Royal United Hospitals Bath NHS Foundation Trust
NHS / Health Body
Action Taken
The Tissue Viability Nursing Team has conducted face-to-face training for all substantive nursing staff, physiotherapists, and occupational therapists on Pierce Ward. Other actions include increasing staffing levels, introducing bedside patient care handovers, and piloting a bespoke Tissue Viability monitoring tool. (AI summary)
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Dear Madam
Response to Regulation 28 Report Regarding Mr Alan Nippard
On the 24th July 2023 a Regulation 28 Report was received, raising the following concern:
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on: risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.
The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SSKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.
A number of other actions have been implemented which include: increasing staffing levels 24 hours per day, the introduction of bedside patient care handovers, the monitoring of comfort- rounds, Senior Sister and Matron ward rounds, checking on patient safety, patient experience, patient care and nursing documentation.
A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and action actions are in place to achieve 95%. Directors’ Office Royal United Hospitals Bath NHS Foundation Trust Combe Park Bath BA1 3NG
I have met with Mr Nippard’s family a number of times and I have shared with them my sincere apologies for the failings in his care. We are committed to ensuring our care does not fall below the standards we expect and these actions will continue to prevent similar lapses of care occurring in the future.
Response to Regulation 28 Report Regarding Mr Alan Nippard
On the 24th July 2023 a Regulation 28 Report was received, raising the following concern:
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on: risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.
The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SSKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.
A number of other actions have been implemented which include: increasing staffing levels 24 hours per day, the introduction of bedside patient care handovers, the monitoring of comfort- rounds, Senior Sister and Matron ward rounds, checking on patient safety, patient experience, patient care and nursing documentation.
A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and action actions are in place to achieve 95%. Directors’ Office Royal United Hospitals Bath NHS Foundation Trust Combe Park Bath BA1 3NG
I have met with Mr Nippard’s family a number of times and I have shared with them my sincere apologies for the failings in his care. We are committed to ensuring our care does not fall below the standards we expect and these actions will continue to prevent similar lapses of care occurring in the future.