NHS England
NHS / Health Body
Noted
NHS England notes that the Trust has responded adequately at a local level and that the matters of concern have been dealt with, and has shared the Regulation 28 Report and both responses with the Regional NHSE/I teams. (AI summary)
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Dear Mr Hodson,
Re: Regulation 28 Report to Prevent Future Deaths – Leonard Arthur Pritchard 18 February 2021
Thank you for your Regulation 28 Report dated 17 June 2021 concerning the death of Leonard Arthur Pritchard on 18 February 2021. Firstly, I would like to express my sincere condolences to Mr Pritchard's family.
The recent inquest concluded Accidental Death with Mr Pritchard’s death a result of 1a Pneumonia 1b Intracranial Haemorrhage 1c Fall II Atrial fibrillation (anti-coagulated), hypertension, Type 2 diabetes mellitus, ischaemic heart disease, dementia.
Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding:
1.During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patients mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from the staff that they consider this mobility aid to patient bed ration was inadequate. There is a clear risk of deaths to patients who require mobility aids and can not have access to them. The Trust should consider addressing this as a matter of urgency.
Interim Chief Executive, NHSI & National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
21 October 2021
2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by. The Trust should consider ensuring this procurement process takes place as a matter of urgency.
I note that your Regulation 28 Report was also sent to University Hospitals Birmingham NHS Trust. The Trust have kindly shared their response and I have seen that the matters of concern have been dealt with and responded too at a local level. Given the content and adequacy of the Trust’s response I do not propose responding further on a national level.
However I can confirm that we have shared this Regulation 28 Report and both responses with the Regional NHSE/I teams to ensure that they have sight of this potential problem and will ensure that the ED departments in their hospitals have access to an adequate supply of mobility aids.
Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information, and especially if you consider there still to be any concern on a national level that needs responding too.
Re: Regulation 28 Report to Prevent Future Deaths – Leonard Arthur Pritchard 18 February 2021
Thank you for your Regulation 28 Report dated 17 June 2021 concerning the death of Leonard Arthur Pritchard on 18 February 2021. Firstly, I would like to express my sincere condolences to Mr Pritchard's family.
The recent inquest concluded Accidental Death with Mr Pritchard’s death a result of 1a Pneumonia 1b Intracranial Haemorrhage 1c Fall II Atrial fibrillation (anti-coagulated), hypertension, Type 2 diabetes mellitus, ischaemic heart disease, dementia.
Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding:
1.During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patients mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from the staff that they consider this mobility aid to patient bed ration was inadequate. There is a clear risk of deaths to patients who require mobility aids and can not have access to them. The Trust should consider addressing this as a matter of urgency.
Interim Chief Executive, NHSI & National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
21 October 2021
2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by. The Trust should consider ensuring this procurement process takes place as a matter of urgency.
I note that your Regulation 28 Report was also sent to University Hospitals Birmingham NHS Trust. The Trust have kindly shared their response and I have seen that the matters of concern have been dealt with and responded too at a local level. Given the content and adequacy of the Trust’s response I do not propose responding further on a national level.
However I can confirm that we have shared this Regulation 28 Report and both responses with the Regional NHSE/I teams to ensure that they have sight of this potential problem and will ensure that the ED departments in their hospitals have access to an adequate supply of mobility aids.
Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information, and especially if you consider there still to be any concern on a national level that needs responding too.