Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Ho
NHS / Health Body
Action Taken
The Trust is granting access to the Acute Trust's Electronic Patient Record ('Sunrise') for triage staff in Neighbourhood Teams and has developed a handover form detailing wound care advice to be sent home with patients. (AI summary)
View full response
Dear Sir,
Re Inquest touching the death of Katrina Insleay
In a Regulation 28 Order dated 13th February 2025, HMAC Puzey raised the following concerns:
(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient's pressure sores when they are discharged from hospital and for follow up to be delayed. This increases the risk of wound infection and consequent sepsis. (2) I am informed (letter received from HWHCT on 31.1.25} that there are established handover procedures and that a statement of practice is being drafted to "formalise" the referral requirements between hospital and NT. l am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
The Trusts have already provided a response to the Coroner’s initial letter of concern, and therefore will focus on further developments since then in this response.
Response to concerns
The Trusts have further considered the impact of not having a shared records system, and the Health and Care Trust are in the process of obtaining access for 2 members of staff per Neighbourhood team (including Evening and Nights community nursing team) to the Acute Trusts Electronic Patient Record – ‘Sunrise’. The access will be given to staff who sit within Triage hubs in the Neighbourhood Teams and triage new referrals. This will enable them to gain detailed patient information, for example, regarding wounds.
Acting Chief Executive Worcester Acute Hospitals NHS Trust Executive Suite Sky Level 3 Charles Hastings Way Worcester WR5 1DD
Tel:
Email: Chief Executives Office 2 Kings Court Charles Hastings Way Worcester WR5 1JR
Tel: 01905 681667 Email:
So far, 18 out of the 26 people identified as needing access, have been granted access but are not yet in full operational use. Once all access has been obtained as planned, this will be reviewed quickly to establish whether more licenses are required.
In addition, the Acute Trust have developed a handover form (copy attached), which will detail wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue Viability records. This will be sent home with the patient and therefore will be available for them to share with professionals who attend their home, as an additional source of information alongside the Electronic Patient Record system.
These steps are in addition to the measures already outlined in the Trusts earlier letter.
I confirm that I have not forwarded a copy of this response to any other Interested Person and would therefore be grateful if you could do so, as appropriate.
I also confirm that the Trusts are content for both the regulation 28 report and the response to be released or published should the Chief Coroner wish.
Re Inquest touching the death of Katrina Insleay
In a Regulation 28 Order dated 13th February 2025, HMAC Puzey raised the following concerns:
(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient's pressure sores when they are discharged from hospital and for follow up to be delayed. This increases the risk of wound infection and consequent sepsis. (2) I am informed (letter received from HWHCT on 31.1.25} that there are established handover procedures and that a statement of practice is being drafted to "formalise" the referral requirements between hospital and NT. l am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
The Trusts have already provided a response to the Coroner’s initial letter of concern, and therefore will focus on further developments since then in this response.
Response to concerns
The Trusts have further considered the impact of not having a shared records system, and the Health and Care Trust are in the process of obtaining access for 2 members of staff per Neighbourhood team (including Evening and Nights community nursing team) to the Acute Trusts Electronic Patient Record – ‘Sunrise’. The access will be given to staff who sit within Triage hubs in the Neighbourhood Teams and triage new referrals. This will enable them to gain detailed patient information, for example, regarding wounds.
Acting Chief Executive Worcester Acute Hospitals NHS Trust Executive Suite Sky Level 3 Charles Hastings Way Worcester WR5 1DD
Tel:
Email: Chief Executives Office 2 Kings Court Charles Hastings Way Worcester WR5 1JR
Tel: 01905 681667 Email:
So far, 18 out of the 26 people identified as needing access, have been granted access but are not yet in full operational use. Once all access has been obtained as planned, this will be reviewed quickly to establish whether more licenses are required.
In addition, the Acute Trust have developed a handover form (copy attached), which will detail wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue Viability records. This will be sent home with the patient and therefore will be available for them to share with professionals who attend their home, as an additional source of information alongside the Electronic Patient Record system.
These steps are in addition to the measures already outlined in the Trusts earlier letter.
I confirm that I have not forwarded a copy of this response to any other Interested Person and would therefore be grateful if you could do so, as appropriate.
I also confirm that the Trusts are content for both the regulation 28 report and the response to be released or published should the Chief Coroner wish.