ELFT
Other
Action Taken
ELFT has taken several actions, including conducting reflective practice sessions, disseminating key learning points to staff, and incorporating VTE risk screening into the nurses' observation form. They are updating their Physical Healthcare Policy to clarify VTE assessment procedures, expected November 2024. (AI summary)
View full response
Dear Sir
RE: REGULATION 28 REPORT
1. This is a formal response to your Regulation 28 report issued at inquest on 12 August 2024 where you set out concerns relating to the care of Ms Nimo Osman under the East London NHS Foundation Trust’s (the ‘Trust’) care.
2. I understand that at the inquest into Ms Osman’s death, you heard evidence from the Trust’s Deputy Borough Lead Nurse (‘BLN’) for Tower Hamlets outlining the learning that has taken place since her sad death. I understand that you remain concerned about the risk of future deaths in relation to the following areas:
2.1. A senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told you in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told you that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to say that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led you to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’.
2.2. You heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). Given the evidence of Nurse B, the undermining of that evidence and reassurance from Nurse A, led you to conclude that there is, at the very least, a
realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist. You considered that further reassurance is required in relation to the following matters of concern:
2.2.1. CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients.
2.2.2. CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients.
2.3. With regard to the Trust’s policy in relation to Venous Thromboembolism, you noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. You were told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk.
3. I wish to assure you and the family of Ms Osman that the Trust has reviewed the issues highlighted within the Regulation 28 Report and has planned the actions outlined below.
RESPONSE
Contacting emergency services
4. I share your concerns that one of the Trust’s nurses was under the impression that an ambulance could only be called if under the instruction of a more senior nurse. This is
certainly not agreed practice at the Trust. Nursing staff do not require permission to call emergency services.
5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summon s help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter.
6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024.
7. On 11 September, after a recorded safety discussion with nursing staff on 29 August 2024, the BLN circulated a memo to all Tower Hamlets Wards reinforcing the message that staff consider that service user’s physical health as well as mental health can contribute to their behaviour. It also confirmed that there are no requirements to seek permission to call emergency services via 999.
CDP2
8. It is important that all staff are aware of the impact that physical health as well as mental health can have on a service user’s behaviour. As outlined in the BLN’s oral evidence, to ensure this information is embedded, all Tower Hamlets in-patient nursing staff and social therapists undertake a mandatory two-day physical health training course. It includes content on service users presenting as unwell and whether this may be related to their mental or physical health. This course started on 03 May 2023 and is delivered regularly. Further training courses will take place on:
• 25 – 26 September 2024
• 14 - 15 October 2024
• 11-12 November 2024
• 16 –17 December 2024.
9. Additionally, Tower Hamlets clinical staff already engage in once weekly emergency scenarios that include when it is appropriate to call 999. By30 November 2025 simulations will take place which include considerations whether something is a physical health verse mental health concern.
10. I understand that the BLN’s oral evidence was that VTE assessments form part of the two-day physical health training outlined in paragraph 8 above. Additionally, both the BLN and Clinical Director for Tower Hamlets circulated an email in January 2023 about the importance of undertaking VTE assessments. This was resent on 1 October 2024 to ensure that staff remain aware of the importance of these assessments.
11. Additionally, all service user admissions are reviewed every morning between Monday- Friday. The Ward Manager or Matron in attendance confirms that a VTE risk assessment is completed. During the weekend and bank holidays, the weekend huddle will consider any admissions and a doctor clerks the patients in. These assessments are audited bi- weekly as part of the service’s physical health assessment audits.
12. Since August 2024, the nurses’ Observations and Measurements form incorporates a screening question for VTE risk. It is a mandatory box to complete on the form and cannot be saved on RiO (the Trust’s electronic record system) until the question has been responded to.
VTE Policy
13. It has come to my attention that the inquest only considered the VTE assessment information as provided in the Trust’s Physical Healthcare Policy v.14.1, February 2021. The Trust has a more recent and separate Venous Thromboembolism (VTE) Reducing Risk policy v. 3, March 2023. The information in the VTE policy is unambiguous and in-line with NICE guidelines. It is accepted that the VTE assessment information contained in
the Physical Healthcare Policy is not clearly set out. Therefore, the VTE information has been removed from the aforementioned policy in a soon to be published update and it has been made clear that the VTE policy is the appropriate reference. The changes to the Physical Healthcare Policy are expected to be agreed through the Physical Health in Mental Health Committee in November 2024.
14. I hope this response provides sufficient reassurance to you and to the family of Ms Osman about the additional learning that has taken place at the Trust because of her death.
15. I would like to offer my sincere and heart-felt condolences to the family at this difficult time.
RE: REGULATION 28 REPORT
1. This is a formal response to your Regulation 28 report issued at inquest on 12 August 2024 where you set out concerns relating to the care of Ms Nimo Osman under the East London NHS Foundation Trust’s (the ‘Trust’) care.
2. I understand that at the inquest into Ms Osman’s death, you heard evidence from the Trust’s Deputy Borough Lead Nurse (‘BLN’) for Tower Hamlets outlining the learning that has taken place since her sad death. I understand that you remain concerned about the risk of future deaths in relation to the following areas:
2.1. A senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told you in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told you that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to say that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led you to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’.
2.2. You heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). Given the evidence of Nurse B, the undermining of that evidence and reassurance from Nurse A, led you to conclude that there is, at the very least, a
realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist. You considered that further reassurance is required in relation to the following matters of concern:
2.2.1. CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients.
2.2.2. CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients.
2.3. With regard to the Trust’s policy in relation to Venous Thromboembolism, you noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. You were told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk.
3. I wish to assure you and the family of Ms Osman that the Trust has reviewed the issues highlighted within the Regulation 28 Report and has planned the actions outlined below.
RESPONSE
Contacting emergency services
4. I share your concerns that one of the Trust’s nurses was under the impression that an ambulance could only be called if under the instruction of a more senior nurse. This is
certainly not agreed practice at the Trust. Nursing staff do not require permission to call emergency services.
5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summon s help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter.
6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024.
7. On 11 September, after a recorded safety discussion with nursing staff on 29 August 2024, the BLN circulated a memo to all Tower Hamlets Wards reinforcing the message that staff consider that service user’s physical health as well as mental health can contribute to their behaviour. It also confirmed that there are no requirements to seek permission to call emergency services via 999.
CDP2
8. It is important that all staff are aware of the impact that physical health as well as mental health can have on a service user’s behaviour. As outlined in the BLN’s oral evidence, to ensure this information is embedded, all Tower Hamlets in-patient nursing staff and social therapists undertake a mandatory two-day physical health training course. It includes content on service users presenting as unwell and whether this may be related to their mental or physical health. This course started on 03 May 2023 and is delivered regularly. Further training courses will take place on:
• 25 – 26 September 2024
• 14 - 15 October 2024
• 11-12 November 2024
• 16 –17 December 2024.
9. Additionally, Tower Hamlets clinical staff already engage in once weekly emergency scenarios that include when it is appropriate to call 999. By30 November 2025 simulations will take place which include considerations whether something is a physical health verse mental health concern.
10. I understand that the BLN’s oral evidence was that VTE assessments form part of the two-day physical health training outlined in paragraph 8 above. Additionally, both the BLN and Clinical Director for Tower Hamlets circulated an email in January 2023 about the importance of undertaking VTE assessments. This was resent on 1 October 2024 to ensure that staff remain aware of the importance of these assessments.
11. Additionally, all service user admissions are reviewed every morning between Monday- Friday. The Ward Manager or Matron in attendance confirms that a VTE risk assessment is completed. During the weekend and bank holidays, the weekend huddle will consider any admissions and a doctor clerks the patients in. These assessments are audited bi- weekly as part of the service’s physical health assessment audits.
12. Since August 2024, the nurses’ Observations and Measurements form incorporates a screening question for VTE risk. It is a mandatory box to complete on the form and cannot be saved on RiO (the Trust’s electronic record system) until the question has been responded to.
VTE Policy
13. It has come to my attention that the inquest only considered the VTE assessment information as provided in the Trust’s Physical Healthcare Policy v.14.1, February 2021. The Trust has a more recent and separate Venous Thromboembolism (VTE) Reducing Risk policy v. 3, March 2023. The information in the VTE policy is unambiguous and in-line with NICE guidelines. It is accepted that the VTE assessment information contained in
the Physical Healthcare Policy is not clearly set out. Therefore, the VTE information has been removed from the aforementioned policy in a soon to be published update and it has been made clear that the VTE policy is the appropriate reference. The changes to the Physical Healthcare Policy are expected to be agreed through the Physical Health in Mental Health Committee in November 2024.
14. I hope this response provides sufficient reassurance to you and to the family of Ms Osman about the additional learning that has taken place at the Trust because of her death.
15. I would like to offer my sincere and heart-felt condolences to the family at this difficult time.