Robert Taylor

Executive Office of the Chair & Chief Executive 
Chair 
Chief Executive 
Executive Office  

: 
: 
: 

16th December 2024  

Mrs Louise Hunt  
HM Senior Coroner for Birmingham and Solihull  

By way of email only: 

Dear Mrs Hunt  

Inquest touching the death of Mr Robert Taylor 
Response to Regulation 28 Report to prevent future deaths 

I  am  writing  in response  to the  Regulation 28  notice issued following  the  conclusion  of the 
inquest  on  21  October  2024,  into the  death  of  Mr  Robert  Taylor  at  Birmingham  Heartlands 
Hospital.   

We have carefully considered the concerns raised within your report to prevent future deaths 
and our response is set out below. 

1.The  central  issue  in  this  case  relating  to  the  fall  on  11/06/24  was  the  lack  of  enhanced 
nursing observations. The Nursing witness was unable to say what steps, if any, had been 
taken  to  try  to  put  enhanced  observations  in  place.  The  Investigation  report  stated  that 
enhanced observations had been  identified  as needed but  did not  expand on  what  actions 
were taken, if any, to obtain enhanced observation nor what actions had been taken after the 
death to ensure enhanced observations for patients that require them. This raises a concern 
for future deaths.  

Within the original learning response (After Action Review) it was identified that the fall in this 
case  was  multifactorial and  advised  that staff  were  unable  to  provide  enhanced  care to  Mr 
Taylor within the ‘what could have gone better’ section.  There were several factors identified 

within the learning response that contributed to the difficulty in being able to provide enhanced 
care.   Staffing levels in relation to the challenging geography of this ward, including the large 
number  of  side  rooms,  was  a  contributory  factor  in  the  lack  of  ability  to  provide  enhanced 
care.  This ward, not accustomed to conventionally receiving a high level of patients requiring 
enhanced care, did receive a substantial number of patients needing enhanced care at the 
time, making it even more difficult for this need to be met within the staffing model which did 
not consider the unique geography.  The creation of a group to review pathways and allocation 
of patients across acute medicine, as in the action plan,  will improve the ability to meet the 
need for any given acute medicine ward to provide enhanced care.   Whilst the original learning 
response does include  actions  to  address these points  it  is  accepted that  witnesses at the 
inquest should have been able to explain these points and what had already been put in place. 

 
 
 
 
 
 
 
 
 
  
       
  
  
 
 
 
 
 
 There  will  be  a  nursing workforce  review  to  cover the  points  above.  It  is  accepted  that  this 
point should have been more explicit within the report and details of the actions set out below 
should have been included. 

By way of assurance on actions to address the concerns raised around enhanced care as set 
out in the action plan in the learning response, the following progress has been made to date: 

•  The  Enhanced  Care  policy  has  been  re-embedded  into  the  ward  and  risks  are 

discussed in the ward huddle following shift handovers.  

•  Acuity was noted to be a contributing factor within this case. There is currently a SNCT 
(Safer Nursing Care Tool) to review of acuity levels as part of the wider Trust review 
of acuity and dependency. Whilst this work progresses increased staffing needs will 
be identified on a case-by-case basis as per the UHB enhanced care policy. Staff will 
be requested through UHB clinical bank services in a timely manner and explored on 
a shift-by-shift basis. 

•  The nurse in charge currently identifies and discusses patients at risk of falls, as well 
as  those  requiring  enhanced  observations,  with  the  Matron,  prior  to  the  0800-
touchpoint meeting. Since the inquest we have made changes in how this information 
is communicated. There is a more risk focused approach being taken and a focus on 
vulnerable  patients  in  higher  risk  environments.  If  a  ward  area  is  unable  to  provide 
assurance that a risk is being mitigated, then additional safety measures to ameliorate 
the risk are put into place.   Examples include: 

o  Discussion in the morning safety huddle regarding risk of falls and patients for 

whom there is concern. 

o  Reorganisation of workload to mitigate and reduce risk 
o  Movement  of  patients  into  more  appropriately  positioned  side  rooms  where 

o 

possible. 
Intermittent  checks  completed  on  patients  within  the  side  room  with 
documentation, including: 

▪  Ensuring that beds are placed in the lowest position possible 
▪  Nursing call bells within reach 
▪  Anti slip socks for mobile patients  
▪  Walking aids within reach 

•  We  have  recognised  that  the  current  layout  of  ward  19  can  be  challenging  when 
nursing patients who are at risk of falls because of having only two 6 bedded bays and 
13 side rooms positioned in a T shape within the ward. In addition, only 4 side rooms 
have partial views (if the door is open), the other 9 have no visibility. 
We  have  spoken  to  the  senior  nursing  team  in  charge  of  the  assessment  area 
regarding environmental challenges and provided a visual map of side rooms, so they 
are aware of the physical layout of the ward. We have asked the assessment areas 
when  allocating  patients  to  be  mindful  of  ward  geography  and  communicate  any 
concerns and risks that patients have such that plans can be put in place to support 
enhanced care and risk of falls. 

In the longer term, a wider piece of work is being planned for January 2025 to review 
side room utilisation. This will allow us to place the right patients into appropriate side 
rooms with a commensurate reduced risk of falls. 

•  Following the death of Mr Taylor the department is currently delivering falls training, 
which is provided by the Falls team and has been attended by qualified nurses and 
health care support workers. To date 42.5% of ward staff have completed training with 
a further  40%  of  staff  booked  on to the  training  for  December  2024.  The remaining 
staff will complete training by the end of January 2025. 

 
 
 
 
 •  Ward monitoring of lying and standing blood pressure has met the trust standards of 
75%. On-going monitoring will continue to monitor compliance and safety huddles are 
reminding staff to review patient’s lying and standing blood pressure on admission or 
review this when clinically indicated.  
In  addition,  we  are  completing  a trial  of  alarmed  falls  beds  and  exploring  long  term 
solutions with falls seats and bed alarm pads. 

• 

•  Verbal feedback following the outcome of the original AAR (After Action Review) was 
given  to  staff  in  relation  to  completing  falls  risk  assessments  on  admission  and 
reviewing the risk of any changes in clinical condition. This is also discussed during 
the morning safety huddles with staff.  A review of compliance has been undertaken 
and shows significant improvement in the completion of falls risk assessments within 
the 6 hours target and the ward are currently exceeding the Trust current compliance 
of 83.2% at 87.4%. Ward 19 have shown a sustained improvement month on month 
with  July  being  68.6%  and  November  at  87.4%,  giving  an  18.8%  improvement. 
Ongoing  monitoring  of  compliance  with  this  standard  is  taking  place  to  ensure 
continuous improvement is sustained. 

2. The witnesses and the investigation report did not address the central issue relating to the 
fall and this raises a concern about the quality of post death investigations being undertaken 
by the Trust. This raises a concern for future deaths.  

As part of a drive to improve patient safety within the NHS, all Trusts have adopted the NHSE 
Patient Safety Incident Response Framework and within that framework learning responses 
[investigations] are to apply a systems-based approach to identify any learning.   

It has been identified that a nursing witness was identified shortly before the inquest.  This 
resulted in the nursing witness attending without having the opportunity to submit a witness 
statement which would have otherwise supported them with answering questions. This has 
been  acknowledged  as  an  oversight  on  behalf  of  the  Trust  on  this  occasion,  as  our  usual 
practice is to identify witnesses earlier on in the process to ensure that they have adequate 
time to prepare for an Inquest.   

Since the inquest the Lead Nurse for falls has worked with the legal service team to revise the 
templates  used  for  the  nursing  witness  statement  to  ensure  that  witnesses  are  capturing 
essential information in relation to a fall to assist the Coroner at Inquest. The template provides 
additional prompts to enable the witness to write a logical account of the  incident, including 
the patients care leading up to the fall, how the fall occurred, and post fall care, including any 
learning identified.  

In addition, our Legal Services Team will ensure that specialist nurse leads for the Trust, for 
example  those  involved  in  Falls  and  Tissue  Viability,  will  be  involved  from  the  start  of  a 
Coronial investigation or inquest process to ensure they have full awareness of issues and 
can contribute to an investigation from a highly experienced professional standpoint. 

Regarding witnesses summonsed to attend inquests, the Legal Services Team are ensuring 
that  our  staff  are  fully  prepared  to  attend  an  inquest  by  arranging  individual  and  group 
meetings and telephone calls with witnesses and their managers together with meetings with 
our instructed solicitors to ensure that staff are supported and are as prepared as fully as they 
can be to give evidence at the inquest.  In addition, a series of training for ward managers and 
nursing staff is being rolled out commencing early next year across all our hospital sites.   

 
 
  
 
 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 in the steps that have been taken 
following Mr Taylor’s death.   

Yours sincerely   

Chief Executive