Northern Care Alliance NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust will update the nursing admission proforma as part of the Electronic Patient Record (EPR) Programme roll-out to ask whether the patient has previously experienced any choking episodes, with implementation planned for Spring 2023. (AI summary)
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Dear Miss Robertson
Northern Care Alliance Trust Headquarters Salford Royal Foundation Trust Salford M6 8HD
Re: Inquest touching the death of Leslie Horsfield I write further to the above matter following receipt of your Regulation 28 report dated 18 June 2021. This correspondence constitutes the Northern Care Alliance NHS Group response to that report. I would like to emphasise that I fully support the use of Regulation 28 reports as an important mechanism for learning and that as an organisation we are continuously looking for ways to improve patient safety. I am therefore grateful to you for sharing your concern and for bringing this matter to my attention.
Having discussed this with senior nursing colleagues within the Trust, it is however maintained that the nursing admission proforma provides the assessor with the ability to adequately explore a patient’s swallowing capability. Whilst the nursing assessment does not ask a specific question in relation to previous episodes of choking, the assessment does clearly question patients in relation to any problems with eating and drinking, the need for modified dietary consistency, or anything else to prompt a referral to Speech and Language Therapy.
(Divisional Director of Nursing), in his letter to you dated 21 May 2021, confirmed that other local Trusts, in their assessment tools, also do not ask this specific choking question. It is the opinion, of very experienced nurses across the Northern Care Alliance, that the nursing admission proforma asks sufficient questions relating to swallow for a patient, with capacity, to be able to volunteer information relating to any choking episodes.
You will of course appreciate that, practically, we cannot legislate within our assessments for every potential ailment a patient may have and, if we were to try to do that, there is a danger that by being
over-prescriptive, registered professionals will not use their experience and judgment but rather rely on the form.
I acknowledge that there are lessons emanating from this inquest, these have been shared with our staff. It is my experience that our employees are always receptive to learning, especially where it promotes good practice and enhances patient safety.
Having considered the matter further, I would like to provide you with assurance that as part of our Electronic Patient Record (EPR) Programme roll-out across the North East Sector, the nursing admission proforma will be updated to ask whether the patient has previously experienced any choking episodes. The timeframe for implementation of EPR across Pennine is Spring 2023.
We would once again like to thank you for bringing this to our attention. I wonder if there is a consideration for this to be recommended nationally. Discussions with external organisations has confirmed this specific question also does not feature within their admission documentation. Although we believe the risk you describe is adequately managed thought the series of questions we currently ask, if you remain of the opinion that change is required, should the recommendation be made national?
I thank you in anticipation and if there is anything else, I can assist you with, please do not hesitate to let me know.
Northern Care Alliance Trust Headquarters Salford Royal Foundation Trust Salford M6 8HD
Re: Inquest touching the death of Leslie Horsfield I write further to the above matter following receipt of your Regulation 28 report dated 18 June 2021. This correspondence constitutes the Northern Care Alliance NHS Group response to that report. I would like to emphasise that I fully support the use of Regulation 28 reports as an important mechanism for learning and that as an organisation we are continuously looking for ways to improve patient safety. I am therefore grateful to you for sharing your concern and for bringing this matter to my attention.
Having discussed this with senior nursing colleagues within the Trust, it is however maintained that the nursing admission proforma provides the assessor with the ability to adequately explore a patient’s swallowing capability. Whilst the nursing assessment does not ask a specific question in relation to previous episodes of choking, the assessment does clearly question patients in relation to any problems with eating and drinking, the need for modified dietary consistency, or anything else to prompt a referral to Speech and Language Therapy.
(Divisional Director of Nursing), in his letter to you dated 21 May 2021, confirmed that other local Trusts, in their assessment tools, also do not ask this specific choking question. It is the opinion, of very experienced nurses across the Northern Care Alliance, that the nursing admission proforma asks sufficient questions relating to swallow for a patient, with capacity, to be able to volunteer information relating to any choking episodes.
You will of course appreciate that, practically, we cannot legislate within our assessments for every potential ailment a patient may have and, if we were to try to do that, there is a danger that by being
over-prescriptive, registered professionals will not use their experience and judgment but rather rely on the form.
I acknowledge that there are lessons emanating from this inquest, these have been shared with our staff. It is my experience that our employees are always receptive to learning, especially where it promotes good practice and enhances patient safety.
Having considered the matter further, I would like to provide you with assurance that as part of our Electronic Patient Record (EPR) Programme roll-out across the North East Sector, the nursing admission proforma will be updated to ask whether the patient has previously experienced any choking episodes. The timeframe for implementation of EPR across Pennine is Spring 2023.
We would once again like to thank you for bringing this to our attention. I wonder if there is a consideration for this to be recommended nationally. Discussions with external organisations has confirmed this specific question also does not feature within their admission documentation. Although we believe the risk you describe is adequately managed thought the series of questions we currently ask, if you remain of the opinion that change is required, should the recommendation be made national?
I thank you in anticipation and if there is anything else, I can assist you with, please do not hesitate to let me know.