Derbyshire County Council
Local Authority
Action Planned
AI-generated response summary
• Derbyshire County Council confirmed it had disseminated urgent communications to care homes, ambulance trusts, and hospital trusts regarding the Red Bag scheme and transfer guidance. • It confirmed the Clinical Commissioning Group lead had met with Deputy Directors of Nursing from Acute Trusts to agree internal actions for effective handover communications. • The council stated it would review the sustainability of the Red Bag pathway, implement an interim transfer document, and expedite a digital records initiative.
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Dear Sir Thank you for your letter dated 30th May 2022, which included the Regulation 28 report regarding the death of Mark Edwin Sumnall. Derbyshire County Council’s Adult Social Care department has now had the opportunity to review the concerns you have identified following your investigation into the death of Mark Edwin Sumnall and to work with partners across the health and social care system to develop an appropriate action plan in response to this. The Derbyshire Care Home Red Bag scheme was launched in 2018 with the intention that the integrated pathway would enable care homes, ambulance services and hospitals to meet the requirements of NICE guideline NG27: Transition between inpatient hospital setting and community or care homes. The red bag is clearly identifiable and is a convenient, and transportable way of ensuring that all the necessary documents and personal items of the care home resident follow them from their care home to hospital, during their hospital stay, and following discharge, back to their care home. It is designed to hold all the essential belongings and standardised documentation that care home and hospital staff need when an individual is admitted to hospital and was implemented as a quality assurance mechanism. Our investigation has identified that there has not been sustained leadership and ongoing system commitment to the scheme despite strong leadership, as well as scheme champions, during the launch and early phases of the scheme. The funding for the scheme was for a fixed term and enabled the initial launch as well as a small stock of red bags to be available to replace any that had been lost during the first few years of the scheme; however, it did not facilitate sustainability of the scheme. As with any quality assurance mechanism, the scheme required continued action to ensure it was effective and this included: project staff time to continue to raise awareness of the scheme via induction training and regular communication with all agencies involved as well as quality monitoring work to ensure the scheme was working effectively and any quality improvement work required was acted upon. The Email:
Date: 21st July 2022 Our Ref: GP Mr Peter Nieto Area Coroner for Derby & Derbyshire, Derby Coroner’s Court, St Katherine’s House St Mary’s Wharf, Mansfield Road, Derby, DE1 3TQ
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effectiveness of the scheme relied upon multi-agency workers knowing of the scheme and ensuring that they implemented it for each admission to hospital from a care home. Our investigation has highlighted that there has not been consistent leadership of the scheme across our system.
As a result of the regulation 28 report, Derbyshire County Council’s Adult Social Care department has taken the following action:
• Met with our colleagues in the Clinical Commissioning Group (CCG) to discuss the Regulation 28 report and actions that need to be taken to prevent future deaths associated with urgent transfer from care homes to hospital
• We have discussed this matter at our system Integrated Care Homes Steering Group on the 22nd June 2022 and agreed as a local system that actions required will be reported to and monitored by the Integrated Care Homes Steering Group. Leads for this work have been identified in Adult Social Care and in the CCG.
• Those leads met on the 24th June 2022 and agreed the following actions:
1. Develop, approve and disseminate urgent communications to care homes asking them to utilise red bags where they have them. Review previous guidance on the scheme and revise and develop guidance on formal communication and handover requirements when transferring a resident to hospital where they do not have a red bag. The timescale for completion of this was by the end of July 2022 and it has been completed.
2. Revise, approve and distribute urgent communications to ambulance trust and hospital trusts previous guidance regarding red bags. Include that a number of red bags continue to be used across Derbyshire, that we are reviewing long term sustainability and ensure all staff members are aware of the contents of the red bag and the importance of them checking the contents as they include crucial information regarding individuals’ needs and any associated risks. The timescale for completion was by the end of July 2022 – and this has been completed.
3. For the CCG lead to meet with the Deputy Directors of Nursing from both Acute Trusts to agree the internal actions each will take to ensure effective and robust handover communications when receiving patients into the hospital in both the emergency department and on assessment and treatment wards. This will include investigation of the contents of red bags when they are used by care homes. The timescale for completion of this was by the end of July 2022 and this has been completed.
4. Review the sustainability of the red bag pathway including consideration of the risks associated with it and opportunities to implement a sustainable approach across the whole of the County footprint. Implement an interim transfer document for use when transferring individuals from care homes to hospital and hospital to care homes pending the digital solution being implemented. The timescale for full roll-out of this across Derbyshire is by the end of September 2022.
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5. Review the Urgent transfer from care home to hospital information standard and link with the local NHS and Local Authority digital transformation leads to expedite an Integrated Care System-wide initiative to implement the new digital standards. This would enable care homes to digitise and transfer individuals’ records electronically to hospital containing all relevant information. The timeframe for the discussion with local NHS and Local Authority digital transformation leads is the end of August 2022. By March 2024, 80% of adult social care providers registered with the Care Quality Commission will have digital social care records, with progress well underway for the remaining 20% by that date.
6. For effective quality monitoring and assurance mechanisms to be implemented and delivered across care home provision, ambulance and hospital trusts to monitor compliance and impact of the above actions and taking corrective action where indicated. For performance to be reported to the integrated Care Homes Steering Group for monitoring and multi-agency action. The timescale for implementation of this is from August 2022 on an ongoing basis.
I trust that this provides you with the assurance that we are taking all appropriate actions to prevent avoidable deaths of this nature in Derbyshire County Council’s Adult Social Care department and across the health and social care system where robust communication at all stages between organisations would have made a difference.
Date: 21st July 2022 Our Ref: GP Mr Peter Nieto Area Coroner for Derby & Derbyshire, Derby Coroner’s Court, St Katherine’s House St Mary’s Wharf, Mansfield Road, Derby, DE1 3TQ
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effectiveness of the scheme relied upon multi-agency workers knowing of the scheme and ensuring that they implemented it for each admission to hospital from a care home. Our investigation has highlighted that there has not been consistent leadership of the scheme across our system.
As a result of the regulation 28 report, Derbyshire County Council’s Adult Social Care department has taken the following action:
• Met with our colleagues in the Clinical Commissioning Group (CCG) to discuss the Regulation 28 report and actions that need to be taken to prevent future deaths associated with urgent transfer from care homes to hospital
• We have discussed this matter at our system Integrated Care Homes Steering Group on the 22nd June 2022 and agreed as a local system that actions required will be reported to and monitored by the Integrated Care Homes Steering Group. Leads for this work have been identified in Adult Social Care and in the CCG.
• Those leads met on the 24th June 2022 and agreed the following actions:
1. Develop, approve and disseminate urgent communications to care homes asking them to utilise red bags where they have them. Review previous guidance on the scheme and revise and develop guidance on formal communication and handover requirements when transferring a resident to hospital where they do not have a red bag. The timescale for completion of this was by the end of July 2022 and it has been completed.
2. Revise, approve and distribute urgent communications to ambulance trust and hospital trusts previous guidance regarding red bags. Include that a number of red bags continue to be used across Derbyshire, that we are reviewing long term sustainability and ensure all staff members are aware of the contents of the red bag and the importance of them checking the contents as they include crucial information regarding individuals’ needs and any associated risks. The timescale for completion was by the end of July 2022 – and this has been completed.
3. For the CCG lead to meet with the Deputy Directors of Nursing from both Acute Trusts to agree the internal actions each will take to ensure effective and robust handover communications when receiving patients into the hospital in both the emergency department and on assessment and treatment wards. This will include investigation of the contents of red bags when they are used by care homes. The timescale for completion of this was by the end of July 2022 and this has been completed.
4. Review the sustainability of the red bag pathway including consideration of the risks associated with it and opportunities to implement a sustainable approach across the whole of the County footprint. Implement an interim transfer document for use when transferring individuals from care homes to hospital and hospital to care homes pending the digital solution being implemented. The timescale for full roll-out of this across Derbyshire is by the end of September 2022.
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5. Review the Urgent transfer from care home to hospital information standard and link with the local NHS and Local Authority digital transformation leads to expedite an Integrated Care System-wide initiative to implement the new digital standards. This would enable care homes to digitise and transfer individuals’ records electronically to hospital containing all relevant information. The timeframe for the discussion with local NHS and Local Authority digital transformation leads is the end of August 2022. By March 2024, 80% of adult social care providers registered with the Care Quality Commission will have digital social care records, with progress well underway for the remaining 20% by that date.
6. For effective quality monitoring and assurance mechanisms to be implemented and delivered across care home provision, ambulance and hospital trusts to monitor compliance and impact of the above actions and taking corrective action where indicated. For performance to be reported to the integrated Care Homes Steering Group for monitoring and multi-agency action. The timescale for implementation of this is from August 2022 on an ongoing basis.
I trust that this provides you with the assurance that we are taking all appropriate actions to prevent avoidable deaths of this nature in Derbyshire County Council’s Adult Social Care department and across the health and social care system where robust communication at all stages between organisations would have made a difference.