Maria de Ceita

SENT VIA EMAIL TO 

HM Area Coroner Mr Tony Murphy  
North London Coroner’s Court  
29 Wood Street  
Barnet  
EN5 4BE 

Legal Services Department 
Sterling Way  
London 
N18 1QX 

Email 

Tel: 

Dear Sir, 

Date: 

25 September 2024 

Re: Inquest touching the death of the late Maria De Ceita  

We write following the inquest touching the death of the late Maria  de Ceita which was heard at 
North  London  Coroner’s  Court  on  16  February  2024.  At  the  conclusion  of  the  hearing,  you 
indicated  that  you  intended  to  issue  a  Prevention  of  Future  Deaths  (PFD)  report  to the  Trust  in 
relation  to  the  concern  you  raised  regarding  documentation  of  falls  risk  assessments.  The  PFD 
report was subsequently issued on 31 July 2024, stating the matter of concern to be “the lack of 
an  effective  system  to  document  and  address  the  risk  of  elderly  patients  falling  while  in  the 
hospital”.  

We set out the steps taken by the Trust below in response to this concern.  

Improving Consistency in Documentation of Falls Risk Assessments and Communication  

On 21 February 2024, the Trust held a meeting between the following senior members of staff: 

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, Chief Nurse  
 - Divisional Director of Nursing, AHP & Quality for Medicine and Urgent Care 

 - Divisional Director of Nursing, AHP and Quality for Community  

  -  Divisional  Clinical  Director  and  Divisional  Director  of  Nursing,  AHP  and 

Quality for Surgery, Anaesthetics, Critical Care and Associated Services  

The Chief Nurse is part of the Trust’s Executive Team and is the senior executive responsible for 
nursing  and  allied  health  care  professionals  and  the  senior  responsible  officer  for  quality 
governance.  The  Divisional  Nursing  Directors  are  responsible  for  the  quality,  workforce,  and 
fundamentals of care at a divisional level.  

At  this  meeting,  and  because  of  the  concern  raised  at  the  inquest,  a  plan  was  discussed 
regarding documentation of falls risk assessments and the communication of the same amongst 
clinicians;  particularly  when  patient  needs  change,  or  when  the  care/risk  dynamics  of  a  ward 
change during the shift. For example, if there is more than one patient on the ward who is at risk 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of  falling,  or  when  a  new  patient  with  complex  needs  is  admitted  during  a  shift  and  requires 
nursing resources to be reallocated/reassessed to incorporate the needs of an additional patient 
with complex needs. The plan, as discussed at the meeting, is set out below.  

1.  Documentation of Falls Risk Assessments and monitoring 

a.  A  baseline  audit  in  June  and  again  in  August,  documented  that  the  majority  of 
patients  received  an  inpatient  falls  risk  assessment  on  admission.  To  ensure  full 
compliance with completing and updating the falls risk assessments, and for better 
oversight  of  any  gaps,  the  initiatives  described  below  have  been  developed  and 
rolled out across the Trust.  

b.  The digital team and our Chief Nursing Information Officer (CNIO) have developed 
a  ward  dashboard  of  digital  assessments  within  Careflow  (part  of  our  electronic 
clinical  patient  system)  where  ward  leaders  can  view  any  outstanding  risk 
assessments, providing an opportunity to ensure they are completed/updated in a 
timely manner. This innovative measure offers us a great opportunity to ensure risk 
assessments can be overseen and monitored across the entire trust.  

c.  The  risk  assessments  are  digitally  monitored  by  ward  managers  and  matrons  in 

real time each shift and the information is refreshed every 24 hours.  

d.  For  individual  patients  that  have  experienced  a  fall,  their  risk  assessment  will  be 

updated accordingly. 

e.  Monthly  falls  summaries  record  the  overall  audit  of  falls  risk  assessments 
completed  (pre  and  post  fall),  providing  assurance  that  risk  assessments  have 
been completed. 

f.  The  monitoring  and  assurance  of  the  Trust’s  falls  profile  is  monitored  through 
divisional governance meetings, the Trust wide fundamentals of care meeting and 
the  Trust  quality  committees.  In  addition,  the  overarching  assurance  around  the 
management of falls prevention access is reported to trust board via the integrated 
performance report.  

2.  Communicating changes on wards which impact risk  

a.  A ‘dynamic risk’ assessment has also been developed and has now been fully 
implemented across all ward areas. This document includes a combination of 
detail from ward-based safety huddles, daily staffing allocations and acuity 
assessments. It is used to assess the shift-by-shift ward risk profile and includes a 
number of key risk factors including the number of patients receiving enhanced 
care e.g. those at high risk of falls and the number of staff on duty.  

b.  The risk assessment documents the team member allocated to support any 
patient/s receiving enhanced care and also documents an allocation of an 
appropriate alternative team member should additional cover be required, or to 
take over to cover the breaks etc.  

c.  Ward managers review the risk assessment a minimum of three times during their 
shift and record any changes. It is also an opportunity for staff to highlight any 
safety matters that need to be escalated/actioned.  

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 d.  The effectiveness of the dynamic risk assessment is being monitored through local 
audit and the need for consistent compliance with its use has been included as 
part of the essential criteria for achieving the appropriate level of assurance via our 
ward accreditation programme. The ward accreditation programme is a process 
through which each ward’s compliance with key quality and safety indicators are 
reviewed by a multi-professional team. The risk assessment process is now a core 
component of assessment during this accreditation process and compliance with 
its completion is an essential component of accreditation for each ward.   

Clinical judgement training  

A programme of tabletop training has also been rolled out via the education team and the Trust 
falls  lead.  This  training  focusses  on  scenario-based  opportunities  to  exercise  clinical  judgement 
and  reasoning  regarding  acuity,  dependency,  and  effective  staff  allocation  during  a  shift. 
Scenarios represent varying acuity levels and changes to the dynamics of the ward during a shift, 
to reflect real-life challenges and to develop a consistent approach in responding to such risks as 
they  arise.  This  training  has  proved  to  be  popular  and  successful  in  supporting  staff  to  make 
decisions  based  on  real-life  scenarios  in  the  classroom,  which  are  directly  transferrable  to  the 
ward environment. Past and future training attendance is monitored via the Trust Phoenix training 
platform and we intend to maintain this training for all new staff.  

Enhanced care register and review of guidelines   

The  Trust  has  revised  its  enhanced  care  guidelines  and  their  application  to  patients  with 
enhanced  care  needs  e.g.  risk  of  falls  and  sets  the  North  Middlesex  University  Hospital  NHS 
Trust’s standards for providing appropriate staffing for patients requiring enhanced care following 
a detailed clinical assessment.  

The  enhanced  care  guidelines  reinforce  the  critical  need  for  assessment  to  identify  the  clinical 
need for enhanced care, the level of enhanced care required. For example, a Registered Nurse 
(RN) may be required for enhanced physical care and a Registered Mental Health Nurse (RMN) 
may  be  required  for  patients  with  enhanced  mental  health  needs.  The  guidelines  require  a 
comprehensive prescription and plan of care which is recorded into the patient’s care records with 
daily reassessment of those needs.  

The Nurse in Charge of the ward ensures all patients have an up-to-date risk assessment, plan of 
care and decision using the enhanced care assessment and in line with safer staffing levels and 
this is reported to the Matron daily.  

The Matron is responsible for reviewing safe staffing levels and decisions made by the  nurse in 
charge  in  line  with  the  enhanced  care  assessments,  making  any  changes  and  recording  why 
these changes were made and notifies the Associate Director of Nursing daily.  

The  Senior  Nurse  of  the  Day  (Matron)  is  responsible  for  ensuring  safe  staffing  levels  across  all 
adult and children inpatient areas taking into consideration the enhanced care  requirements and 
decisions made by the Nurse in Charge and Matron responsible for the individual wards. This role 
is supported by the Associate Director of Nursing identified on a daily basis who leads the twice 
daily safe staffing reviews for the Trust. Out of hours, the Senior Nurse of the Day responsibility is 
taken over the by Clinical Site Manager and Matron. 

  
 
 
  
 
 
 
 
 
 
 
 
 
 The  guidelines  also  describe  the  specific  roles  and  responsibilities  within  the  nursing  structure, 
with daily senior oversight being provided by the Associate Directors of Nursing on a daily basis 
and weekly oversight and scrutiny by the Divisional Directors of Nursing.  

The  Trust  has  also  implemented  an  enhanced  care  register  to  ensure  visibility  of  all  patients 
across  the  organisation  receiving  enhanced  care  and  allows  senior  oversight,  scrutiny  and 
challenge and ensures the timely review of patients.  

These changes have been cascaded across the organisation through the Divisional Directors of 
Nursing to all Ward Managers, Matrons and Associate Directors of Nursing and forms part of the 
daily management of patients in the effective clinical assessment of complex needs, the planning 
and  implementation  of  those  needs  and  the  recording  and  communication  of  the  clinical  plan 
across all staff to ensure there is an effective system to address the risk to patients at risk of falls 
and other complex care needs.  

If you require any further information in respect of the Trust’s actions and ongoing work following 
this inquest, please do not hesitate to contact us.  

Yours faithfully, 

Chief Nurse 

Medical Director