Cornwall Partnership NHS Foundation Trust
NHS / Health Body
Action Planned
Cornwall Partnership NHS Foundation Trust will update a SOP and training video regarding side effects of anticoagulation medication, make POCT training mandatory, seek investment for additional CASP training sessions for registered community nurses and develop learning from experience posters. (AI summary)
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Dear Mr Cox
Regulation 28 report to prevent future deaths following the inquest into the death of Mrs Valerie Simmons
I am writing in response to the Regulation 28 report, in my role as Director of Nursing and Allied Health Professionals on behalf of Cornwall Partnership NHS Foundation Trust.
I wish to begin by offering my sincere condolences to Mrs Simmons’ family. I am deeply sorry for their loss.
In this letter I will outline the action we will take to address the concerns raised at Mrs Simmons’ inquest and to provide assurance that our learning has been identified and actioned. I will set out the context of the community nursing roles and responsibilities with patients receiving anticoagulant medication, explaining the polices and training currently in place.
Three meetings have been held during November 2023, with community nursing clinical, operational, and patient safety leads to understand the specific issues in this case to ensure the right response to the concerns you have raised:
Page 2
1. The use of observations when there is a change in a patient’s presentation.
2. Training related to the risks of hypovolaemia in an anti-coagulated patient. The community nursing service aims to deliver high quality nursing services spanning care pathways between primary and secondary care. This service provides a pivotal role ensuring the co-ordination and seamless provision of care to people in their place of residence, with the aim of promoting personalised and anticipatory care to promote independent living.
The Cornwall Partnership NHS Foundation Trust, (CFT) integrated community standard operating procedure (SOP), which includes community nursing, states that an integrated team core assessment is the agreed initial assessment which must be completed on a community nurses’ first visit to a patient. Additional assessments will be completed as clinically indicated. The expectation is that basic observations are taken on initial assessment as a baseline so that if the patient’s clinical presentation changes, they are repeated and compared.
In this case, Mrs Simmons was receiving regular visits by community nurses to administer anticoagulant injections and international normalised ratio (INR) point of care testing. Anticoagulants are used to reduce the risk of thrombo-embolic complications in patients at increased risk. People prescribed anticoagulant medication will routinely have a laboratory blood test performed to ensure their INR is within therapeutic limits. This ratio is a representation of the pro-thrombin time and is measurement of how long it takes the blood to clot. A high ratio INR may indicate an increased risk of bleeding, a low ratio may indicate a risk of blood clot development. Community nurses use a portable INR monitoring device for point of care testing, (POCT) providing an instant measurement of INR to reflect the anticoagulant. POCT is an established part of community nursing clinical practice and offers rapid provision of tests for people in their own homes. A CFT SOP has been developed to ensure that consistent procedures are in place throughout Cornwall. The SOP applies to both registered (e.g., nurses) and unregistered (e.g., health care assistants) community nursing staff members responsible for INR point of care testing. The procedure described in this standard should only be carried out by, registered and unregistered,
Page 3 members of the community nursing team who have been specifically trained and assessed as competent in the use of the INR POCT device, and who can demonstrate an understanding of the role of INR testing including a basic interpretation of the INR result. Practitioners must demonstrate competence and be signed off before performing this role. However, on review of the SOP and training video, conducted in response to the Regulation 28 report, we have identified that it does not include awareness on the tendency of patients taking anticoagulants to have bleeding complications such as haematomas, or how to manage the side effects/consequences for example hypovolaemia. (A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise. Sometimes, haematomas may not show up as a bruise and can be deeply located. Haematomas are usually caused by an injury to blood vessel walls [such as veins or arteries] which allow the blood to escape and collect together to form a lump).
The groups first recommendation for action to take in response to the Regulation 28 report is for an update of the INR POCT SOP and training video to include awareness of symptoms and prompt for basic observations in any change of clinical presentation such as a haematoma. The recommendation of the group is that POCT training is essential and mandatory for community nursing staff undertaking POCT as a clinical skill.
On review of training for community nursing, we have identified that the community assessment of sick patient training, (CASP) is a mandatory training requirement for the acute care at home and home first teams only. As a result of learning from this incident, the group has recommended that CASP would be an advantageous course to be added to the registered community nurse’s mandatory training, particularly as the acuity of patients in the community is increasing.
The CASP training will update mandatory skills for registered community nurses to cover:
• Recognition of the deteriorating patient.
Page 4
• NEWS2 assessment (National Early Warning Score which is a tool to improve the detection and response to clinical deterioration in adult patients).
• Communication including the importance of documentation.
• Sepsis
• Anaphylaxis
• Acute kidney injury
• Diabetes (including Hypoglycaemia)
• Breathing issues
• Clinical observations and physical health assessment
The training will support community nurses to use clinical observations when there is a change in patients’ clinical presentation.
This recommendation will lead to 260 staff needing additional CASP training which will require 3-4 further courses to be delivered per year. The decision has been made to follow this recommendation.
We recognise that policy updates and training changes can take time. To reassure the family, as part of our meetings, we have undertaken learning from experience to develop a poster which will be shared across all community nursing teams demonstrating the importance of recognising the signs of a deteriorating patient and highlighting the importance of taking and recording basic observations when there is change in clinical presentation.
Thank you for highlighting your concerns. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
Page 5
Regulation 28 report to prevent future deaths following the inquest into the death of Mrs Valerie Simmons
I am writing in response to the Regulation 28 report, in my role as Director of Nursing and Allied Health Professionals on behalf of Cornwall Partnership NHS Foundation Trust.
I wish to begin by offering my sincere condolences to Mrs Simmons’ family. I am deeply sorry for their loss.
In this letter I will outline the action we will take to address the concerns raised at Mrs Simmons’ inquest and to provide assurance that our learning has been identified and actioned. I will set out the context of the community nursing roles and responsibilities with patients receiving anticoagulant medication, explaining the polices and training currently in place.
Three meetings have been held during November 2023, with community nursing clinical, operational, and patient safety leads to understand the specific issues in this case to ensure the right response to the concerns you have raised:
Page 2
1. The use of observations when there is a change in a patient’s presentation.
2. Training related to the risks of hypovolaemia in an anti-coagulated patient. The community nursing service aims to deliver high quality nursing services spanning care pathways between primary and secondary care. This service provides a pivotal role ensuring the co-ordination and seamless provision of care to people in their place of residence, with the aim of promoting personalised and anticipatory care to promote independent living.
The Cornwall Partnership NHS Foundation Trust, (CFT) integrated community standard operating procedure (SOP), which includes community nursing, states that an integrated team core assessment is the agreed initial assessment which must be completed on a community nurses’ first visit to a patient. Additional assessments will be completed as clinically indicated. The expectation is that basic observations are taken on initial assessment as a baseline so that if the patient’s clinical presentation changes, they are repeated and compared.
In this case, Mrs Simmons was receiving regular visits by community nurses to administer anticoagulant injections and international normalised ratio (INR) point of care testing. Anticoagulants are used to reduce the risk of thrombo-embolic complications in patients at increased risk. People prescribed anticoagulant medication will routinely have a laboratory blood test performed to ensure their INR is within therapeutic limits. This ratio is a representation of the pro-thrombin time and is measurement of how long it takes the blood to clot. A high ratio INR may indicate an increased risk of bleeding, a low ratio may indicate a risk of blood clot development. Community nurses use a portable INR monitoring device for point of care testing, (POCT) providing an instant measurement of INR to reflect the anticoagulant. POCT is an established part of community nursing clinical practice and offers rapid provision of tests for people in their own homes. A CFT SOP has been developed to ensure that consistent procedures are in place throughout Cornwall. The SOP applies to both registered (e.g., nurses) and unregistered (e.g., health care assistants) community nursing staff members responsible for INR point of care testing. The procedure described in this standard should only be carried out by, registered and unregistered,
Page 3 members of the community nursing team who have been specifically trained and assessed as competent in the use of the INR POCT device, and who can demonstrate an understanding of the role of INR testing including a basic interpretation of the INR result. Practitioners must demonstrate competence and be signed off before performing this role. However, on review of the SOP and training video, conducted in response to the Regulation 28 report, we have identified that it does not include awareness on the tendency of patients taking anticoagulants to have bleeding complications such as haematomas, or how to manage the side effects/consequences for example hypovolaemia. (A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise. Sometimes, haematomas may not show up as a bruise and can be deeply located. Haematomas are usually caused by an injury to blood vessel walls [such as veins or arteries] which allow the blood to escape and collect together to form a lump).
The groups first recommendation for action to take in response to the Regulation 28 report is for an update of the INR POCT SOP and training video to include awareness of symptoms and prompt for basic observations in any change of clinical presentation such as a haematoma. The recommendation of the group is that POCT training is essential and mandatory for community nursing staff undertaking POCT as a clinical skill.
On review of training for community nursing, we have identified that the community assessment of sick patient training, (CASP) is a mandatory training requirement for the acute care at home and home first teams only. As a result of learning from this incident, the group has recommended that CASP would be an advantageous course to be added to the registered community nurse’s mandatory training, particularly as the acuity of patients in the community is increasing.
The CASP training will update mandatory skills for registered community nurses to cover:
• Recognition of the deteriorating patient.
Page 4
• NEWS2 assessment (National Early Warning Score which is a tool to improve the detection and response to clinical deterioration in adult patients).
• Communication including the importance of documentation.
• Sepsis
• Anaphylaxis
• Acute kidney injury
• Diabetes (including Hypoglycaemia)
• Breathing issues
• Clinical observations and physical health assessment
The training will support community nurses to use clinical observations when there is a change in patients’ clinical presentation.
This recommendation will lead to 260 staff needing additional CASP training which will require 3-4 further courses to be delivered per year. The decision has been made to follow this recommendation.
We recognise that policy updates and training changes can take time. To reassure the family, as part of our meetings, we have undertaken learning from experience to develop a poster which will be shared across all community nursing teams demonstrating the importance of recognising the signs of a deteriorating patient and highlighting the importance of taking and recording basic observations when there is change in clinical presentation.
Thank you for highlighting your concerns. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
Page 5