East Suffolk and North Essex NHS Foundation Trust
NHS / Health Body
Action Taken
ESNEFT sets a 6 hour assessment timeframe for falls risk assessments, from admission to hospital or change of ward. The Trust is working towards completing weekly checks on patient documentation and implements a Care Gap Analysis process for falls. (AI summary)
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Dear Mr Stewart
REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF MICHAEL JOHN BURKE WHICH CONLUDED ON 15 FEBRUARY 2024
I write in connection with the above mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024.
I would like to take this opportunity to extend my condolences to Mr Burke’s family for their loss.
The Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024 highlighted concerns that Ipswich Hospital had inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and the arrangements for the handover of tasks (particularly falls assessments) between shifts.
The information presented below is intended to describe the actions which have been taken/are being taken East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised.
Completing falls risk assessments on admission/transfer to ward
East Suffolk and North Essex NHS Foundation Trust is committed to reducing the number of patient falls; minimising harm from falls that occur, whilst providing an enabling environment and effective rehabilitation.
Nationally there is no guidance on timeframes for carrying out falls assessments on admission/transfer to a ward but East Suffolk and North Essex NHS Foundation Trust recognise that a patient is most vulnerable to fall within the first 12 hours of presentation/admission.
For this reason East Suffolk and North Essex NHS Foundation Trust sets a 6 hour assessment timeframe, from admission to hospital or change of ward, for the assessment to be carried out, to make patients as safe as can be.
As part of the ongoing review process of our policies, the Trust has reviewed and updated their Falls Prevention Policy, which provides staff with guidance on the need to complete a moving and handling assessment and Falls Prevention Integrated Care Pathway within 6 hours of a decision to admit or transfer wards. This policy will be signed off at the Patient Safety Group on 18 June 2024.
Staff are trained on fall prevention as part of their induction training, Band 2 and upwards, as well as receiving continued training as highlighted below. The Falls Prevention policy is located on the Intranet and can be accessed by all staff.
The Trust has also carried out a review of the Integrated Patient Record, which forms an appendix to the Falls Prevention Policy, has been amended and now includes an updated Falls risk assessment proforma, which highlights the need for the assessment to be completed within the 6 hour time period of admission/change of ward.
The standard position is therefore that each patient admitted to the hospital or changing ward will have a moving and handling assessment and Falls Prevention Integrated Care Pathway completed within 6 hours of a decision to admit or transfer wards.
Handover of tasks during change of shift
On a daily basis there are 2 staff handovers, one when the daytime shift come on to the ward in the morning and one when the night time shift come on to the ward in the evening.
During the staff handover, the outgoing shift brief the incoming shift with information of the patients on the ward. This handover includes actions that need to be carried out. These actions are recorded on the staff handover sheet for the oncoming shift to action.
This would include circumstances were a moving and handling assessment and Falls Prevention Integrated Care Pathway still needed to be completed for a patient who has been admitted to or transferred to the ward. This action would be recorded on the handover sheet and then picked up by the oncoming shift members and completed.
The wards also use whiteboards to records actions that are required for patients and will ticked these off once they have been actioned.
Audit of paperwork
As part of the Trust’s accountability framework, patient notes are audited frequently to ensure that they are being completed correctly and to identify any issues with compliance in completing notes.
The Ward Manager carries out a weekly check of documentation and records on the online proforma the results of the check. This weekly check includes a review of the moving and handling assessment and Falls Prevention Integrated Care Pathway.
In addition the Matrons also carry out a monthly quality audit which is also completed using an online proforma. This monthly quality audit also includes a review of the falls documentation.
The Trust have implemented a Care Gap Analysis and After Action Review process for falls. The Care Gap Analysis will generate themes and trends with falls to help support change.
These audits and reviews enable the Trust to highlight any areas of learning and training that may arise. Compliance with completing the moving and handling assessment and the Falls Prevention Integrated Care Pathway for the final quarter of the 2023/2024 financial year was 94.08%.
Electronic Patient Records
The Trust has recently signed a contract to transition their patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.
This will have the benefit of being more user friendly and provide greater compliance with completing documents, as the system is able to be programmed to ensure areas of information are documented before being able to proceed through the system.
It is also possible to set alerts that are triggered by timeframes to ensure staff are notified of any immediate actions that need to be carried out.
I hope the above information demonstrates the processes that are in place to ensure documentation is being completed in the appropriate manner and handed over to the oncoming shift. Through the various audits set out above the Trust review documentation and are able to highlight any areas of concern and address any areas of learning or training that need to be covered. If I can be of further assistance, please do not hesitate to contact me.
REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF MICHAEL JOHN BURKE WHICH CONLUDED ON 15 FEBRUARY 2024
I write in connection with the above mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024.
I would like to take this opportunity to extend my condolences to Mr Burke’s family for their loss.
The Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024 highlighted concerns that Ipswich Hospital had inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and the arrangements for the handover of tasks (particularly falls assessments) between shifts.
The information presented below is intended to describe the actions which have been taken/are being taken East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised.
Completing falls risk assessments on admission/transfer to ward
East Suffolk and North Essex NHS Foundation Trust is committed to reducing the number of patient falls; minimising harm from falls that occur, whilst providing an enabling environment and effective rehabilitation.
Nationally there is no guidance on timeframes for carrying out falls assessments on admission/transfer to a ward but East Suffolk and North Essex NHS Foundation Trust recognise that a patient is most vulnerable to fall within the first 12 hours of presentation/admission.
For this reason East Suffolk and North Essex NHS Foundation Trust sets a 6 hour assessment timeframe, from admission to hospital or change of ward, for the assessment to be carried out, to make patients as safe as can be.
As part of the ongoing review process of our policies, the Trust has reviewed and updated their Falls Prevention Policy, which provides staff with guidance on the need to complete a moving and handling assessment and Falls Prevention Integrated Care Pathway within 6 hours of a decision to admit or transfer wards. This policy will be signed off at the Patient Safety Group on 18 June 2024.
Staff are trained on fall prevention as part of their induction training, Band 2 and upwards, as well as receiving continued training as highlighted below. The Falls Prevention policy is located on the Intranet and can be accessed by all staff.
The Trust has also carried out a review of the Integrated Patient Record, which forms an appendix to the Falls Prevention Policy, has been amended and now includes an updated Falls risk assessment proforma, which highlights the need for the assessment to be completed within the 6 hour time period of admission/change of ward.
The standard position is therefore that each patient admitted to the hospital or changing ward will have a moving and handling assessment and Falls Prevention Integrated Care Pathway completed within 6 hours of a decision to admit or transfer wards.
Handover of tasks during change of shift
On a daily basis there are 2 staff handovers, one when the daytime shift come on to the ward in the morning and one when the night time shift come on to the ward in the evening.
During the staff handover, the outgoing shift brief the incoming shift with information of the patients on the ward. This handover includes actions that need to be carried out. These actions are recorded on the staff handover sheet for the oncoming shift to action.
This would include circumstances were a moving and handling assessment and Falls Prevention Integrated Care Pathway still needed to be completed for a patient who has been admitted to or transferred to the ward. This action would be recorded on the handover sheet and then picked up by the oncoming shift members and completed.
The wards also use whiteboards to records actions that are required for patients and will ticked these off once they have been actioned.
Audit of paperwork
As part of the Trust’s accountability framework, patient notes are audited frequently to ensure that they are being completed correctly and to identify any issues with compliance in completing notes.
The Ward Manager carries out a weekly check of documentation and records on the online proforma the results of the check. This weekly check includes a review of the moving and handling assessment and Falls Prevention Integrated Care Pathway.
In addition the Matrons also carry out a monthly quality audit which is also completed using an online proforma. This monthly quality audit also includes a review of the falls documentation.
The Trust have implemented a Care Gap Analysis and After Action Review process for falls. The Care Gap Analysis will generate themes and trends with falls to help support change.
These audits and reviews enable the Trust to highlight any areas of learning and training that may arise. Compliance with completing the moving and handling assessment and the Falls Prevention Integrated Care Pathway for the final quarter of the 2023/2024 financial year was 94.08%.
Electronic Patient Records
The Trust has recently signed a contract to transition their patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.
This will have the benefit of being more user friendly and provide greater compliance with completing documents, as the system is able to be programmed to ensure areas of information are documented before being able to proceed through the system.
It is also possible to set alerts that are triggered by timeframes to ensure staff are notified of any immediate actions that need to be carried out.
I hope the above information demonstrates the processes that are in place to ensure documentation is being completed in the appropriate manner and handed over to the oncoming shift. Through the various audits set out above the Trust review documentation and are able to highlight any areas of concern and address any areas of learning or training that need to be covered. If I can be of further assistance, please do not hesitate to contact me.