Gloucestershire Health and Care NHS Foundation Trust
NHS Trust
Action Taken
Gloucestershire Health and Care NHS Foundation Trust details several actions taken including updating medical training for bank staff, providing a refresher session and competency assessment on choking, and updating the resuscitation action card. (AI summary)
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Dear Mr Wooderson Ref; The Late Severine Kelly IChief Executive, in response to your Regulation 28 Prevention of am writing on behalf 0 2024 relating to this case. Future Deaths Report dated 21 February established a number of concerns In regard %f practice andesaining On conclusion of the inquest, yoU following risk related Incidents, access t0 regarding seouscitation; the updating %f risk aseslleenle 'from emergency services when they arrived povaable andine tetephone and tne sgnoityirg efieoloague pfzoticerandgeacy pleased thatwe have been on site. The Trust has now had opportunity to reflect on its similar tragic event recurring in the future: 'identify improvements which will minimize the risk of a able to from Miss Kelly's death has focused on the 6 issues you identified. The learning "bank" stafif, at the hospital on 1 October 2022, Was Up The medical training of certain to date System (LMS) "Care t0 Learn' records staff training The Trusts Leaming Management 'Stetutory and Mandatory topics: The LMS is web-based completions, monitors compliance of 'on any device with an Internet connection; and can be accessed by all GHC staff managers accessing a Trust computer or laptop; Logging into the system requires the same detailsras This also t0 Bank Slaff: Logeioge,nnere is no additional username or password required team and banding is fed into Care to Learn on & daily basle Staff iniormation including job role, information is used t0 identify ad allocate the from our Electronic Staff Record (ESR) this To ensure staff remain compllant email appropriate levei of iraining t0 the individuals to the expiry date then again month notifications from the are sent 3 months prior and individual staff before. At this {the manager also receives an emai' Gotficiatiodditian zgene aeminderg: a daily reeceive aoiemaii notification when they 90 out %f date In addition Tableau; fe60 froreivCared erearn otakenonto the Trusrs 'Business Inteligenceareoringmdariarviduableaan compliance at Trust; Team and Individual level and managers which displays access this information. [always improving /respectfutand kind makinga difference working together Gloucezler Business Park, Brockxcrth Gloucaster; GL3 AAW 2nnoar Avenuer key not and and applies profile. and system point and
'Resuscilation Bank' as an annual reguirement on therr teveing Curently Clinical Bank staff have to undertake either Level 2 or Level profiles and are provided with the option t0 choose with just one option is because the LMS Resuscitation training: The reason they are presented were not able to easily identify where hastnot previously been loaded with their location aswee that information regarding their Bank otanreveoworkinge However; recent work on this soirg Tforwar we will be able to use this to location is now being into Cere t0 Learro aniorgoianimg tatdeir proilbe abig teung that i9 looreiaccuracely allocate ihe correct Ilevel resuscieatiotiorainn9 ei theininghand, itherefore, fuoreeacana Staff will only be presented with one option for since Miss Kelly's death as have to choose the correct level for their role- This is a key which bank staff work: now be targeted to the requirements of the location in training can requirements is available on the e Additionally; the status Of al Bank Staffsetraleing bOopfiaacanaqalocaentneriavaa shit) Matron rostering Aliocate Sysiem (the system we use tocbook compliance. This means thateven eerard managers are thereiore aware ofCidvicinaing, areinecog oiancesite sewnole be #Tsomerindividuals are Out Of date Wfcispecullc train9indieidualdsavallabie each shift to respond meovie by ensuring that there are sufticiens frlllacier i2di7cbutsavawa more robust due to the to medical emergencies This system was in place in engde to matching locations to bank staff training improvements aware of the need to update risk assessments Speciaice llyppreverite 2: Staff needed to be 'thaecoidpe injurious to & patient. Specifically, action following a medical event suffered a similar choking incident in 2021. hearing with all clinical staff at Wotton Lawn Hospital We have shared the outcome of the that; following a medical emergency have aroduced a practice notice to remind clinic collaguen tonfironanghis has been circulated theevencis reviewed by the medical team/ward Doctor can mandates that following a medical theoegnoutthe site and discussed atteam eetingsenthe mticeheandatein te pafentgecord the evengngt thas the potential [0 hark asgesfnenzmentbe upobted acePracte Notice 5 ncluded medical history any relevant risk assessmentmustbe that we can evidence this in the Appendix 1_ We will also complete a quarterly to ensura as record and the resuit will be shared with the Hospital Matron: healthcare to assist Severine and speak to the 999-emergencyaceivico; was 3: A doctor; attempting mobile phone: He did not have the facility of a obliged to leave the to use a that he could have to the porigule (andline telephone which would have meant service without leaving the patient: Wotton Lawn i8 currently in the process %f testing Mitel DECat Modern Matron, from a base unit; SO we to ensure that phones arinethospital site Poriable landlines opeaacefroon he bag0unio Idistance proves to be pese have the range to function effectively at distance Wi-Fi based phones: We envisage too 'in some areas, we have a further option to explore will write again after this date to that permanene solution wili be in place by 1 May 2024, and provide confirmation Lawn hospital was unsure which ward he should attend A paramedic attending Wotton theshospital: This led to & delay in the paramedic due to lack of guidance from staff at attending on Severine: the outcome of the hearing with all clinical stafi at Wottoa As with the 21d issue; we have shared providing ciarity with the actions that must be Lawn Hospital and have produced a practice notice medical emergency can confirm aken wnenr emergency services have been Called to altendss meetings. The Practice beergecirculated throughout the site and discussed at team that this has Notice is included as Appendix 2. not pulled will not update can profiles. and: 'and audit patient - spoken need great
be uncertainty at which stage of & medical emergency a medical There seemed to service: professional should call the ambulance actions to be taken in the event %f 2 medical We have reviewed the existing process regarding have attached a copy of the Escalation emergency belleve that this remains fil for purpose; This forms of the Care of the Proergrurev Acitonecard for your Informatioeinforcderdial restsicitirons {Taining courses: Local Peeriorating Patient Policy and will be reinforced Jte a1 Iocal induction for new starters; escalalion procedures are also included as 10 OhCoss site aadmionduceosure thai staif have Gseraiorer arocaiton site shouid be famliarwvith sericuocchokingaepisode; we have develaped awareness of how to respond t0 serious choking Adult Choking (revised in simwuaatfioc sto complement the Resusciatiop; AntoreVeird Resusctatior Tfraning from choking "ZO22)whichohas been Included as part Of the Level 3 November have attached this scenario as Appendix 4 April 2024. 2022 appeared not to have a working intemal clock An AED used on the 1 October IPad SPIs supplied by Welmedical: We have liaised with The AEDs used by tne Trust are 'clocks on all devices are working but are at the Weimedical and can confim that the Internal changed by the end user remains unaffected ef manufacturing This function cannot be Importantly though, each time the Doiaroi loanutfatibraton and repiacemen alavenisridiatioe epgodanily thouge event involving AEDris activated, it keeps a timed log of all events but this will not necessarily Kelly. This timed lag forms the record af the response; Miss align with Greenwich Mean Time: with Miss Kelly's family and relay our deepest be Kvou could sharea copraoftesnqueoridentihedissk continue to reiect on the learning apoiogyogme gaps in service provisionafav be patients [cougedhe Changer made: from her death aim to improve the safety of patients If I can be of further assistance; please let me know:
'Resuscilation Bank' as an annual reguirement on therr teveing Curently Clinical Bank staff have to undertake either Level 2 or Level profiles and are provided with the option t0 choose with just one option is because the LMS Resuscitation training: The reason they are presented were not able to easily identify where hastnot previously been loaded with their location aswee that information regarding their Bank otanreveoworkinge However; recent work on this soirg Tforwar we will be able to use this to location is now being into Cere t0 Learro aniorgoianimg tatdeir proilbe abig teung that i9 looreiaccuracely allocate ihe correct Ilevel resuscieatiotiorainn9 ei theininghand, itherefore, fuoreeacana Staff will only be presented with one option for since Miss Kelly's death as have to choose the correct level for their role- This is a key which bank staff work: now be targeted to the requirements of the location in training can requirements is available on the e Additionally; the status Of al Bank Staffsetraleing bOopfiaacanaqalocaentneriavaa shit) Matron rostering Aliocate Sysiem (the system we use tocbook compliance. This means thateven eerard managers are thereiore aware ofCidvicinaing, areinecog oiancesite sewnole be #Tsomerindividuals are Out Of date Wfcispecullc train9indieidualdsavallabie each shift to respond meovie by ensuring that there are sufticiens frlllacier i2di7cbutsavawa more robust due to the to medical emergencies This system was in place in engde to matching locations to bank staff training improvements aware of the need to update risk assessments Speciaice llyppreverite 2: Staff needed to be 'thaecoidpe injurious to & patient. Specifically, action following a medical event suffered a similar choking incident in 2021. hearing with all clinical staff at Wotton Lawn Hospital We have shared the outcome of the that; following a medical emergency have aroduced a practice notice to remind clinic collaguen tonfironanghis has been circulated theevencis reviewed by the medical team/ward Doctor can mandates that following a medical theoegnoutthe site and discussed atteam eetingsenthe mticeheandatein te pafentgecord the evengngt thas the potential [0 hark asgesfnenzmentbe upobted acePracte Notice 5 ncluded medical history any relevant risk assessmentmustbe that we can evidence this in the Appendix 1_ We will also complete a quarterly to ensura as record and the resuit will be shared with the Hospital Matron: healthcare to assist Severine and speak to the 999-emergencyaceivico; was 3: A doctor; attempting mobile phone: He did not have the facility of a obliged to leave the to use a that he could have to the porigule (andline telephone which would have meant service without leaving the patient: Wotton Lawn i8 currently in the process %f testing Mitel DECat Modern Matron, from a base unit; SO we to ensure that phones arinethospital site Poriable landlines opeaacefroon he bag0unio Idistance proves to be pese have the range to function effectively at distance Wi-Fi based phones: We envisage too 'in some areas, we have a further option to explore will write again after this date to that permanene solution wili be in place by 1 May 2024, and provide confirmation Lawn hospital was unsure which ward he should attend A paramedic attending Wotton theshospital: This led to & delay in the paramedic due to lack of guidance from staff at attending on Severine: the outcome of the hearing with all clinical stafi at Wottoa As with the 21d issue; we have shared providing ciarity with the actions that must be Lawn Hospital and have produced a practice notice medical emergency can confirm aken wnenr emergency services have been Called to altendss meetings. The Practice beergecirculated throughout the site and discussed at team that this has Notice is included as Appendix 2. not pulled will not update can profiles. and: 'and audit patient - spoken need great
be uncertainty at which stage of & medical emergency a medical There seemed to service: professional should call the ambulance actions to be taken in the event %f 2 medical We have reviewed the existing process regarding have attached a copy of the Escalation emergency belleve that this remains fil for purpose; This forms of the Care of the Proergrurev Acitonecard for your Informatioeinforcderdial restsicitirons {Taining courses: Local Peeriorating Patient Policy and will be reinforced Jte a1 Iocal induction for new starters; escalalion procedures are also included as 10 OhCoss site aadmionduceosure thai staif have Gseraiorer arocaiton site shouid be famliarwvith sericuocchokingaepisode; we have develaped awareness of how to respond t0 serious choking Adult Choking (revised in simwuaatfioc sto complement the Resusciatiop; AntoreVeird Resusctatior Tfraning from choking "ZO22)whichohas been Included as part Of the Level 3 November have attached this scenario as Appendix 4 April 2024. 2022 appeared not to have a working intemal clock An AED used on the 1 October IPad SPIs supplied by Welmedical: We have liaised with The AEDs used by tne Trust are 'clocks on all devices are working but are at the Weimedical and can confim that the Internal changed by the end user remains unaffected ef manufacturing This function cannot be Importantly though, each time the Doiaroi loanutfatibraton and repiacemen alavenisridiatioe epgodanily thouge event involving AEDris activated, it keeps a timed log of all events but this will not necessarily Kelly. This timed lag forms the record af the response; Miss align with Greenwich Mean Time: with Miss Kelly's family and relay our deepest be Kvou could sharea copraoftesnqueoridentihedissk continue to reiect on the learning apoiogyogme gaps in service provisionafav be patients [cougedhe Changer made: from her death aim to improve the safety of patients If I can be of further assistance; please let me know: