Stockport NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust had already begun improvement work related to MUST, nutrition and hydration prior to the inquest, including monthly steering group meetings, training (90.76% compliance), ward audits, and nutrition/hydration information boards. Quality assurance checks and daily safety huddles now include a review of nutrition and hydration concerns and weight completion where appropriate; the Trust also participated in Malnutrition Awareness Week in October 2021. (AI summary)
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Dear Ms Mutch,
Re: Regulation 28: Report to Prevent Future Deaths
I am writing following the inquest of the late Mr Alan Harry Hunter that concluded on 13 September
2021. I am sorry that you found cause to issue Stockport NHS Trust with a Report to Prevent Future Deaths, issued to us on 25 October 2021. Please be assured that the matters of concern are of the upmost priority to us; we would like to provide you with assurance that actions have been taken since the time of Mr Hunter’s death to improve the care we provide to patients.
Matters of Concern: The inquest heard that the quality of documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.
I would like to provide assurance that prior to Mr Hunter’s inquest, improvement work related to MUST, nutrition and hydration had already commenced with a number of actions undertaken to improve the care we provide to patients and the way in which we document and evidence that care. The Nutrition and Hydration Steering Group takes place on a monthly basis and is chaired by the Deputy Chief Nurse. This Group reports to the Patient Safety Group chaired by the Medical Director and has oversight of improvements to nutrition and hydration across the Trust. Reports received by the Group include the training compliance position for MUST screening training which is currently reported at 90.76% trust wide, the compliance position for quality metrics standards for nutrition and hydration and fluid balance monitoring undertaken by senior nurses. Each clinicalDivision of the Trust provides a key issues and assurance report to the Group on a monthly basis. MUST training is mandatory for all nursing staff (registered nurses and health care assistants) and is required upon induction and refreshed every three years.
In March 2021 we introduced a ward based electronic tool (patientrack e-observations platform) to
monitor nutrition and hydration. This daily risk assessment uses a range of clinical factors affecting hydration status and provides a RAG status for the patient that informs the nurse how to monitor the patient’s hydration.
In addition to this, in April 2021 the Trust launched the Stockport Accreditation and Recognition System (StARS), an accreditation programme designed to measure the quality of care provided throughout the Trust. The scheme incorporates key clinical indicators and support standards related to the CQC Fundamental standards, including food and drink. The StARS framework includes 14 inpatient standards including Nutrition and Hydration and fluid balance charts. The Trust has set a trajectory to complete assessments of all inpatient areas (including reassessment), four community areas, paediatrics and the Emergency Department by the end of 2021/22. We are on track to meet this trajectory despite significant pressures across Trust services. Where services are identified as not achieving the required standard then support with a programme for improvement is given.
A seven minute briefing document has been developed related to nutrition and MUST assessment and cascaded to teams. The seven minute briefing format is a standardised method of communication used at Stockport NHS Trust to provide teams with key information to improve patient and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, MUST assessments and the use of food charts, and the importance of protected mealtimes.
Following the inquest of Mr Hunter where concerns were raised regarding monitoring of his diet and weight, an incident report was submitted to the Risk Management System (Datix) to ensure that full and appropriate lesson learning would be undertaken related to this case. Duty of Candour was also completed to ensure that Mr Hunter’s next of kin was aware of the investigation and able to engage in the investigation process. The investigation report has now been finalised and this is shared alongside this letter to provide assurance regarding the completeness of the review.
Within the investigation report a robust action plan has been provided that gives additional updates on the continuation of improvements across the Trust. This includes the identification of Nutrition and Hydration Champions across wards, tool box training sessions provided across ward areas between July and October 2021 covering MUST, fluid balance, food charts and specialist referrals and the development of Nutrition and Hydration Information Boards in ward areas.
The action plan also describes the audit processes now in place to ensure oversight of the MUST assessment and the completion of food charts. The Quality Assurance Checks completed by Matron twice weekly include a patient care section which looks at completion of nutrition assessment, that the assessment is up to date, and that fluid balance charts are up to date. The documentation section of the Quality Assurance Check audits that the MUST assessments are completed to the required standard and that standards of documentation are upheld, for example that all nursing entries are legible, signed, dated and timed. Alongside regular audit, daily safety huddles with the matron and ward managers take place to review any concerns in regard to patients. This holistic review includes a review of any nutrition and hydration concerns. It has been agreed with the Divisional Director of Nursing for Surgery that with immediate effect that this will also include a check that weight of the patient has been completed where appropriate.
Finally I would like to confirm that in October 2021, the Trust took part in Malnutrition Awareness Week, with a timetable of activities including MUST audit, drop in sessions with the nutritional nurses and a presentation from the speech and language therapy team.
I would like to thank you for highlighting your concerns to us. I hope that my response and the additional information provided gives assurance that we take your concerns very seriously and that action has been taken to improve the processes for managing the nutritional and hydration needs of our patients. If you require any further clarification with regard to any information provided, please do not hesitate to contact me.
Re: Regulation 28: Report to Prevent Future Deaths
I am writing following the inquest of the late Mr Alan Harry Hunter that concluded on 13 September
2021. I am sorry that you found cause to issue Stockport NHS Trust with a Report to Prevent Future Deaths, issued to us on 25 October 2021. Please be assured that the matters of concern are of the upmost priority to us; we would like to provide you with assurance that actions have been taken since the time of Mr Hunter’s death to improve the care we provide to patients.
Matters of Concern: The inquest heard that the quality of documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.
I would like to provide assurance that prior to Mr Hunter’s inquest, improvement work related to MUST, nutrition and hydration had already commenced with a number of actions undertaken to improve the care we provide to patients and the way in which we document and evidence that care. The Nutrition and Hydration Steering Group takes place on a monthly basis and is chaired by the Deputy Chief Nurse. This Group reports to the Patient Safety Group chaired by the Medical Director and has oversight of improvements to nutrition and hydration across the Trust. Reports received by the Group include the training compliance position for MUST screening training which is currently reported at 90.76% trust wide, the compliance position for quality metrics standards for nutrition and hydration and fluid balance monitoring undertaken by senior nurses. Each clinicalDivision of the Trust provides a key issues and assurance report to the Group on a monthly basis. MUST training is mandatory for all nursing staff (registered nurses and health care assistants) and is required upon induction and refreshed every three years.
In March 2021 we introduced a ward based electronic tool (patientrack e-observations platform) to
monitor nutrition and hydration. This daily risk assessment uses a range of clinical factors affecting hydration status and provides a RAG status for the patient that informs the nurse how to monitor the patient’s hydration.
In addition to this, in April 2021 the Trust launched the Stockport Accreditation and Recognition System (StARS), an accreditation programme designed to measure the quality of care provided throughout the Trust. The scheme incorporates key clinical indicators and support standards related to the CQC Fundamental standards, including food and drink. The StARS framework includes 14 inpatient standards including Nutrition and Hydration and fluid balance charts. The Trust has set a trajectory to complete assessments of all inpatient areas (including reassessment), four community areas, paediatrics and the Emergency Department by the end of 2021/22. We are on track to meet this trajectory despite significant pressures across Trust services. Where services are identified as not achieving the required standard then support with a programme for improvement is given.
A seven minute briefing document has been developed related to nutrition and MUST assessment and cascaded to teams. The seven minute briefing format is a standardised method of communication used at Stockport NHS Trust to provide teams with key information to improve patient and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, MUST assessments and the use of food charts, and the importance of protected mealtimes.
Following the inquest of Mr Hunter where concerns were raised regarding monitoring of his diet and weight, an incident report was submitted to the Risk Management System (Datix) to ensure that full and appropriate lesson learning would be undertaken related to this case. Duty of Candour was also completed to ensure that Mr Hunter’s next of kin was aware of the investigation and able to engage in the investigation process. The investigation report has now been finalised and this is shared alongside this letter to provide assurance regarding the completeness of the review.
Within the investigation report a robust action plan has been provided that gives additional updates on the continuation of improvements across the Trust. This includes the identification of Nutrition and Hydration Champions across wards, tool box training sessions provided across ward areas between July and October 2021 covering MUST, fluid balance, food charts and specialist referrals and the development of Nutrition and Hydration Information Boards in ward areas.
The action plan also describes the audit processes now in place to ensure oversight of the MUST assessment and the completion of food charts. The Quality Assurance Checks completed by Matron twice weekly include a patient care section which looks at completion of nutrition assessment, that the assessment is up to date, and that fluid balance charts are up to date. The documentation section of the Quality Assurance Check audits that the MUST assessments are completed to the required standard and that standards of documentation are upheld, for example that all nursing entries are legible, signed, dated and timed. Alongside regular audit, daily safety huddles with the matron and ward managers take place to review any concerns in regard to patients. This holistic review includes a review of any nutrition and hydration concerns. It has been agreed with the Divisional Director of Nursing for Surgery that with immediate effect that this will also include a check that weight of the patient has been completed where appropriate.
Finally I would like to confirm that in October 2021, the Trust took part in Malnutrition Awareness Week, with a timetable of activities including MUST audit, drop in sessions with the nutritional nurses and a presentation from the speech and language therapy team.
I would like to thank you for highlighting your concerns to us. I hope that my response and the additional information provided gives assurance that we take your concerns very seriously and that action has been taken to improve the processes for managing the nutritional and hydration needs of our patients. If you require any further clarification with regard to any information provided, please do not hesitate to contact me.