Linda Heath

Dear HM Coroner (Mrs Sally Robinson, Assistant Coroner) Regulation 28 Report following the inquest into the death of Mrs Heath We provide the formal response of the Care Quality Commission (CQC) to the Regulation 28 Preventing Future Deaths report made by HM Coroner (Mrs Sally Robinson, Assistant Coroner) following the inquest into the death of Mrs Heath. (‘the Regulation 28 Report’). In the Regulation 28 Preventing Future Deaths report HM Coroner raised the following concerns: CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary. (2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery. (3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition. (4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers.

Hull University Teaching Hospitals NHS Trust NHS trust’s do not report deaths to CQC, and we first became aware of the death of Mrs Heath on 10 May 2024 from your prevention of Future Death Report where we were a named responder. Following receipt of this report CQC held a management review meeting and agreed to request the inquest medical evidence bundle. In addition, we asked Hull University Teaching Hospitals NHS Trust to provide evidence of any action they had taken to date following the tragic death of Mrs Heath. We reviewed all the information obtained by the CQC and concluded there were no grounds to suspect a criminal offence. The trust’s last comprehensive inspection was in November 2022 and the report was published in March 2023. CQC rated the trust as “Requires Improvement.” A copy of the report can be found on our website - Trust - RWA Hull University Teaching Hospitals NHS Trust (23/03/2023) INS2-13905362001 (cqc.org.uk) CQC hold monthly engagement meetings with the trust to ensure that the fundamental standards of quality and safety are being met. At this meeting we review the trust’s progress on their post inspection action plan and ensure improvements made are sustainable and embedded. Since Mrs Heath’s death in March 2022 the trust have completed a number of actions relating to the management of pressure ulcers to eliminate the risk of this happening again.
• Mandatory training compliance levels for tissue viability for registered and non-registered nursing and midwifery teams are reported monthly to the safer skin committee. Tissue viability training now includes national e-learning modules, trust e-learning training videos in recognising and treating of moisture associated skin damage and chronic wound assessments.

• Audits for tissue viability and ward assurance are reported monthly to the safer skin committee who monitor any recommendations actions required and check compliance against an evidence based framework.

• Introduction of a senior nurse to regularly review patients who have moderate to high risk pressure sores. They ensure all members of the multidisciplinary team are involved in the patient care as needed. Referrals can be made to the tissue viability teams as well as plastic surgery. They are responsible for arranging onward referrals to district nursing teams and arranging appropriate equipment prior to discharge.

• Updated standard operating procedures for digital wound photography to include photographs of wounds on admission, when transferred to a clinical areas to identify improvements / deterioration of wound appearance.

• Monthly meetings with community health care partnership (CHCP) to work in partnership to improve communication for discharges and transfers of care across both healthcare providers.
• Clinical areas now display monthly posters for the number of days they have been “pressure ulcer free”.

• Updated standing operating procedures for ordering equipment such as dynamic mattresses.

• Updated patient information leaflet “preventing pressure ulcers – working together with patients and carers to prevent pressure ulcers”. St Andrew’s surgery at Elliott Chappell Health Centre CQC inspected St Andrew’s surgery at Elliott Chappell Health Centre in November
2017. The report was published in January 2018 and it was rated as good. A copy of the report can be found on our website - Elliott Chappell Health Centre NewApproachComprehensive Report (GPPractices Location Oct 2017)_INS2- 3890813910 (cqc.org.uk) City Health Care Partnership CQC inspected Community health services for adults in November 2016 and rated it as good. In June 2022 we carried out a focussed inspection based upon the quality of management of wound care within the Hull and East Riding community nursing service. The inspection did not look at other services provided by City Health Care Partnership or other areas of the community nursing service. This inspection was not rated, which meant the existing rating of good remains in place. CQC did not identify any required enforcement action during this inspection. A copy of the report can be found on our website - Core Service - Community health services for adults - (28/11/2022) INS2-12629169601 (cqc.org.uk) A national professional advisor and senior specialist for Primary and Community Care at CQC have reviewed the coroner’s letter, evidence bundle, the clinical records and practice response to the integrated care board who would cover the oversight of this GP practice. The findings will be shared with the operations team for Primary and Community Care to consider alongside other information held by CQC. This will inform our regulatory response. During the inspection process we routinely review correspondence, tasks and referrals. We will use the regulation 28 report to remind colleagues of the importance of this process. There will be ongoing monitoring of this provider via our monitoring and inspection process.

In addition to our inspection activity, CQC continually monitors all the information we hold about services for any themes and trends. We review intelligence data from a range of sources. For example, for trust’s we look at incidents reported to National Reporting and Learning System (NRLS) and Strategic Executive Information Systems (StEIS). This will now include incidents reported to the “Learn from Patient Safety Events” system (LPSIR). We also receive information from local authority safeguarding teams and attend meetings safeguarding meetings. We also engage with other regulators (such as the Environmental Health Agency or local Clinical Commissioning Groups) and Fire and Rescue Services or the Police. CQC receive information directly from patients or relatives of people who use services. This is extremely valuable to us as they are best placed to know whether they / their relative received safe, compassionate, and high-quality care. CQC also receive information from whistle-blowers (serving or former members of staff). If the CQC receives any information of concern about a service our aim is to respond as quickly as possible, assessing the risk using our new single assessment framework methodology and identifying the appropriate action to take. We will use our enforcement powers if regulations are not being met. CQC will discuss the concerns you have raised about Mrs Heath’s death at our next engagement meeting with the Hull University Teaching Hospitals NHS Trust. If we are not assured that improvements have been made, we will make an appropriate regulatory response. CQC’s next inspection of these services are not yet confirmed, however we have adopted a more risk based approach to inspections should CQC receive negative intelligence or have further concerns about the service we would carry out responsive inspections. CQC hope that this response addresses your concerns.

Dear Ms Robinson

Linda Heath – NMC response to Regulation 28 Prevention of Future Deaths Report

Thank you for sending your Regulation 28 Prevention of Future Deaths Report (PFD) in connection with the death of Linda Heath for us to review in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I write on behalf of the Nursing and Midwifery Council (NMC) to confirm the action we are taking in response to the concerns raised.

Firstly, I am very sorry to hear about the circumstances of Linda’s death and I would like to offer my sincere condolences to her family for their loss. We take the concerns you have raised with us very seriously.

We have used the information in the PFD to reflect on the action we can take to address the concerns you have identified and to make sure they do not occur again where we have the power to do so. We set out below the action we have taken to ensure that the professionals on our register are fit to practise safely and professionally and that the public is protected in line with our role.

Additionally, I would like to apologise for the delay in acknowledging and responding to your report. We are taking steps to identify why the report did not reach the correct team in time for us to respond in accordance with the statutory deadline and will make appropriate improvements to prevent this from happening in future.

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Your concerns

I note that your investigation concluded that Linda died at Hull Royal Infirmary from sepsis caused by an infected sacral sore, also known as a pressure sore. Linda had been discharged in February 2022 with a grade 2/healing sore. A combination of management issues by healthcare professionals, including her not being referred for district nursing care, led to a worsening of her condition. Along with Linda’s pre- existing co-morbidities this led to an admission to Hull Royal Infirmary on 5 March
2022. Despite surgical treatment the situation worsened. Tissue viability nursing was not reinstituted post-operatively. Difficulties in care with nutrition and hospital acquired infections unfortunately led to Linda’s death on 31 March 2022.

You have raised the following concerns in the PFD report:

1. The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary.

2. Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery.

3. No trigger appears to exist whereby General Practitioners conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition.

4. An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers.

Our role

The NMC is the independent regulator of more than 808,000 nurses and midwives in the UK and nursing associates in England. We’re here to protect the public by upholding high professional nursing and midwifery standards, which the public has a right to expect. We maintain the integrity of the register of those eligible to practise and we investigate concerns about individual professionals.

Our Code of Conduct contains the professional standards that registered nurses, midwives and nursing associates must uphold. We will investigate alleged breaches of the Code when we become aware of them under our fitness to practise process.

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We have two clear aims for fitness to practise:

a. a professional culture that values equality, diversity and inclusion, and prioritises openness and learning in the interests of public safety, and

b. nurses, midwives and nursing associates who are fit to practise safely and professionally.

In appropriate circumstances we enforce the standards set out in the Code through fitness to practise proceedings. Fitness to practise proceedings can result in a range of outcomes, ranging from the provision of advice to the registrant by the NMC to removal from the register.

Our response to the concerns raised

The concerns that you have raised indicate that a nurse or nursing associate’s skills, knowledge, education or behaviour may have fallen below the standards needed to deliver safe and effective care.

Your report has been shared with our fitness to practise department, who will screen the case in accordance with our fitness to practise process. We screen cases to make sure that we’re the right organisation to address the concerns and it’s serious enough that regulatory action needs to be taken. It’s important to note that more often than not, employers can deal with most cases without the need for regulatory action.

In line with our screening process, we will now take steps to:

• confirm whether the concerns you have raised relate to a professional or professionals on our register;
• establish if there is evidence of a serious concern that could require us to take regulatory action to protect the public;
• confirm if there is clear evidence to show that a nurse, midwife or nursing associate is currently fit to practise.

If concerns are identified that relate to someone on our register, our screening team will carry out an initial risk assessment in relation to each concern. If they identify particular risks, such as a risk of harm to the public, the case may be referred to an interim order hearing. Interim order cases may include cases of serious lack of competence or poor clinical practice. An interim order has the effect of restricting the nurse or nursing associate’s practice with immediate effect.

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To help with our screening enquiries, we contacted your office on 23 August 2024, 5 September 2024 and 16 September 2024 to obtain further information. We have sought disclosure of the Serious Incident report to help us with our enquiries and are waiting for a response.

Finally, we recognise the impact that FtP proceedings can have on families, which is why we have a Public Support Service (PSS) to help support people through the process and understand how the investigation process works. Through it, our public support officers can answer individual questions or provide one-to-one meetings and help explain the different decisions that could be made. If we do proceed with an investigation our PSS team will reach out to Linda’s family to offer support. More information about our PSS can be found here NMC public support service - The Nursing and Midwifery Council.

Conclusion

We are taking steps to investigate the concerns raised to identify whether we need to take regulatory action in relation to a professional or professionals on our register. We are also making enquiries to ensure PFD reports are shared across the organisation more swiftly in the future.

Once again, I offer my heartfelt condolences to Linda’s family. If you have any further questions concerning this case or the steps we are taking, please do not hesitate to contact us.