Black Country Healthcare NHS Foundation
NHS / Health Body
Action Taken
The Trust uses an Electronic Observation system (eObs) with colour-coded prompts to highlight overdue observations and requires staff to record the rationale for any overdue observation. They are introducing dynamic push notifications to highlight missed or abnormal observations. (AI summary)
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Dear Sir, Firstly, on behalf of Black Country Healthcare NHS Foundation Trust may I extend our most sincere condolences to the family of Ms Jordan. During the inquest the evidence revealed matters giving rise to concerns in such a way that there is a risk that future deaths will occur unless action is taken. In response to your regulation 28 report to prevent future deaths we have outlined below the actions Black Country Healthcare has taken to address the matters of concern that affected our organisation. The matters of concern are as follows;
1. During the course of the inquest, I heard evidence that Ms Shannon Lee Jordan was under observations to be performed at 15-minute intervals.
2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.
We have enclosed alongside this letter, evidence shared with the court prior to the inquest which outlines that Level 2 intermittent observations must be completed within 15 minutes. This is unambiguous within our policies, training materials and resources on our Trust intranet and we can provide you with assurance that there is no reference to 30 minutes in regards to intermittent observations.
In terms of functionality the Electronic Observation (eObs) system will alert the member of staff responsible for observations by clearly highlighting the patient details on the tablet in red and moving them to the top of the list.
eObs uses integrated colour-coded prompts within the ward summary views to ensure that staff are continuously informed of patients’ observation requirements in real time and supports task prioritisation at-a-glance, when actively logged into the application. The colour-coded status indicators are;
• None Recorded (Purple)
• Due (Amber)
• Overdue (Red) This functionality acts as an immediate visual cue, reducing the risk of missed or delayed observations. Where an observation is overdue, a narrative box is completed by the member of staff completing the observation to record the rationale. Screenshots of this functionality are below.
As a Trust we are always seeking to use technology to improve clinical standards and patient safety, future improvements we are making to the eObs system will see real-time visibility for nurses in charge and management teams, supporting proactive oversight. Further, we are introducing dynamic push notifications to highlight missed or abnormal observations, prompting timely escalation in line with policy requirements.
In addition, you wrote that; There is no national standard, and each Trust can implement its own time interval for observation checks to be completed. The Chief Nuse for Black Country Healthcare has liaised with NHS England in relation to your request as Trust polices are aligned with national guidance. I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 report very seriously and will continue to take action to reduce the likelihood of a similar incident from reoccurring. We hope that these embedded systems provide the court with appropriate assurance.
1. During the course of the inquest, I heard evidence that Ms Shannon Lee Jordan was under observations to be performed at 15-minute intervals.
2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.
We have enclosed alongside this letter, evidence shared with the court prior to the inquest which outlines that Level 2 intermittent observations must be completed within 15 minutes. This is unambiguous within our policies, training materials and resources on our Trust intranet and we can provide you with assurance that there is no reference to 30 minutes in regards to intermittent observations.
In terms of functionality the Electronic Observation (eObs) system will alert the member of staff responsible for observations by clearly highlighting the patient details on the tablet in red and moving them to the top of the list.
eObs uses integrated colour-coded prompts within the ward summary views to ensure that staff are continuously informed of patients’ observation requirements in real time and supports task prioritisation at-a-glance, when actively logged into the application. The colour-coded status indicators are;
• None Recorded (Purple)
• Due (Amber)
• Overdue (Red) This functionality acts as an immediate visual cue, reducing the risk of missed or delayed observations. Where an observation is overdue, a narrative box is completed by the member of staff completing the observation to record the rationale. Screenshots of this functionality are below.
As a Trust we are always seeking to use technology to improve clinical standards and patient safety, future improvements we are making to the eObs system will see real-time visibility for nurses in charge and management teams, supporting proactive oversight. Further, we are introducing dynamic push notifications to highlight missed or abnormal observations, prompting timely escalation in line with policy requirements.
In addition, you wrote that; There is no national standard, and each Trust can implement its own time interval for observation checks to be completed. The Chief Nuse for Black Country Healthcare has liaised with NHS England in relation to your request as Trust polices are aligned with national guidance. I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 report very seriously and will continue to take action to reduce the likelihood of a similar incident from reoccurring. We hope that these embedded systems provide the court with appropriate assurance.