Action Taken
The Trust outlines actions taken since January 2022, including the creation of NHS Humber Health Partnership and various groups sharing knowledge to improve patient safety. They have implemented a new NEWS2 escalation process, mandatory training, and a frailty pathway, and are actively participating in the Learning Disabilities Mortality Review programme. (AI summary)
View full response
Dear Mr Steele,
Re: Hull University Teaching Hospitals NHS Trust response to the Regulation 28 Report issued by His Majesty’s Assistant Coroner, Mr Edward Steele, dated, 23 December 2024
Thank you for sharing your report with us regarding the sad passing of Mr Lodge. Having considered your report carefully the Trust wish to provide a detailed update regarding the work carried out by the Trust since January 2022 which will hopefully alleviate any concerns you may have regarding the risk of future deaths. We take the matters raised in your report seriously and we hope this letter is helpful in outlining how we are committed to learning.
The Trust wish to express their sincere condolences to David’s family for their loss of not only David but his father Mr Peter Lodge.
In formulating this response, we have sought opinion from a number of professionals within the Trust.
Hull University Teaching Hospitals NHS Trust (HUTH) along with North Lincolnshire and Goole NHS FT (NLAG) have recently joined forces to create NHS Humber Health Partnership which has brought a wealth of expertise together to create structure and improvements to patient safety. The creation of NHS Humber Health Partnership has created more structure than ever before. Various groups from HUTH such as the Resuscitation, Deteriorating Patients and Sepsis Steering Group and the NLAG Resuscitation Committee have come together to share their knowledge and experiences and created a route of escalation to the
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
Quality and Safety Committee. NHS Humber Health Partnership follow the NHSE model of prevent, identify, escalate and respond.
Since the coming together of the two Trusts a number of key work streams have been created, some of which are addressed below, including education, Martha’s Rule, and patient engagement. NHS Humber Health Partnership believe that Patient engagement is vital. Feedback from patients and families is being obtained and the information gathered is being used to develop our improvement strategy which will feed in to our work around sepsis and deteriorating patients. The Partnership has seen the setup of the Patient Engagement Work stream which was a subsidiary group from the Resuscitation, Deteriorating Patient and Sepsis Steering Group.
In addition, the Dementia Volunteers have also been instrumental in helping to gather patient feedback and there is a plan in place for the volunteers to assist with gathering feedback from learning disability patients and their carers.
Caring for Patients with Learning Disabilities
1. A Mental Health, Learning Disabilities and Autism Steering Group was established in 2020 and held bi-monthly meetings chaired by the Assistant Chief Nurse. The group was made up of staff from all health groups, Training and Development, Patient Experience, Allied Health, Dementia Team, Mental Health Liaison Team, Learning Disabilities Liaison Nurse, Governance, Human Resources, Information Services and the Safeguarding Teams. The group reported to the Trust Patient Experience Sub Committee until the last meeting in July
2024. Governance arrangements have now changed within the new NHS Humber Health Partnership and there are now five Operational Groups including, Vulnerabilities, Midwifery, Children Safeguarding, Adult Safeguarding and Looked After Children and each group feeds in any concerns raised to the Strategic Safeguarding Board. Following the Coroners Inquest the case of David Lodge has been raised and escalated to the Strategic Safeguarding Board.
2. In June 2020, the Safeguarding Adults team in consultation with the Community Learning Disabilities team established a reasonable adjustment admission pathway for David (digitally stored on Lorenzo) to ensure his needs were considered and where possible met for all repeat attendances at Hull University Teaching Hospitals.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
3. From May 2021 to date, Hull Clinical Commissioning Group has commissioned one fulltime equivalent Learning Disability Liaison Nurse role, hosted by Humber Teaching Foundation Trust with an honorary contract within Hull University Teaching Hospitals NHS Trust. There are posters printed and displayed in the Emergency Department to make staff aware of this role and the poster includes contact details so the team are able to contact if support is required.
4. The Learning Disability Liaison Nurse is based within the Safeguarding Adults team and provides support to patients, carers and their relatives. The Liaison Nurse supports the Trust and its clinical staff providing expert specialist advice pertaining to Learning Disabilities; this includes structured judgement reviews, patient safety and safeguarding investigations.
5. Due to the innovative role, the learning disability liaison nurse straddles acute and secondary care so can work closely with family, carers and the community Learning Disability team to ensure care is person-centred.
6. In June 2022 Hull University Teaching Hospitals collaborated with the ICB and partners to produce a standardised health passport for people with a learning disability which are brought in by the individual or carer and scanned into the electronic patient record programme, Lorenzo, in case of repeat attendances.
7. These improvements have been embedded and are in use across adults and children services alongside training compliance reviews.
8. Fundamental Standards Safeguarding audits have been in place across the organisation since
2021. This audit reviews both service users feedback and clinicians’ knowledge of safeguarding. Compliance over 2022 and 2023 is seen in the table below.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
8/4/22 Emergency Care X 2 documents – v1.5 96% 28/4/22 AMU X 1 document – v1.5 91% 29/9/22 Emergency Care X 1 document – v1.5 92% 13/10/22 ED Majors X 1 document – v1.5 100% 8/9/22 AMU X 1 document – v1.5 91% 28/4/23 AMU X 1 document – v1.6 91% 19/6/23 Emergency Care X1 document – v1.6 100% 6/10/23 Emergency Care X1 document – v1 ED specific 99% 9/10/23 ED Majors X1 document – v1 ED specific 99%
9. In 2022, a virtual ward for learning disability and safeguarding was developed within the electronic nursing records. Once a learning disability diagnosis is recorded, an electronic flag for learning disabilities remains in place and is pulled through to future episodes of care within HUTH. This mechanism allows the adult safeguarding team and learning disability liaison nurse to identify patients quickly following their admission and then contact the wards (mon- fri) to provide specialist support and advice on reasonable adjustments and care.
10. In 2018/19 NHSE/NHSi introduced a national benchmarking exercise to audit the performance against the learning disability improvement standards across NHS organisations. These improvement standards reflect the strategic objectives and priorities in national publications, for example Transforming Care for People with Learning Disabilities and Learning Disability Mortality Review (LeDeR).
11. The Trust has completed this yearly audit and actioned findings. Learning from best practice saw the introduction of the Northeast and Cumbria Learning Disabilities Diamond Standard Acute Care Pathway in 2022/23 in the emergency department, planned admissions and outpatient attendances.
12. The Diamond Standard work supported immediate improvements within the emergency
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
department by accommodating the individual with learning disabilities and/or autism into quieter areas or side rooms and aim to triage, treat and discharge or admit the individual rapidly to reduce waiting times and avoid distress.
13. As a Trust we are now rolling out, as of January 2025 the Oliver McGowan mandatory training on Learning Disability and Autism. The training is named after Oliver McGowan, whose death shone a light on the need for health and social care staff to have better training. The Health and Care Act 2022 introduced a statutory requirement that regulated service providers must ensure their staff receive learning disability and autism training appropriate to their role. The Trust provide the Government's preferred and recommended training for health and social care staff.
14. Oliver's Training also supports the NHS Long Term Workforce Plan ambition by upskilling the wider health and care workforce to provide appropriately adjusted care for people with a learning disability and autistic people to reduce health inequality. The Trusts aim in providing the training to all staff is to prevent avoidable deaths like Oliver’s from happening again.
15. The first phase of the training programme was rolled out to all staff within the ED department.
The matters of concern raised are addressed as follows:
A concern that pain is not being accurately assessed in people who are unable to communicate using words.
16. In 2001, Clinical Guideline 171, Guideline for Acute and Peri-Operative Pain Relief in Adult Patients provided clinicians with the Abbey Pain Scale and the DisDAT assessment tools for use in practice. The Abbey Pain Scale was developed for patients who cannot verbalise pain and the DisDAT tool is for patients with learning difficulties to support assessment of distress and discomfort.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
17. Compliance with Guideline 171 is completed by way of yearly audits undertaken by the Acute Pain Team.
18. The Acute Pain Team assess and provide advice to Clinicians and Nurses on referral in relation to effective pain management for patients during their hospital admission across the Trust. The team offer effective pain control to both surgical and medical inpatients.
19. The Acute Pain Team also provide training to doctors, nurses and other health professionals in effective pain management. The Clinicians and Nurses have access to online training and face to face training is also held at various times though out the year. Training sessions are provided at Induction for Junior Doctors which is mandatory and further mandatory training is provided at Junior Doctors 6 month turn round. The Junior Doctors also receive additional information pain assessment and pain control for their reference which they can take away with them following the training sessions.
20. The Acute Pain Team also provide specific training to Clinicians twice yearly and training is also provided to the ICU department on average twice yearly. Reference is made to the Abbey Pain Scale during all training sessions provided.
21. In addition to the training highlighted above, face to face bespoke training in pain assessment is delivered by the Acute Pain Team when requested by specific hospital departments.
22. There is an eLearning Pain Assessment module on HUTH’s training platform (HEY247). Up to December 2024 317 staff had completed this module, 36 of whom are based in the emergency department or acute assessment unit. On the 27 February 2025 it was agreed at the Learning and Organisational Steering Group meeting that the eLearning module for pain assessment will be mandated across the Trust for all registered Nurses.
23. Further work to improve the use of the Abbey Pain Scale by clinicians has been undertaken. This includes a Standard Operating Procedure, a ‘How to..’ guide and cascade training with targeted areas including the Emergency Department Clinical Nurse Educators.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
24. The role of the Clinical Nurse Educators is to provide knowledge and skills to the nursing team relevant to the urgent and emergency care service. The team keep abreast of changes in practice and responds through policy and guidance updates. They provide induction training to new starters and will support members of the team facing additional education needs.
25. In addition to the training provided, as outlined above, following the 2022 CQC inspection (published March 2023), the trust acknowledged that pain assessment was not consistently assessed for patients who were non-verbal and/or unable to use the visual pain assessment scale. In response the Acute Pain Team implemented an action plan to address the issues raised which included the following in addition to other action taken.
• Laminated posters regarding pain assessment and general management of pain and The Abbey Pain Assessment Tool (including QR codes for the SOP, the record chart and guide to opioid prescribing) were distributed to every ward and department across the Trust to be prominently displayed on the ward.
• An email was distributed to the Senior Executive Nursing Team, all Matron's, Band 7 and 6s across the Trust, instructing that the posters were displayed in staff rooms, work stations and anywhere that is visible for the clinical team to access.
• The Trust created and handed out credit card sized laminated guides which can be carried in ID badges regarding pain assessment tools and the basic analgesic ladder. The laminated guides were distributed to staff on the wards and at the Link Nurse meeting. A Link Nurse Meeting is a meeting which is held once per year and the last meeting was held in October 2024. Link Nurse’s have responsibility to upgrade their knowledge which is then disseminated to all staff and staff can refer to the Link Nurse with their particular questions. At this meeting work around pain assessment was the main focus along with training on the Abbey Pain Assessment tool.
• A blog was posted on the Trust intranet explaining pain assessment scales and the types of tools which are used in the Trust. The blog highlights the posters which have been distributed and how to use the QR codes to find information regarding the Abbey
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
Pain Assessment Tool. There is also advice about completing the e-learning module available on the Trust intranet regarding Pain Assessment.
26. The Acute Pain Team continue to work with the ICU Department to ensure that appropriate assessment is conducted for all patients, including those ventilated or sedated, with the possibility of developing a QR code for the on-line Critical Care Pain Observation Tool (CPOT). CPOT tool is a tool for assessing pain in ventilated patients and is used in the ICU department which staff can access and use when assessing pain. An email was sent in May 2024 to all Critical Care Staff to remind staff of the CPOT tool in Level 3 care. In addition the CPOT observation tool was laminated and a copy is kept at each bedside for reference with additional guidance for staff to follow. The Pain Link Team went through the CPOT tool with each member of staff. In May 2022, the Trust introduced electronic recording as part of its move towards a paper light organisation. Nervecentre was introduced to record clinicians’ documentation and assessments. This included the recording of National Early Warning Score (NEWS). Within the NEWS module was the mandatory recording of the standard pain assessment. This is a verbal response by the patient who describes their experience of pain between zero (no pain) and three (severe pain).
27. In April 2024, Hull University Teaching Hospitals Acute Pain Team completed an audit to review progress regarding the assessment of pain. The results produced from the Emergency Department audit showed that pain was being assessed in 100% of cases. However the audit demonstrated awareness of the Abbey Pain Assessment tool remained low. This concern was escalated to the Chief Nurse, Corporate Patient Experience Committee. At the time there was no distinction in relation to which pain tool was being used and therefore further action was taken in November 2024 as indicated below in terms of changes on Nervecentre.
28. In response, the Acute Pain Team proceeded to complete two Quality Improvement Projects (QIP’s) on awareness and promoting the use of the Abbey Pain Tool.
a. QIP 1 – aimed at peri-operative staff within theatres, anaesthetics and the critical care service.
b. QIP 2 – aimed at medicine and care of the elderly teams
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
29. Both QIPs included the Acute Pain Team attending induction training for new starters, teaching sessions, poster campaigns, drop-in sessions and attendance at governance meetings. Results have demonstrated a good increase in awareness across all staffing groups.
30. In November 2024, a stand-alone pain assessment measure section, not as part of the NEWS assessment, was introduced into Nervecentre in response to provide equitable pain assessment for all patients. Nervecentre was amended to enable clinicians to electronically record pain assessment when using an ‘alternative tool’, for example the Abbey Pain Assessment Tool or the Visual Pain Assessment Tool to ensure patients who require a reasonable adjustment to accurately assess their pain was accurately recorded.
31. A supporting Standard Operating Procedure was written along with a ‘How to..’ guide to support clinicians using the new standard pain assessment module to ensure clinicians are patient-focused by using the correct pain assessment tool for their patients communication/reasonable adjustment needs. In relation to the Abbey pain assessment there is a link to the presentation online and the documentation is available via the QR code.
32. Whilst it is too early to tell if this has resulted in a demonstrable improvement of clinician’s pain assessments, the Acute Pain and Digital Teams will continue to audit and monitor the progress and plan to convert the paper-based Abbey Pain Assessment Tool to an electronic version.
33. Further audit priorities are to include the quality of assessment and corresponding analgesic provision and evaluation. This will be led by the Lead Nurse for Vulnerabilities, supported by the Learning Disabilities Liaison Nurse.
A concern that basic examinations are not being carried out for learning disabled adults at risk of pneumonia in the Emergency Department.
34. The Emergency Department has adopted the Royal College of Emergency Medicine Learning Disabilities Toolkit, following the conclusion of the inquest.
35. Basic examinations, including a chest or respiratory system examination, are routinely carried out in the Emergency Department and are part of the routine physical examination of a patient that presents with symptoms or signs that require such assessment, including those who are
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
at risk of pneumonia. Appropriate clinical examinations are carried out, as recommended and taught in clinical education. It is clinical judgment as to whether a patient requires a chest examination or other examination.
36. Basic examinations are undertaken on all patients and safe methods would be used to ensure that it is done effectively and appropriately across all groups of patients.
37. If examination of the chest is essential but not possible, the clinician would weigh the risks/benefits of sedating or restraining the patient in order to perform this. This would be if that particular examination is essential in the management of the patient. In situations where any examination or treatment is essential and the patient is agitated or disturbed, the Royal College of Emergency Medicine has published the Best Practice Guidance on Acute Behavioural Disturbance which provides necessary guidance. This guidance is utilised by clinicians in the Emergency Department.
38. The Emergency Department has not identified any evidence to suggest that basic examinations are not being carried out specifically in patients with learning disabilities. Nevertheless the Emergency Department and the Trust continually reflect on how the care and treatment can be improved for patients with learning disabilities.
A concern that NEWS2 scores above 7 are not appropriately escalated.
39. The Emergency Department follows the CP326: Recognition of the Deteriorating Adult Patient Policy. This is a Trust wide policy and is therefore also used outside of the Emergency Department.
40. The Policy has recently been reviewed and is in the final stages of the Trust Governance approval processes. It is expected that the updated policy will be signed off in May 2025. The policy has been updated to include the Trust NEWS2 Score Escalation Ladder which incorporates an additional step when assessing a patients NEWS2 score. The additional step takes in to account the family or carer’s views and concerns about a patient’s physical wellbeing, or any other abnormal parameters despite normal NEWS2 e.g, reduced urine output, deranged blood results, mottled limbs or just a gut feeling. If there is a concern raised,
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
41. that would then result in an increased frequency of monitoring and observations would be rechecked after any interventions or every 15 minutes. If the Clinician doesn’t respond to concerns raised staff are directed to contact the Consultant in Charge.
42. The updated policy provides clear guidelines on the escalation process in terms of who to escalate to and what the response time should be. The response times will be in accordance with the National Guidelines.
43. The above policy update is also in line with ‘Martha’s Rule’, which is a major NHS England patient safety initiative providing patients and families with a way to seek an urgent review if their own or loved one’s condition deteriorates and they are concerned this is not being responded to. HUTH are not part of the NHS England Trust Pilot scheme which ends at the end of March 2024. However, the Trust have attended all of the NHS England conferences regarding Martha’s Rule and have adopted the nationally recognised patient wellness questionnaire which is being trialled within the Trust and which we are working hard to embed. The Trust have already seen some referral’s under Martha’s Rule to the Critical Care Outreach Team (CCOT). The Trust are committed to empowering patient, families, carers and staff, including Nurses and Juniors Doctors to ensure their concerns are listened to and acted upon. Martha’s Rule is also there to encourage and empower staff to have the ability to raise concerns outside of the official escalation channels.
44. In addition to and alongside the above policy update a separate Trust Standard Operating Procedure (SOP) to incorporate Martha’s Rule will be introduced. The wording of the SOP will follow NHS England’s recommendations. It is anticipated that if concerns are raised and no action is taken or the action taken is deemed insufficient the patient could be escalated directly to the critical care team for assessment. Under Martha’s Rule the patient or their family will not require the treating Doctors opinion to contact the Critical Care Outreach team.
45. In addition, as is already the case, if a patient’s care has been escalated to the Critical Care Outreach Team and then stepped down, due to an improvement in presentation, patients are always reminded that if they have any further concerns they can ask the nurse or switchboard to bleep the CCOT to re-escalate and they do not have to go through a Clinician to do this.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
46. Each time there is an escalation under Martha’s Rule a Trust DATIX will be raised to monitor trends, gather evidence of clinical incidences and highlight issues and concerns in Trust processes.
47. Training on the topic of deteriorating patients was provided to all staff until September 2024, however, the training had to be stalled due to unforeseen circumstances. The monthly training is due to resume in April 2025 in time for the updated policy roll out.
48. In addition to the monthly training outlined above the Nurses Training in Simulation and Sepsis team (NUT-S), have been running training sessions since 2022. The NUTS-S team was created off the back of the incident involving Mr Lodge which prompted the development of learning and the NUTS-S team have used Mr Lodge’s case as a simulated example within the training sessions. The training was developed by the Trust’s Deputy Director, Hull Institute of Learning and Simulation which began as a Pilot training session and was first delivered to the Nurses in the Acute Medicine Department and was later rolled out to include the Nursing Team within the Emergency Department and it is now Trust wide. The training covers different scenarios, however the structure and focus is always the same and includes a patient who shows signs of deterioration. The focus of the training is to assess, recognise deterioration and escalate and there is always a discussion around the human factors. The training is delivered by the Trust Approved Nurse Fellow in simulation. An example of the simulation training would include a patient with learning difficulties who is unable to express pain, with a NEWS2 sore of 7 and who is showing signs of deterioration. The NUTS-S team continues to run weekly training sessions which are Trust wide and can be department focused if there are specific issues identified regarding identifying deteriorating patients.
49. The aim of the Trust team is for the training to become mandatory and discussions are being held with the Trust in this regard. In 2024 the NUTS-S team began work on developing the training further with the aim of rolling out the training to multi professionals working in high risk areas and dealing with deteriorating patients and a business case has been presented to the Board for approval. The overall aim of the training is to improve patient safety.
50. A Task and Finish Group has also been set up to make sure education meets the needs of all staff groups including medical staff, nursing staff and Health Care Support Workers who come into contact with a deteriorating patient and also to cover learning outcomes relating to sepsis.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
51. In relation to Sepsis the Trust has carried out a substantial amount of work in the Acute Assessment Unit and the Emergency Department and data is collected on a daily basis relating to sepsis screening and the implementation of the correct management. Since the recent changes to NICE guidance the Trust have updated their policy and screening tools and created digital versions.
52. Over the last 18-24 months many changes have been implemented in the Emergency Department for incoming patients who need prompt treatment. The Emergency Department at present have 2 out of 8 bays within the initial assessment area which are earmarked for quick assessment and treatment. These are used, when capacity allows, for patients who are clinically unwell and may have a high NEWS. This allows for closer supervision and quick assessment of these patients.
53. The Emergency Department have also introduced an Escalation Clinician and Safety Nurse to support the escalation and management of patients that are deteriorating or have deteriorated. They are designated on every shift and their role would include responding to escalation, reviewing and treating patients. This is in addition to nursing staff escalating any patient with a high NEWS or those they have clinical concerns about. The role of the designated ‘Escalation Clinician’ is to respond to any escalating concerns as soon as possible.
54. The Emergency Department have also introduced a Sepsis Champion on every shift, a role performed by an F2 grade clinician, who will ensure that those identified with possible sepsis are treated appropriately.
55. At the streaming desk in the Emergency Department (walk-in area) there is always at least a band 6 nurse whose role is to escalate any clinical concerns immediately to the appropriate clinician if they identify any patient who is self-presenting and needs urgent review.
56. Patients with high NEWS in the Emergency Department are initially managed by the clinicians in the Emergency Department, with the support of or the direct involvement from registrars or consultants. If it is felt that their care would need the expertise and resources beyond the ED, the care is then escalated to the speciality teams and/or ICU as clinically required.
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
57. In addition we have seen the introduction of the High Observation Bay (HOB) in AMU which is for higher acuity patients who are placed in the bay with a higher nursing ratio.
52. The Emergency Department continue to be under significant pressures due to capacity. All the above measures are in place to minimise the risk of NEWS scores not being appropriately escalated. The Trust will continue to monitor the effectiveness of the measures that have been implemented.
A concern that opportunities for learning from serious incidents are being lost.
53. Information of Davids death was provided by the emergency department to the Mental Capacity Act lead. No concerns were raised regarding omissions in care or treatment during the hours spent at Hull University Teaching Hospitals. A safeguarding concern was submitted to the relevant Local Authority for investigation due to the pathway of admission and prior knowledge of community safeguarding issues. Mr Lodge’s death was also reported to LeDeR who confirmed that a review of care would be completed at the conclusion of the inquest.
54. Serious Incidents are declared following a patient safety event whereby the severity of harm caused is determined to be moderate or higher. Harm was not deemed to have been caused by Hull University Teaching Hospitals therefore a serious incident was not declared.
55. However, since Mr Lodge’s death, Trust process and procedure has developed and going forward a Structured Judgement Review (SJR) is completed for all patient’s with identified learning disabilities and who sadly pass away while receiving care and treatment at the Trust. The SJR will be completed by the Vulnerabilities and Enhanced Care. The SJR will be completed despite the outcome of the initial clinical review of the care and treatment provided and despite the outcome of the decision from LeDeR in terms of their investigation.
56. The Trust hold Weekly Patient Safety Summit (WPSS) meetings to discuss patient safety concerns. Senior Clinical and Nursing staff as well as Clinical and Governance Leads from the Care Groups all attend this meeting.
57. Service condition 26 of the NHS Standard Contract requires any provider of services to the NHS to participate in the projects within the National Clinical Audit and Patient Outcomes
United by Compassion: Driving for Excellence.
Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust
58. Programme relevant to the Services. This includes the Learning Disabilities Mortality Review programme (LeDeR) of which NHS Humber Health Partnership is a member of the Humber Steering Group. Mr Lodge’s case was referred to LeDeR prior to the inquest and action was to be considered following the conclusion of the inquest. The Trust are aware that the LeDeR Panel Review Group are carrying out of full review of the care and treatment Mr Lodge received. The Panel Review Group meet every two weeks and the action plan ensuing from the review, which relates to the Trust will be monitored at the Panel Review meetings. The action plan across the ICB would be managed by the Humber Steering Group.
59. The Humber LeDeR Steering Group have developed learning briefings with good practice and areas for improvement presented from reviews that have occurred across the Humber region in both primary and secondary care. These briefings are shared at the internal Mental Health, Learning Disability & Autism Steering Group, internal End of Life Steering Group and with the Trusts mortality team manager. In addition, the briefings are made available on the Trust Learning Disabilities intranet website for staff to access.
60. Learning from the Humber LeDeR briefings that are directly related to the Trust are discussed, with subsequent improvement actions and implementation plans agreed and monitored at the Mental Health, Learning Disability & Autism Steering Group. . We trust this responds to the matters raised within the prevention of future deaths report.