabilitation Division, which covers Perry Trees Centre, already 
had  some  Enhanced  Supervision  training but  it  has  now  been  deemed  as  Essential  to 
Role and added to the Division’s Training Needs Analysis (TNA).  

The Division will hold an Essential to Role training week which will follow the new starter’s 
Induction week. The aim is for all new starters to complete the Essential to Role training 
week  within  2  months  of  commencing  in  post.  Falls  training,  including  Enhanced 
Supervision  training  will  be  incorporated  into  this  programme.  The  division  are  also 
undertaking a review of how we robustly oversee competency with all existing staff.  

2.  “Falls risk assessment training is on the essential role training programme, however, I am 
concerned that this area is not covered suitably on induction of staff to the [Perry Trees] 
centre. This leaves a gap, particularly with agency staff, and I am not satisfied that with 
the  current  processes,  agency  staff  will  be  fully  versed  on  the  completion  of  these  risk 
assessments.” 

The  division  have  developed  a  wider  Divisional  Falls  Action  Plan  and  will  place  the 
Essential  to  Role  falls  risk  assessment  training  onto  the  divisional  mandatory  training 
tracker to enable compliance monitoring.  

Each ward has a local induction checklist for temporary staff (bank and agency) who have 
not worked on the ward previously. The Lead Matron has reviewed the induction checklist 
to  ensure  that  essential  elements  of  Falls  Risk  Assessments  and  Falls  Prevention  are 
included. Auditing of this checklist will be the responsibility of each Matron and discussed 
as part of the Inpatients Quality Review meeting.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust will be working with National Health Service Professionals (NHSP) to provide a 
greater number of bank workers, which will reduce our dependency on agency workers. 
NHSP  have  agreed  to  have  discussions  regarding  what  Essential  to  Role  training  is 
required for these new bank staff. This gives BCHC the opportunity to add Falls Training, 
including  Falls  Risk  Assessment  training  and  Enhanced  Supervision  training  onto  their 
training plan.  

3.  “I was told that since this incident, falls risk assessments are being audited for compliance. 
I was also told that they are not being audited for correctness. I am therefore concerned 
that errors, and consequently, staff training needs, would not be picked up in these audits.” 

The completion of a falls risk assessment has been audited for compliance for some time 
as part of the Trust’s Essential Care Indicators (ECIs) audit. ECI’s take place monthly in 
the inpatient areas and are undertaken by the matron for each site. The discussion and 
learning from the round table has prompted additional measures to be introduced which 
will  ensure  that  the  assessment  accurately  reflects  the  risk  of  the  patient  falling  and 
interventions  required.  The  Matron  will  be  undertaking  spot  check  reviews  of  falls  risk 
assessments as part of the current care rounding. In addition, the division will develop a 
quarterly  falls  prevention  effectiveness  audit.  This  will  audit  correctness  of  falls  risk 
assessments  and  impact  of  care  plans.  The  findings  of  the  audits,  and  progress  with 
subsequent  actions,  will  be  shared and monitored  within  the  Inpatient  Quality &  Safety 
Committee.  

CONCLUSION 

The Trust has recently launched an Essential Care Framework which provides the guidance 
and the tools to enable clinical teams to self assess how well they meet what matters most 
to our patients and their relatives. This is being led by our Chief of Nursing and Therapies. 
The work being carried out to improve our falls risk assessments training and our enhanced 
supervision training will be incorporated into this framework. 

In addition, the Trust is embarking on a major change in our response to patient safety 
incidents, known as the Patient Safety Incident Response Framework (PSIRF). PSIRF is a 
significant shift in the NHS as to how we respond to all incidents, including serious 
incidents. This will require a cultural and operational change for all staff in the Trust, and the 
work arising out of this Prevention of Future Death Report also be reflected in how we 
shape our Patient Safety Incident Investigation (PSII) reports that will be replacing Root 
Cause Analyses. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 I trust this response provides the assurance you seek that the Trust shares your concern 
that future deaths in similar situations should be prevented, and indeed that the work now 
being carried out will reduce considerably any possibility of a similar outcome in future. 

Yours sincerely 

Chief Executive Officer 

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