Devon Partnership NHS Trust
NHS / Health Body
Action Taken
Devon Partnership NHS Trust highlights existing policies and practices: ward managers are responsible for ensuring staff are familiar with policy and trained, daily risk meetings take place, and the hospital operates a risk recording system. It will conduct monthly audits of patient observation charts and update patient information sharing procedures. (AI summary)
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CONFIDENTIAL Trust Headquarters Wonford House Dryden Road Exeter EX2 9AF
Date: 5 February 2024 Re. Paul Perrott Regulation 28 Report for the attention of Deborah Archer – Assistant Coroner, Plymouth Torbay and South Devon. REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:
1. Devon Partnership NHS Trust
2. , Langdon Hospital
3. , Langdon Hospital ACTION SHOULD BE TAKEN Although there have already been changes made to policies and procedures in the hospital arising out of this death action should be taken:
• To review the procedures in place on the wards to ensure that observation charts are regularly checked by ward management and concerns fed back to staff quickly and appropriately
• To ensure that staff members are required and able to easily familiarise themselves with the full history in relation to each patient they care for as opposed to simply being made aware of any risks that present on the day which may not take account of historical or contextual risk. Audit Process and Checking Of Completion of Observations The therapeutic engagement and observation policy (CO6) appendix 1 clearly states the responsibilities of staff in respect of completing patient observations. In addition, “the nurse in charge is responsible for ensuring that there are adequate staff resources for the implementation of engagement and observations and that all staff required to undertake these are competent to carry out this task”. The policy also states the responsibilities of individual staff as detailed below. Ward Managers are responsible for ensuring that all their staff are familiar with this policy and are trained in the implementation of engagement and observations for the inpatients on their
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ward. The Therapeutic Engagement and Observation Competency Assessment has been developed to assist with this and to record that training has taken place. Nurse in Charge: The inpatient nurse in charge of the shift is responsible for ensuring that all staff authorised or delegated to carry out the intervention of engagement and observations are competent to carry out this task. This includes any Allied Health Professionals, Bank or agency staff who are requested to undertake this duty. All inpatient Registered staff - have a professional obligation and individual accountability for their practice and are responsible for ensuring they are familiar with this policy, adhere to its requirements and associated procedures. This includes ensuring all documentation is uploaded to the Digital Care Record in the correct place. Delegation to Unregistered Staff and Students: The Registered Nurse remains accountable for the decision to delegate engagement and observation to an unregistered member of staff or student in training, also for ensuring they are sufficiently knowledgeable and competent to undertake the role. Students may only undertake solo engagement and observation following an assessment of their competence and confidence by their mentor and once the Therapeutic Engagement and Observation Competency Assessment has been completed. Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meeting. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards. An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing. Evidence previously provided to the coroner highlighted there is a regular audit process in place regarding the quality monitoring of observations but this is a retrospective audit. The amendment to policy will ensure all staff are clear on responsibilities for checking observation completion on a shift by shift basis and actions to be taken where gaps or omissions are identified. In addition, the patient observation record has a tick box on each observation sheet where the nurse in charge adds their initials to evidences completion on a shift by shift basis. This has been reviewed on each inpatient ward by the senior nurse manager to check it is being completed by the nurse in charge. Clinical Risk Assessment for Patients All clinicians and practitioners are responsible for developing, updating and maintaining their competencies in relation to assessing, formulating and managing clinical risks. Registrant Clinical staff complete this training 3 yearly as a minimum requirement. The Clinical risk assessment policy focus on risk to self is the same as the general principles for clinical risk assessment. This is that each patient has a personalised risk assessment which outlines potential risks, the immediacy and severity of those risks, whether a clinical risk
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is stable, increasing or decreasing and what protective measures can be put in place to manage the risk. Mental state examination is a key factor in assessing risk as well as historical, static and dynamic risk factors. A mental state examination consists of a review of a patient’s appearance and behaviour, speech, mood, affect (observed emotional state), thoughts, perceptions, cognition and insight. Mental state examination focuses on a person’s state of mind at the time of the assessment. In addition, where applicable, patients are offered 1:1 sessions by clinicians. Significant and complex risk (or the potential for those risks) should be discussed in a multi disciplinary team meeting and reviewed at regular intervals until the risk is felt to have reduced. This is regarded as a good practice (4 steps to safety programme). This is already embedded in the hospital. This model acknowledges the dynamic nature of risk and the significance of relevant historical risk factors. In addition, it allows for flexibility in making adjustments to risk management plans. The ward handover document has been re-designed. As such, there is a document for each patient which has a photograph of the patient and a section where key historical risk is recorded. This approach makes it possible for a new staff to the ward to have quick access to useful historical risk information during their shifts. This takes into consideration that most patients have lengthy hospital stay with a significant amount of information within the clinical patient record. The handover document is accessible to staff both in hardcopy and electronically. In addition, the new electronic recording platform has been designed in such a way that all clinically relevant risk information are captured on a single domain. This can be updated as new information is received. This is a departure from a system of multiple risk information recording domains. This document is accessible to ward staff even when a patient moves to another ward. The hospital also employs the use of HCR-20 (Historical Clinical Risk management) tool. This recommended tool is a structured tool to assess the risk of violence and it records historical risk factors in details. The task of completing the HCR-20 document is usually undertaken by the hospital psychology department. The document is presented and shared with members of the Multidisciplinary team after 3 months of admission then every 6 months till a patient is discharged. The HCR-20 assessment is completed for every patient. This is also stored electronically and available to all staff. Besides documentations, relevant historical factors are discussed in risk meetings attended by members of the multidisciplinary team. There is a daily risk meeting (except Tuesday when clinical review meetings take place) on all the wards. Furthermore, historical risk information are discussed, shared and recorded in patient’s note between teams when a patient moves ward. Relevant to risk management, the Trust operates a Risk recording system. There is an already embedded practice where an account of incident is recorded electronically and once uploaded, this is risk information is immediately cascaded electronically to members of the multidisciplinary team and hospital managers. This is received via their NHS emails. The hospital holds a Directorate operational meeting three times a week. This is attended by ward managers, clinicians, senior nurses, managers and profession Leads. Any significant risk event within the directorate is discussed and learning is shared. The risk information as part of the message from the meeting is cascaded via email to all staff.
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As part of risk management, the hospital added a practice in 2020 that ensures there is also staff member in the main ward area who is able to identify any risk issue and respond appropriately.
- MSc RGN RMN Executive Chief Nursing Officer & Allied Professions Lead Director of Infection Prevention & Control Trusts Caldicott Guardian Honorary Senior Lecturer University of Exeter. Signed: Date: 05/02/2024
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Date: 5 February 2024 Re. Paul Perrott Regulation 28 Report for the attention of Deborah Archer – Assistant Coroner, Plymouth Torbay and South Devon. REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:
1. Devon Partnership NHS Trust
2. , Langdon Hospital
3. , Langdon Hospital ACTION SHOULD BE TAKEN Although there have already been changes made to policies and procedures in the hospital arising out of this death action should be taken:
• To review the procedures in place on the wards to ensure that observation charts are regularly checked by ward management and concerns fed back to staff quickly and appropriately
• To ensure that staff members are required and able to easily familiarise themselves with the full history in relation to each patient they care for as opposed to simply being made aware of any risks that present on the day which may not take account of historical or contextual risk. Audit Process and Checking Of Completion of Observations The therapeutic engagement and observation policy (CO6) appendix 1 clearly states the responsibilities of staff in respect of completing patient observations. In addition, “the nurse in charge is responsible for ensuring that there are adequate staff resources for the implementation of engagement and observations and that all staff required to undertake these are competent to carry out this task”. The policy also states the responsibilities of individual staff as detailed below. Ward Managers are responsible for ensuring that all their staff are familiar with this policy and are trained in the implementation of engagement and observations for the inpatients on their
LEGAL\65940745v1 1
ward. The Therapeutic Engagement and Observation Competency Assessment has been developed to assist with this and to record that training has taken place. Nurse in Charge: The inpatient nurse in charge of the shift is responsible for ensuring that all staff authorised or delegated to carry out the intervention of engagement and observations are competent to carry out this task. This includes any Allied Health Professionals, Bank or agency staff who are requested to undertake this duty. All inpatient Registered staff - have a professional obligation and individual accountability for their practice and are responsible for ensuring they are familiar with this policy, adhere to its requirements and associated procedures. This includes ensuring all documentation is uploaded to the Digital Care Record in the correct place. Delegation to Unregistered Staff and Students: The Registered Nurse remains accountable for the decision to delegate engagement and observation to an unregistered member of staff or student in training, also for ensuring they are sufficiently knowledgeable and competent to undertake the role. Students may only undertake solo engagement and observation following an assessment of their competence and confidence by their mentor and once the Therapeutic Engagement and Observation Competency Assessment has been completed. Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meeting. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards. An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing. Evidence previously provided to the coroner highlighted there is a regular audit process in place regarding the quality monitoring of observations but this is a retrospective audit. The amendment to policy will ensure all staff are clear on responsibilities for checking observation completion on a shift by shift basis and actions to be taken where gaps or omissions are identified. In addition, the patient observation record has a tick box on each observation sheet where the nurse in charge adds their initials to evidences completion on a shift by shift basis. This has been reviewed on each inpatient ward by the senior nurse manager to check it is being completed by the nurse in charge. Clinical Risk Assessment for Patients All clinicians and practitioners are responsible for developing, updating and maintaining their competencies in relation to assessing, formulating and managing clinical risks. Registrant Clinical staff complete this training 3 yearly as a minimum requirement. The Clinical risk assessment policy focus on risk to self is the same as the general principles for clinical risk assessment. This is that each patient has a personalised risk assessment which outlines potential risks, the immediacy and severity of those risks, whether a clinical risk
LEGAL\65940745v1 2
is stable, increasing or decreasing and what protective measures can be put in place to manage the risk. Mental state examination is a key factor in assessing risk as well as historical, static and dynamic risk factors. A mental state examination consists of a review of a patient’s appearance and behaviour, speech, mood, affect (observed emotional state), thoughts, perceptions, cognition and insight. Mental state examination focuses on a person’s state of mind at the time of the assessment. In addition, where applicable, patients are offered 1:1 sessions by clinicians. Significant and complex risk (or the potential for those risks) should be discussed in a multi disciplinary team meeting and reviewed at regular intervals until the risk is felt to have reduced. This is regarded as a good practice (4 steps to safety programme). This is already embedded in the hospital. This model acknowledges the dynamic nature of risk and the significance of relevant historical risk factors. In addition, it allows for flexibility in making adjustments to risk management plans. The ward handover document has been re-designed. As such, there is a document for each patient which has a photograph of the patient and a section where key historical risk is recorded. This approach makes it possible for a new staff to the ward to have quick access to useful historical risk information during their shifts. This takes into consideration that most patients have lengthy hospital stay with a significant amount of information within the clinical patient record. The handover document is accessible to staff both in hardcopy and electronically. In addition, the new electronic recording platform has been designed in such a way that all clinically relevant risk information are captured on a single domain. This can be updated as new information is received. This is a departure from a system of multiple risk information recording domains. This document is accessible to ward staff even when a patient moves to another ward. The hospital also employs the use of HCR-20 (Historical Clinical Risk management) tool. This recommended tool is a structured tool to assess the risk of violence and it records historical risk factors in details. The task of completing the HCR-20 document is usually undertaken by the hospital psychology department. The document is presented and shared with members of the Multidisciplinary team after 3 months of admission then every 6 months till a patient is discharged. The HCR-20 assessment is completed for every patient. This is also stored electronically and available to all staff. Besides documentations, relevant historical factors are discussed in risk meetings attended by members of the multidisciplinary team. There is a daily risk meeting (except Tuesday when clinical review meetings take place) on all the wards. Furthermore, historical risk information are discussed, shared and recorded in patient’s note between teams when a patient moves ward. Relevant to risk management, the Trust operates a Risk recording system. There is an already embedded practice where an account of incident is recorded electronically and once uploaded, this is risk information is immediately cascaded electronically to members of the multidisciplinary team and hospital managers. This is received via their NHS emails. The hospital holds a Directorate operational meeting three times a week. This is attended by ward managers, clinicians, senior nurses, managers and profession Leads. Any significant risk event within the directorate is discussed and learning is shared. The risk information as part of the message from the meeting is cascaded via email to all staff.
LEGAL\65940745v1 3
As part of risk management, the hospital added a practice in 2020 that ensures there is also staff member in the main ward area who is able to identify any risk issue and respond appropriately.
- MSc RGN RMN Executive Chief Nursing Officer & Allied Professions Lead Director of Infection Prevention & Control Trusts Caldicott Guardian Honorary Senior Lecturer University of Exeter. Signed: Date: 05/02/2024
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