Sheffield Teaching Hospitals NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has already completed several actions, including providing further training to the staff member involved, reviewing issues with senior staff and external expertise, modifying the patient meal observation chart, and implementing a 'Meal Time Huddle' to ensure staff are aware of patients' dietary requirements. (AI summary)
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Dear Ms Coombs Prevention of Future Deaths Report Joan Howard write to formally respond to your Prevention of Future Deaths (PFD) Report dated 10 February 2020, following the very sad death of Mrs Joan Howard. wanted to say at the outset how saddened | am by Mrs Howard's death and how sincerely am for the undoubted distress and upset this has caused her family. fully appreciate your and the family's concerns that a basic element of Mrs Howard's care managing her dysphagia diet was not properly implemented despite her needs being clearly documented and her family advocating for her_ truly hope that we can learn this and take actions to ensure as far as is possible that nothing similar happens As you are aware from) (letter to you of 20 March 2020, we are assured that the further information (concerning a Trainee Clinical Support Worker) that came to light following the inquest is consistent with your findings and conclusions. The learning and actions that we are now taking are comprehensive and the member of staff concerned has received appropriate training along with on-going support: Our review of the issues raised by this case, along with consideration of the PFD Report;, has involved six senior members of staff and external expertise , commissioned from a Human Factors specialist. The senior staff involved comprised the Deputy Chief Nurse, the Head of Speech and Language Therapy (SLT), the Nurse Director Lead for Nutrition and Hydration, the Catering Manager, the Deputy Head of Learning and Development; and the Lead Nurse for Technology and Innovation: As a result of their discussions, we have agreed actions to address the specific steps you have requested we take_ Some of these actions have already been completed and others will be completed as soon as is practicable, in the context of the current situation nationally in relation to COVID-19 and our response to this The steps you request relate to three issues Training, Standard Operating Procedure (SOP) and Information regarding dietary needs: My response below describes actions we have agreed to address each of these three areas_ Sheffield Hospitals hospital the community Charlty proud to make a difference Chain Chief Executive: sorry from again:. the and
Training By way of background, the Head of SLT explained at the inquest that the International Dysphagia Diet Standardisation Initiative (IDDSI) was implemented across the Trust by October 2018, ahead of the national target date of April 2019_ Training was undertaken across all relevant care groups through a cascade approach involving matrons, educators and ward staff. In addition, training was provided as part of certain key courses, for example the Prepare to Care course for Trainee Clinical Support Workers, and the Newly Qualified Registered Nurse Preceptorship training: Training was supported by ward-based posters and information_ It is accepted that this approach did not make IDDSI training mandatory, nor could we be sure that every member of staff involved in mealtime procedures (including, for example, housekeepers) had received training in IDDSI through the cascade mechanism_ We recognise the need for all staff engaged in mealtime duties to receive training in IDDSI and this will be achieved as outlined below: IDDSI training will be added to Job Specific Essential Training (JSET), making it necessary training for all hospital and intermediate care based registered nurses, clinical support workers (CSW), trainee nursing associates, and housekeepers involved in mealtime procedures. Plans to include IDDSI training in JSET have been submitted to our Professional Education Group (PEG) for ratification. PEG is chaired by the Deputy Chief Nurse and, once JSET proposals have been approved, the target is to achieve 85% compliance by April 2021_ Compliance will be monitored through staff annual appraisals and at the point of recruitment within the care groups, with oversight provided by PEG IDDSI training will no longer be delivered by cascade , but through an e-learning package entitled 'Meal Service Safety' . This approach will ensure consistency, appropriate levels of understanding, and refresher training: The training package will consist of three elements: IDDSI, the Standard Operating Procedure (SOP) which was shared at the inquest and has since been updated (copy attached), and guidance on handling hot food: The training will ensure staff are familiar with IDDSI principles and terminology, and all stages in the SOP_ There will be specific focus on the 'Safety Pause' which has now been labelled the 'Mealtime Safety Huddle' as this is a concept with which nurses are already familiar The e-learning will also include guidance on handling hot food which, although not an issue in serious incident, is important in maintaining staff safety. The training programme has already been finalised and is awaiting a final decision from PEG in relation to the target audience so that it can then be put in place by 30th April 2020. Compliance figures will be monitored through PEG_ Compliance with IDDSI, including the SOP will be monitored through two existing audits which will be expanded to include IDDSI compliance_ The first audit is the biannual Hydration and Nutrition Assurance Toolkit (HANAT): This has been updated to include specific questions in relation to the SOP and will be reviewed by the Nutrition Steering Group prior to the next audit to include questions in relation to handling of hot food. The second audit is the annual 'Power of 3' audit of meal service, which has been updated to include audit of IDDSI, SOP compliance, and handling of hot food. This audit is undertaken by representatives from catering, dietetics, and senior nursing and involves the completion of an audit of meal service on one ward in each of the care groups annually: In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners_ The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service. the again the
Student nurses receive formal training through the universities and this includes teaching regarding dysphagia, swallowing, thickening, and SALT. They also spend 50% of their experience in practice and this will include practical training and supervision when caring for patients with dysphagia. Both Sheffield Hallam University and the University of Sheffield cover these elements within their student nurse training programmes, however the University of Sheffield training programme also incorporates IDDSI training: Consistency in student nurse training is therefore an issue which will need further discussion and we will give this matter appropriate consideration as soon as is practicable_ Regarding bank and agency staff working within the Trust, these staff are recruited through NHS Professionals, and many are existing STH staff working additional hours over their contracted hours. These staff will have received their training as part of their substantive role_ For non-STH employees, IDDSI does not form part of the mandatory training provided by NHS Professionals and this is therefore an issue which we will consider further as soon as practicable. In the interim, the additional measures now in place through the SOP and the Mealtime Safety Huddles, which are the responsibility of Trust Registered Nurses, will provide a further safety barrier at mealtimes Standard Operating Procedure (SOP) for Ward Meal Service Following the inquest; the SOP (attached) has been updated to include a description of the purpose and approach to mealtime safety huddle. It has also been updated so that reference is made to specialist advice on patient fluid consistency and special dietary requirements in relation to snack boxes and light bites. The updated SOP is a component of the e-learning package. It has been shared with matrons, included in Catering Folder on each ward, and is available to order through the Trust's Xerox 'print on demand' process Compliance with the SOP will be audited as described above. Obtaining and utilising information regarding dietary needs Capture of Information on Admission There is a process for assessment of a patient's dietary and other needs on admission. For patients admitted directly to wards and assessment units this is by use of a bespoke clinical data capture form (an e-form) , which is based on national guidelines, in the electronic patient record. is recognised that information may accompany the patient into hospital, but that patients and their families are also good sources of accurate information, which staff should access in completing this form. In the Emergency Department (ED) patients' nutritional needs and risks are documented on hourly rounding charts and communicated in verbal handover between shifts Transfer of Information In order to improve the systematic communication of this information as patients are transferred around the hospital, following this incident our process for safe patient transfer known as 'Ticket to Ride' is reviewed and updated to include dietary requirements. This includes documentation of any issues in relation to dysphagia. 'Ticket to Ride' forms part of our policy on the safe transfer of patients and changes we are now making will ensure that information about dietary needs is formally documented and is not dependent upon verbal handover when a patient moves from one area of the hospital to another. the key the being the key
Information on the Ward/Clinical area Work has now been completed to incorporate the national IDDSI descriptors into the Electronic Whiteboard (EWB): This work had already been planned, but was expedited as a result of this incident: As a consequence, patients' eating and drinking requirements, food texture and fluid consistency are now recorded on EWB. This is a visible prompt to all ward staff (not just nurses) about the patient's individual requirements. This information then automatically populates the multi-disciplinary handover sheet that is printed from the EWB for ward staff to refer to_ The EWB is recognised as a Multi-Disciplinary Team handover and effective communication tool within the Trust In relation to patients who are transferred from ward temporarily, for example for an outpatient appointment or tests elsewhere within the Trust; it is accepted that inpatients remain the responsibility of the host ward in many aspects of their care, including nutrition and hydration. In addition, the outpatient or diagnostic area is able to access information from the EWB, to confirm or clarify the patient's eating and drinking requirements_ Our Patient Transfer Policy clarifies that the host ward must ensure up to date information about the patient is communicated to the receiving area to enable the immediate needs of the patient to be met on arrival. For those patients who are admitted to hospital already requiring texture modified diets in the community, the ward teams can now record the information straight onto the EWB and the correct diet signage can be placed above the patient's bed immediately: The SOP prompts staff to ensure that swallowing assessment detail is placed above the patient's bed, and wards will now be provided with a supply of signage and related patient information forms so that temporary signage will not be required. Signage is also available to order through the Xerox 'print on demand' service and can be downloaded from the Trust intranet site. Signage now also includes a description of the IDDSI levels alongside the level of diet the patient is so that this information is clearly visible and easily accessible for staff 'at a glance'_ Compliance all stages of the SOP , including the issue of communication within the ward area, will be subject to audit as described above Having outlined the actions we have agreed to take in response to this incident and to the PFD Report; hope that have been able to convey how seriously we have viewed this matter Whilst we will be unable to implement all these changes in the near future, given the urgency of the situation in relation to COVID-19, we are absolutely committed to learning from Mrs Howard's death and implementing the remaining actions at the earliest opportunity Finally, hope that my response has addressed the concerns and actions you identified in your PFD Report and please contact me if you have any queries or points of clarification:
Training By way of background, the Head of SLT explained at the inquest that the International Dysphagia Diet Standardisation Initiative (IDDSI) was implemented across the Trust by October 2018, ahead of the national target date of April 2019_ Training was undertaken across all relevant care groups through a cascade approach involving matrons, educators and ward staff. In addition, training was provided as part of certain key courses, for example the Prepare to Care course for Trainee Clinical Support Workers, and the Newly Qualified Registered Nurse Preceptorship training: Training was supported by ward-based posters and information_ It is accepted that this approach did not make IDDSI training mandatory, nor could we be sure that every member of staff involved in mealtime procedures (including, for example, housekeepers) had received training in IDDSI through the cascade mechanism_ We recognise the need for all staff engaged in mealtime duties to receive training in IDDSI and this will be achieved as outlined below: IDDSI training will be added to Job Specific Essential Training (JSET), making it necessary training for all hospital and intermediate care based registered nurses, clinical support workers (CSW), trainee nursing associates, and housekeepers involved in mealtime procedures. Plans to include IDDSI training in JSET have been submitted to our Professional Education Group (PEG) for ratification. PEG is chaired by the Deputy Chief Nurse and, once JSET proposals have been approved, the target is to achieve 85% compliance by April 2021_ Compliance will be monitored through staff annual appraisals and at the point of recruitment within the care groups, with oversight provided by PEG IDDSI training will no longer be delivered by cascade , but through an e-learning package entitled 'Meal Service Safety' . This approach will ensure consistency, appropriate levels of understanding, and refresher training: The training package will consist of three elements: IDDSI, the Standard Operating Procedure (SOP) which was shared at the inquest and has since been updated (copy attached), and guidance on handling hot food: The training will ensure staff are familiar with IDDSI principles and terminology, and all stages in the SOP_ There will be specific focus on the 'Safety Pause' which has now been labelled the 'Mealtime Safety Huddle' as this is a concept with which nurses are already familiar The e-learning will also include guidance on handling hot food which, although not an issue in serious incident, is important in maintaining staff safety. The training programme has already been finalised and is awaiting a final decision from PEG in relation to the target audience so that it can then be put in place by 30th April 2020. Compliance figures will be monitored through PEG_ Compliance with IDDSI, including the SOP will be monitored through two existing audits which will be expanded to include IDDSI compliance_ The first audit is the biannual Hydration and Nutrition Assurance Toolkit (HANAT): This has been updated to include specific questions in relation to the SOP and will be reviewed by the Nutrition Steering Group prior to the next audit to include questions in relation to handling of hot food. The second audit is the annual 'Power of 3' audit of meal service, which has been updated to include audit of IDDSI, SOP compliance, and handling of hot food. This audit is undertaken by representatives from catering, dietetics, and senior nursing and involves the completion of an audit of meal service on one ward in each of the care groups annually: In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners_ The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service. the again the
Student nurses receive formal training through the universities and this includes teaching regarding dysphagia, swallowing, thickening, and SALT. They also spend 50% of their experience in practice and this will include practical training and supervision when caring for patients with dysphagia. Both Sheffield Hallam University and the University of Sheffield cover these elements within their student nurse training programmes, however the University of Sheffield training programme also incorporates IDDSI training: Consistency in student nurse training is therefore an issue which will need further discussion and we will give this matter appropriate consideration as soon as is practicable_ Regarding bank and agency staff working within the Trust, these staff are recruited through NHS Professionals, and many are existing STH staff working additional hours over their contracted hours. These staff will have received their training as part of their substantive role_ For non-STH employees, IDDSI does not form part of the mandatory training provided by NHS Professionals and this is therefore an issue which we will consider further as soon as practicable. In the interim, the additional measures now in place through the SOP and the Mealtime Safety Huddles, which are the responsibility of Trust Registered Nurses, will provide a further safety barrier at mealtimes Standard Operating Procedure (SOP) for Ward Meal Service Following the inquest; the SOP (attached) has been updated to include a description of the purpose and approach to mealtime safety huddle. It has also been updated so that reference is made to specialist advice on patient fluid consistency and special dietary requirements in relation to snack boxes and light bites. The updated SOP is a component of the e-learning package. It has been shared with matrons, included in Catering Folder on each ward, and is available to order through the Trust's Xerox 'print on demand' process Compliance with the SOP will be audited as described above. Obtaining and utilising information regarding dietary needs Capture of Information on Admission There is a process for assessment of a patient's dietary and other needs on admission. For patients admitted directly to wards and assessment units this is by use of a bespoke clinical data capture form (an e-form) , which is based on national guidelines, in the electronic patient record. is recognised that information may accompany the patient into hospital, but that patients and their families are also good sources of accurate information, which staff should access in completing this form. In the Emergency Department (ED) patients' nutritional needs and risks are documented on hourly rounding charts and communicated in verbal handover between shifts Transfer of Information In order to improve the systematic communication of this information as patients are transferred around the hospital, following this incident our process for safe patient transfer known as 'Ticket to Ride' is reviewed and updated to include dietary requirements. This includes documentation of any issues in relation to dysphagia. 'Ticket to Ride' forms part of our policy on the safe transfer of patients and changes we are now making will ensure that information about dietary needs is formally documented and is not dependent upon verbal handover when a patient moves from one area of the hospital to another. the key the being the key
Information on the Ward/Clinical area Work has now been completed to incorporate the national IDDSI descriptors into the Electronic Whiteboard (EWB): This work had already been planned, but was expedited as a result of this incident: As a consequence, patients' eating and drinking requirements, food texture and fluid consistency are now recorded on EWB. This is a visible prompt to all ward staff (not just nurses) about the patient's individual requirements. This information then automatically populates the multi-disciplinary handover sheet that is printed from the EWB for ward staff to refer to_ The EWB is recognised as a Multi-Disciplinary Team handover and effective communication tool within the Trust In relation to patients who are transferred from ward temporarily, for example for an outpatient appointment or tests elsewhere within the Trust; it is accepted that inpatients remain the responsibility of the host ward in many aspects of their care, including nutrition and hydration. In addition, the outpatient or diagnostic area is able to access information from the EWB, to confirm or clarify the patient's eating and drinking requirements_ Our Patient Transfer Policy clarifies that the host ward must ensure up to date information about the patient is communicated to the receiving area to enable the immediate needs of the patient to be met on arrival. For those patients who are admitted to hospital already requiring texture modified diets in the community, the ward teams can now record the information straight onto the EWB and the correct diet signage can be placed above the patient's bed immediately: The SOP prompts staff to ensure that swallowing assessment detail is placed above the patient's bed, and wards will now be provided with a supply of signage and related patient information forms so that temporary signage will not be required. Signage is also available to order through the Xerox 'print on demand' service and can be downloaded from the Trust intranet site. Signage now also includes a description of the IDDSI levels alongside the level of diet the patient is so that this information is clearly visible and easily accessible for staff 'at a glance'_ Compliance all stages of the SOP , including the issue of communication within the ward area, will be subject to audit as described above Having outlined the actions we have agreed to take in response to this incident and to the PFD Report; hope that have been able to convey how seriously we have viewed this matter Whilst we will be unable to implement all these changes in the near future, given the urgency of the situation in relation to COVID-19, we are absolutely committed to learning from Mrs Howard's death and implementing the remaining actions at the earliest opportunity Finally, hope that my response has addressed the concerns and actions you identified in your PFD Report and please contact me if you have any queries or points of clarification: