University Hospital of Derby and Burton
NHS / Health Body
Action Taken
UHDB already had a SBAR form for transferring patients within site and out to community sites and a STOP Safe Transfer of the Patient Tool for acute to acute ambulance hospital transfers. The Derbyshire Shared Care Record became operational in December 2021 to improve information sharing between health and social care professionals. (AI summary)
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Dear Miss Kaushal We are writing in response to your Regulation 28 report (undated) following the conclusion of the inquest touching upon the death of Mr Kenneth Perkins on 28 April 2022. This is a joint response to the Regulation 28 report prepared by UDHB and OCHS. UHDB received a copy of the Regulation 28 report on 29 June 2022. OCHS were first notified of the Regulation 28 report on 19 July 2022 following contact from UHDB. During the inquest you identified concerns with the process of information sharing between care providers on transfer. Further evidence was submitted by both Trusts before the final hearing on 28 April 2022. UHDB were advised that no witnesses were required to attend on 28 April 2022, and OCHS were not aware of the final hearing date and were unrepresented. The Coroner's concerns are noted as follows in the Regulation 28 report: Mr Perkins was transferred from 1/keston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls. The Royal Derby Hospital did not (but should have) requested a transfer document from 1/keston. That history would have allowed an enhanced level ofcare and obseNation to be put in place so as to prevent further falls. Community to acute hospital transfer
Chair: Interim Chief Executive.
Please visit www.uhdb.nhs.uk for the latest advice on attending our hospitals during COVID-19.
OCHS response: In line with the evidence already submitted to the Court, DHCS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for OCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins. In cases involving an emergency transfer, a Nurse on the Ward will complete a SBAR form (Situation, Background, Assessment, Recommendation). The SBAR form is a nationally recognised, easy to use, structured form of communication that enables information to be transferred accurately between individuals. The SBAR consists of standardised prompt questions in four sections to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition and the likelihood for errors. As the structure is shared, it also helps staff anticipate the information needed by colleagues and encourages assessment skills. Using SBAR prompts staff to formulate information with the right level of detail. The four sections are:
• Situation - what the Nurse has found i.e., a patient with a suspected stroke.
• Background - Medical History, dates of admission reason for admission to ward.
• Assessment-Observations, what the Nurse believes the problem to be.
• Recommendation - what course of action has been decided on, for example transfer to Hospital. The policy and process are well embedded within OCHS and we are not aware of any incidents or complaints relating to patients being transferred to an Acute Hospital without the appropriate documentation or medication. UHDB response: UHOB received an SBAR handover from staff at llkeston Community Hospital. Matron Campbell confirmed this in her supplemental report and explained that under risk factors the following is documented: under the moving and handling 'WZF plus 1 (wheeled zimmer frame and the assistance of 1 member of staff)" and under additional information "falls - high risk". The information from the transferring care provider is taken into consideration by the Trust, but it is not decisive. On admission to the Trust staff should complete further assessments to assess the patient's abilities and needs at that specific time, including mental capacity and falls risk assessment. If the transferring care provider sends no information on transfer, the expectation is that nursing staff at UHDB will telephone the care provider to obtain update to date information about the patient. Matron confirmed that this is well embedded into practice at the Trust. As UHDB received a completed form detailing mobility and falls risk, there was no indication to contact ICH for further information.
Developments in information sharing Updated transfer documentation at UDHB UHDB had already identified the need to strengthen and reinforce accurate and timely communication on transfer of patients. UHDB already had a SBAR form used for transferring patients within site (completed electronically) on extramed) and out to community sites (paper based) (appendix 1 ), this has been in place on the Derby sites since 2015 and was implemented across Burton sites in November 2021. A further form the STOP Safe Transfer of the Patient Tool (appendix 2) has been developed for acute to acute ambulance hospital transfers and was introduced in November 2021 . This form is mainly used for transfers between Emergency Departments and high dependency areas (respiratory and renal). Cascade training in these areas was used to support implementation. Derbyshire Shared Care Record In order to better improve the sharing of information about Patients in Derbyshire the Integrated Care System (Joined Up Care Derbyshire) developed the Derbyshire Shared Care Record. This became operational in December 2021. It means that health and social care professionals working across all Derby and Derbyshire's NHS and local authority organisations are able to access the same, appropriate information to support their care of individual patients. This is completely confidential and secure and is designed to help doctors, nurses and other health and social care professionals directly involved in a patient or client's care to make better, safer decisions. All Joined Up Care Derbyshire health and social care organisations are participating in the Derbyshire Shared Care Record. This includes both OCHS and UHDB. Please do not hesitate to let us know if you require any further information. We are satisfied that appropriate processes are in place to support information sharing between care providers. Best wishes
Interim Chief Executive Chief Executive
Chair: Interim Chief Executive.
Please visit www.uhdb.nhs.uk for the latest advice on attending our hospitals during COVID-19.
OCHS response: In line with the evidence already submitted to the Court, DHCS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for OCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins. In cases involving an emergency transfer, a Nurse on the Ward will complete a SBAR form (Situation, Background, Assessment, Recommendation). The SBAR form is a nationally recognised, easy to use, structured form of communication that enables information to be transferred accurately between individuals. The SBAR consists of standardised prompt questions in four sections to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition and the likelihood for errors. As the structure is shared, it also helps staff anticipate the information needed by colleagues and encourages assessment skills. Using SBAR prompts staff to formulate information with the right level of detail. The four sections are:
• Situation - what the Nurse has found i.e., a patient with a suspected stroke.
• Background - Medical History, dates of admission reason for admission to ward.
• Assessment-Observations, what the Nurse believes the problem to be.
• Recommendation - what course of action has been decided on, for example transfer to Hospital. The policy and process are well embedded within OCHS and we are not aware of any incidents or complaints relating to patients being transferred to an Acute Hospital without the appropriate documentation or medication. UHDB response: UHOB received an SBAR handover from staff at llkeston Community Hospital. Matron Campbell confirmed this in her supplemental report and explained that under risk factors the following is documented: under the moving and handling 'WZF plus 1 (wheeled zimmer frame and the assistance of 1 member of staff)" and under additional information "falls - high risk". The information from the transferring care provider is taken into consideration by the Trust, but it is not decisive. On admission to the Trust staff should complete further assessments to assess the patient's abilities and needs at that specific time, including mental capacity and falls risk assessment. If the transferring care provider sends no information on transfer, the expectation is that nursing staff at UHDB will telephone the care provider to obtain update to date information about the patient. Matron confirmed that this is well embedded into practice at the Trust. As UHDB received a completed form detailing mobility and falls risk, there was no indication to contact ICH for further information.
Developments in information sharing Updated transfer documentation at UDHB UHDB had already identified the need to strengthen and reinforce accurate and timely communication on transfer of patients. UHDB already had a SBAR form used for transferring patients within site (completed electronically) on extramed) and out to community sites (paper based) (appendix 1 ), this has been in place on the Derby sites since 2015 and was implemented across Burton sites in November 2021. A further form the STOP Safe Transfer of the Patient Tool (appendix 2) has been developed for acute to acute ambulance hospital transfers and was introduced in November 2021 . This form is mainly used for transfers between Emergency Departments and high dependency areas (respiratory and renal). Cascade training in these areas was used to support implementation. Derbyshire Shared Care Record In order to better improve the sharing of information about Patients in Derbyshire the Integrated Care System (Joined Up Care Derbyshire) developed the Derbyshire Shared Care Record. This became operational in December 2021. It means that health and social care professionals working across all Derby and Derbyshire's NHS and local authority organisations are able to access the same, appropriate information to support their care of individual patients. This is completely confidential and secure and is designed to help doctors, nurses and other health and social care professionals directly involved in a patient or client's care to make better, safer decisions. All Joined Up Care Derbyshire health and social care organisations are participating in the Derbyshire Shared Care Record. This includes both OCHS and UHDB. Please do not hesitate to let us know if you require any further information. We are satisfied that appropriate processes are in place to support information sharing between care providers. Best wishes
Interim Chief Executive Chief Executive