Swansea Bay University Health Board
NHS / Health Body
Action Taken
The Health Board has made changes to policies, procedures, guidance and training regarding nutrition and hydration since 2012. They have also adopted Clinical Standards for Inpatient Nutritional Support since 2017, with audits every 2 years. (AI summary)
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Dear Sir, ' . . Re: The inquest into the death of Ms Catherine Best- As a result of thf;) inquest into the death of Ms Catherine Best held on 8th and 9th: July 2021, and the Prevention of Future Deaths Repo_rt made against the Health Board, the Nutrition and Dietetic service would like to respond and outline. the·clianges made to the relevant polici~s, proc~dures, guidance and training in· .relation to nutrition and hydration since 2012. · Governanc• Structure Within Swansea Bay.University Health .Board ·(SBUHB) the Executive Nurse· Director
-has corporate responsibility for Nutrition and Hydratiqn. The governance structure is via the Hea_lth _Board Nutrition ·and Hydration Steering Committee, which meets quarterly and reports to the Health Board Quality and Safety Gqvemance Gro.up which also meets quarterly. The Steering Committee has responsibility. to ensure that the relevant Health ·and Care Standard (2.5 Nutrition and Hyd_ration) are met. The Terms of Reference for Nutritiqn and Hydration Steering Committee: Pencadlys BIP Baa Abartawa, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters', Ona Talbot , . Gateway, Po~ Talbot, ~A12 7BR . . . . Bwrdd lechyd PrlfysgolBae.Abertawe yw enw gweithredu Bwrdd lechyd Lleol F'rlfysgol Bae Abertawe Swansea Bas, University Health Boatd Is the operational name of Swansea Bay University Local Health Board
2 i1 New Terms of · Reference - ~utritio I also attach the Feedback to Quality and Safety Forum/ Gqvemance Group: HBQualityand HBQualityand ReportforQSGG, Safety- Patient NutrSafety- Patient NutrNutrion update.doc . . Minimum Nutrition Standards . . The ·All-Wales Nutrition and Catering Standards for FoQd and_ Fluid Provision for Hospital lnp~tients (launched October 2011) have been· adopted within SBUHB and formed the basis of the Health Board Nutrition and Catering Policy which was published-:in M~y 2013. This replaced the previous Nutriti~n and Catering Framework
-and describes the responsibilities, ·meeting structure and .governance arrangements for the organisation.. The policy is reviewed every 3 years. and is currently under. planned revie~ which is due t~ be completed September 2021. ~ @ all wales nutrition CID1222 Nutrition and catering stands Hydration and Cate, Identification of Nutritional Risk and Nutritional Care Pathway . . The All-Wales Hospitat Nutrition Care Pathway Protocol was adopted within- the predecessor organisations of SBUHe· in 2008. As part of this p~thway,. the Adult Nutrition Risk Screening Tool (WAASP) was used for the identification of nutritional risk. This tool is used for every patient on admission to ensure fhe early iden~ification and intervention for patients at risk or p~,enting with malnutrition or dehydration. The. pathway ~lso mandated the use of Al~ Wales Food and Fluid Charts which monitor /' patient's oral food and fluid intake to 'identify those patients at risk of malnutrition and to aid referral 'to specialist teams such as dietetics or speech and language therapists to identify p,oor intakes. · Audits of compliance. with the· care pathway, nutritional risk screening and the implementation of nutritional _care plans are undertaken on a monthly basis Via the Health & Care Standards Care inlUcators. Monthly Quality Assurance Matrons audits monitor if risk assessments· are completed.. The Health Board also has a programme of Quality Assurance audits which would include reviewing compliance ~ith .Nutrition and risk assessments.· Pencadlys BIP Bae Abertawa, Un Porthfa Talbot, Port Talbot, SA12 7BR / SWanaea Bay UHB Haadquai1ara, One Talbot
- Gatewav, Port Talbot. SA12 7BR Bwrdd lechyd Prtfysgol Baa Abertawe yw enw gwelthredu Bwrdd 1a<ihyd Lleol Prffysgol Bee Abertawe Swansea Bay University Health Board Is the openitlonal name of Swansea Bay University Local. Health Board
3 Link to folders Docu rnentary Safe Care2 (1).xls Patient Survey1.xlsx Evidence1 (1).xlsx . . In addition. the Nutrition and Dietetic ·service undertake an annual audit of nutrition risk screening and provide feedbac·k on ·the findings to the Nutrition and Hydration Steering Committee. Local feedback .~nd action plans have been agreed to support · improvements_in nutritional care. ·In 20-19, the "All Wales iri Patient Nutrition Risk Screening Tool" was adopted within SBUHB following the Welsh Health Circular (2019) 026. The tool inclu.des additional guidance on referral to Nutrition and Dietetic Services, including for those who require enteral. tube feeding or where clinical judgm~iit indicates that there are additional nutrit1onal concerns. The implementation ·of the All Wales Tool was supported by additional training sessions provided by the Nutrition·& Dietetic Service and the launch of an e learning module. Compliarice·-with· the e learning module will be monitored through the Nutrition and -Hydration Steering Committee. · II1 lEJ ·CID494 All Wales Adult Nutritional Ri? Training including-~urse Induction . ' . The Nutrition and Dietetic Service delivers training on the id.entification of l'JU~ritional risk, nutritional care pathways and enteral tube feeding as pa,t of the New Registrant and Nurse lri~uction programmes. · ~ clinical induction of 2020 UPDATE.doc new registrants-nut · · ln addition to thee- learning module supporting the All Wal~s Nutrition Risk.S(iir:eening
-Toor; there are additional elearning modules on _the use of Food and Fluid Record Chart charts. These are .mandated for-registered nursjng staff on a one off basis. Monitoring of compliance of E- reaming modules is undertaken via individual service delivery groups and is reported to the Nutrition arid Hydration Steering Committee on ~ ·ql:Jarterly basis. Each delivery ·group .will produce an action plan to support· improvements in performance. Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swar,sea Bay UHB Headquarters, Ona Talbot . Gateway, Port Talbot, SA12 7BR · . . · Bwrdd lachyd Prlfysgol Bae Abertawe yw enw gwelthradu Bwrdd lachyd Llaol Pr1fysgol Baa Abartawe swa·nsaa· Bay Unlvar:sl~y Health Board Is the operational name af Swansea Bay University Local Health Board
4 ~ .. . Nutrition steering C~mmitte Report.do Medical Education The Nutrition and Dietetic Service deliver training sessions. on nutrition and enteraV · · parenteral nutritio11 for F1 and F2 medical staff as part of their ongoing professional developme_nt. · · ManJgement of Refeedlng Syndrome and Out of Hours Enteral Feeding Regime ' ' ' The Swansea Bay University Health· Board -·Guidance on the ·Managemer:it of ·Refeeding Syndrome and the Standard Out of Hours Enteral Feeding Regime have been reviewed three yearly since they were published in 2011 .. These 2 documents were reviewed most recently in April 2020 to reflect _changes in the recom·mendation for electrolyte supplementation ·and energy provision in the National Guidance1• . @ m CID3S0 Enteral · . CID376 Guideline Feeding R~gimen foforthe Managemen The standard enteral feeding regime in critical care areas was also ·updated in 2020'. to reflect changes in clinical practice.· Adctitional SBUHB Guidance on the Nutritional Management of Patients with Eating Disorders during acute admissions and a Standard Enteral Feeding Regime for patients with ·Eating Disorders were published in June 2012. This guidance has been updated to reflect changes in the recommendations ofthe'MARSIPAN working group2 and is reviewed every· 3 years. J CID486 Nutritional Management of Pati Insertion and Management of NG Feeding tubes The Health Board policy on The Insertion and Management of NG Feeding Tubes was updated in 2018 and includes reference to the .clinical decision making process to support NG tube feeding. · ll Pancadlys BIP Baa Abartawa, Un ·Porthf■ Talbot, Port Talbot, SA12 7BR / Swan■- Bay UHB Headquarters, Ona Talbot · Gateway, Port Talbot, SA12 7BR Bwrdd lechyd Pr1fysgol Bae Abertawe yw enw gwelthredu Bwrdd lechyd Ueol Pr1fysgol Bae Abertawe Swansea Bay University Health Board Is the operatlonal narne of swansea Bay University Local Heallh ~oard
5 .. ,, A programme of competency based tr~1ning was delivered to support ·the implementation of the updated policy.: The policy is re.viewed every 3 years . . , . rn CID504 ABMU Policy for the insertion anr Additional Care Plan for the Management of High Nutrltlonal Risk during ·the .COVID 19 P•ndemic . During the COVIP 1_ 9 pandemic- a Care Plan for the Management of High· Nutrition.al Risk was implemented to support .areas in the· event of low staffing levels or staff redeploym~nt. · · · · · · · ~ CID3200 Pathway for Management of ·. The Nutrition and Dietetic service are· con~inuing to work wit_h colleagues to develop this care plan to support areas c;:,f staff shortage. · · · Nutrition and Dietetic Servi.ce Clinical Standards for In Patient Nutritl~"'al Support . . _The Clinical Stan.dards for· Inpatient Nutritional Support have been adopted by the Health Board since 2017. They inciude ~fereric_e to consideration of-enteral nutrition for patients who are unable to nieet their _nutritional requirements orally. An audit of compliance·to the stand~rds is undertaken every 2 ye~rs by the Nutrition and Dietetic Service with the next planned audit in autumn 2021 . The results and-Action Plan for improvement a·~e agreed with the Nutrition and Dietetic Service Clinical Governance meetings. · · Acute Nutrition ·support Clinical Stai j I hope ·that the information contained in·the Health Board's response'will provide you with the assurance required in relation to the Pr~vention of Future Deaths.Report that ·was receiv~d as a result of the Ms Best inquest. · Pencadlys BIP Bae Abertawe, Un Porthfa Talbot; Port Talbot, SA12 7BR / Swansea Bay UHB Headquartera, One Talbot . Gateway, Port Talbot, SA12 7BR . . Bwrdd lechyd Prlfysgol l;lae Abartawe ·yw enw gwelthradu.Bwrdd lechyd Lleol Pr1fysgol Baa Abertawa Swansea Bay University Health Board Is the operational name.of Swansea:Bay l/nl~rslty ~cal Health Board
6 please do not hesitate to conta_ct the Health Board if you have any queries.
-has corporate responsibility for Nutrition and Hydratiqn. The governance structure is via the Hea_lth _Board Nutrition ·and Hydration Steering Committee, which meets quarterly and reports to the Health Board Quality and Safety Gqvemance Gro.up which also meets quarterly. The Steering Committee has responsibility. to ensure that the relevant Health ·and Care Standard (2.5 Nutrition and Hyd_ration) are met. The Terms of Reference for Nutritiqn and Hydration Steering Committee: Pencadlys BIP Baa Abartawa, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters', Ona Talbot , . Gateway, Po~ Talbot, ~A12 7BR . . . . Bwrdd lechyd PrlfysgolBae.Abertawe yw enw gweithredu Bwrdd lechyd Lleol F'rlfysgol Bae Abertawe Swansea Bas, University Health Boatd Is the operational name of Swansea Bay University Local Health Board
2 i1 New Terms of · Reference - ~utritio I also attach the Feedback to Quality and Safety Forum/ Gqvemance Group: HBQualityand HBQualityand ReportforQSGG, Safety- Patient NutrSafety- Patient NutrNutrion update.doc . . Minimum Nutrition Standards . . The ·All-Wales Nutrition and Catering Standards for FoQd and_ Fluid Provision for Hospital lnp~tients (launched October 2011) have been· adopted within SBUHB and formed the basis of the Health Board Nutrition and Catering Policy which was published-:in M~y 2013. This replaced the previous Nutriti~n and Catering Framework
-and describes the responsibilities, ·meeting structure and .governance arrangements for the organisation.. The policy is reviewed every 3 years. and is currently under. planned revie~ which is due t~ be completed September 2021. ~ @ all wales nutrition CID1222 Nutrition and catering stands Hydration and Cate, Identification of Nutritional Risk and Nutritional Care Pathway . . The All-Wales Hospitat Nutrition Care Pathway Protocol was adopted within- the predecessor organisations of SBUHe· in 2008. As part of this p~thway,. the Adult Nutrition Risk Screening Tool (WAASP) was used for the identification of nutritional risk. This tool is used for every patient on admission to ensure fhe early iden~ification and intervention for patients at risk or p~,enting with malnutrition or dehydration. The. pathway ~lso mandated the use of Al~ Wales Food and Fluid Charts which monitor /' patient's oral food and fluid intake to 'identify those patients at risk of malnutrition and to aid referral 'to specialist teams such as dietetics or speech and language therapists to identify p,oor intakes. · Audits of compliance. with the· care pathway, nutritional risk screening and the implementation of nutritional _care plans are undertaken on a monthly basis Via the Health & Care Standards Care inlUcators. Monthly Quality Assurance Matrons audits monitor if risk assessments· are completed.. The Health Board also has a programme of Quality Assurance audits which would include reviewing compliance ~ith .Nutrition and risk assessments.· Pencadlys BIP Bae Abertawa, Un Porthfa Talbot, Port Talbot, SA12 7BR / SWanaea Bay UHB Haadquai1ara, One Talbot
- Gatewav, Port Talbot. SA12 7BR Bwrdd lechyd Prtfysgol Baa Abertawe yw enw gwelthredu Bwrdd 1a<ihyd Lleol Prffysgol Bee Abertawe Swansea Bay University Health Board Is the openitlonal name of Swansea Bay University Local. Health Board
3 Link to folders Docu rnentary Safe Care2 (1).xls Patient Survey1.xlsx Evidence1 (1).xlsx . . In addition. the Nutrition and Dietetic ·service undertake an annual audit of nutrition risk screening and provide feedbac·k on ·the findings to the Nutrition and Hydration Steering Committee. Local feedback .~nd action plans have been agreed to support · improvements_in nutritional care. ·In 20-19, the "All Wales iri Patient Nutrition Risk Screening Tool" was adopted within SBUHB following the Welsh Health Circular (2019) 026. The tool inclu.des additional guidance on referral to Nutrition and Dietetic Services, including for those who require enteral. tube feeding or where clinical judgm~iit indicates that there are additional nutrit1onal concerns. The implementation ·of the All Wales Tool was supported by additional training sessions provided by the Nutrition·& Dietetic Service and the launch of an e learning module. Compliarice·-with· the e learning module will be monitored through the Nutrition and -Hydration Steering Committee. · II1 lEJ ·CID494 All Wales Adult Nutritional Ri? Training including-~urse Induction . ' . The Nutrition and Dietetic Service delivers training on the id.entification of l'JU~ritional risk, nutritional care pathways and enteral tube feeding as pa,t of the New Registrant and Nurse lri~uction programmes. · ~ clinical induction of 2020 UPDATE.doc new registrants-nut · · ln addition to thee- learning module supporting the All Wal~s Nutrition Risk.S(iir:eening
-Toor; there are additional elearning modules on _the use of Food and Fluid Record Chart charts. These are .mandated for-registered nursjng staff on a one off basis. Monitoring of compliance of E- reaming modules is undertaken via individual service delivery groups and is reported to the Nutrition arid Hydration Steering Committee on ~ ·ql:Jarterly basis. Each delivery ·group .will produce an action plan to support· improvements in performance. Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swar,sea Bay UHB Headquarters, Ona Talbot . Gateway, Port Talbot, SA12 7BR · . . · Bwrdd lachyd Prlfysgol Bae Abertawe yw enw gwelthradu Bwrdd lachyd Llaol Pr1fysgol Baa Abartawe swa·nsaa· Bay Unlvar:sl~y Health Board Is the operational name af Swansea Bay University Local Health Board
4 ~ .. . Nutrition steering C~mmitte Report.do Medical Education The Nutrition and Dietetic Service deliver training sessions. on nutrition and enteraV · · parenteral nutritio11 for F1 and F2 medical staff as part of their ongoing professional developme_nt. · · ManJgement of Refeedlng Syndrome and Out of Hours Enteral Feeding Regime ' ' ' The Swansea Bay University Health· Board -·Guidance on the ·Managemer:it of ·Refeeding Syndrome and the Standard Out of Hours Enteral Feeding Regime have been reviewed three yearly since they were published in 2011 .. These 2 documents were reviewed most recently in April 2020 to reflect _changes in the recom·mendation for electrolyte supplementation ·and energy provision in the National Guidance1• . @ m CID3S0 Enteral · . CID376 Guideline Feeding R~gimen foforthe Managemen The standard enteral feeding regime in critical care areas was also ·updated in 2020'. to reflect changes in clinical practice.· Adctitional SBUHB Guidance on the Nutritional Management of Patients with Eating Disorders during acute admissions and a Standard Enteral Feeding Regime for patients with ·Eating Disorders were published in June 2012. This guidance has been updated to reflect changes in the recommendations ofthe'MARSIPAN working group2 and is reviewed every· 3 years. J CID486 Nutritional Management of Pati Insertion and Management of NG Feeding tubes The Health Board policy on The Insertion and Management of NG Feeding Tubes was updated in 2018 and includes reference to the .clinical decision making process to support NG tube feeding. · ll Pancadlys BIP Baa Abartawa, Un ·Porthf■ Talbot, Port Talbot, SA12 7BR / Swan■- Bay UHB Headquarters, Ona Talbot · Gateway, Port Talbot, SA12 7BR Bwrdd lechyd Pr1fysgol Bae Abertawe yw enw gwelthredu Bwrdd lechyd Ueol Pr1fysgol Bae Abertawe Swansea Bay University Health Board Is the operatlonal narne of swansea Bay University Local Heallh ~oard
5 .. ,, A programme of competency based tr~1ning was delivered to support ·the implementation of the updated policy.: The policy is re.viewed every 3 years . . , . rn CID504 ABMU Policy for the insertion anr Additional Care Plan for the Management of High Nutrltlonal Risk during ·the .COVID 19 P•ndemic . During the COVIP 1_ 9 pandemic- a Care Plan for the Management of High· Nutrition.al Risk was implemented to support .areas in the· event of low staffing levels or staff redeploym~nt. · · · · · · · ~ CID3200 Pathway for Management of ·. The Nutrition and Dietetic service are· con~inuing to work wit_h colleagues to develop this care plan to support areas c;:,f staff shortage. · · · Nutrition and Dietetic Servi.ce Clinical Standards for In Patient Nutritl~"'al Support . . _The Clinical Stan.dards for· Inpatient Nutritional Support have been adopted by the Health Board since 2017. They inciude ~fereric_e to consideration of-enteral nutrition for patients who are unable to nieet their _nutritional requirements orally. An audit of compliance·to the stand~rds is undertaken every 2 ye~rs by the Nutrition and Dietetic Service with the next planned audit in autumn 2021 . The results and-Action Plan for improvement a·~e agreed with the Nutrition and Dietetic Service Clinical Governance meetings. · · Acute Nutrition ·support Clinical Stai j I hope ·that the information contained in·the Health Board's response'will provide you with the assurance required in relation to the Pr~vention of Future Deaths.Report that ·was receiv~d as a result of the Ms Best inquest. · Pencadlys BIP Bae Abertawe, Un Porthfa Talbot; Port Talbot, SA12 7BR / Swansea Bay UHB Headquartera, One Talbot . Gateway, Port Talbot, SA12 7BR . . Bwrdd lechyd Prlfysgol l;lae Abartawe ·yw enw gwelthradu.Bwrdd lechyd Lleol Pr1fysgol Baa Abertawa Swansea Bay University Health Board Is the operational name.of Swansea:Bay l/nl~rslty ~cal Health Board
6 please do not hesitate to conta_ct the Health Board if you have any queries.