Philip Taylor

Dear Ms Mutch

Regulation 28 Report - Mr Philip Jess TAYLOR

I refer to your letter dated 17 December 2021 in relation to the above and I am sorry to learn of circumstances surrounding the death of Mr Taylor and offer my sincere condolences to his family.

Whilst the Regulation 28 Report requests information from a number of different organisations, this response aims to address the issues highlighted as specific to NHS Stockport Clinical Commissioning Group (CCG).

You have raised two points which I will address in order:-

 GP did not carry a thermometer when attending Mr Taylor at the care home

Following a review of the events surrounding this particular case, Dr explained that when visiting the Care Home to attend Mr Taylor he did carry equipment with him, including a thermometer and pulse oximeter. However he had left his main bag in the car when he entered the home. On reflection he acknowledges that he should have ensured that he did have access to this equipment in case of need and he

confirms that it is now his practice to carry this equipment with him whenever he attends a patient away from the practice.

 Delay in updating the clinical records following the visit

In circumstances where a patient is attended after the end of the surgery working day it was Dr practice to update the clinical record on his return to the practice, which on occasion could be the following morning as care home visits can often take place at the end of the working day. Stockport GPs do have access to mobile technology enabling immediate update of the clinical system at the time of the consultation. Dr has confirmed that he will now carry the mobile technology with him and will update patient records immediately following consultation / visit.

I am mindful that steps taken now cannot undo what happened in this case, and I am satisfied that from a clinical perspective, the failure to carry equipment / update records did not impact on the outcome for this gentleman. However my expectation is that all Stockport GPs do carry basic equipment to enable the recording of clinical observations and for patient records to be updated at the point of consultation, wherever possible. I am sorry that this did not happen in this case and I will ensure that appropriate checks are made to ensure that Dr adheres to this standard of practice.

Dear HM Senior Coroner Alison Mutch OBE

Prevention of future death report following inquest into the death of Philip Taylor Thank you for sending us a copy of the prevention of future death report issued following the sad death of Philip Taylor. Our condolences are with the family and friends of Mr Taylor.

We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by 11 February 2021.

Mr Taylor was resident at Bamford Close, a location registered with CQC at Adswood Lane West, Cale Green, Stockport, SK3 8HT. The Registered Provider in operation of Bamford Close at the time of Mr Taylor’s death was Borough Care Ltd. The Provider is registered for the regulated activity Accommodation for persons who require nursing or personal care. The registered manager at the time was Selina Taylor.

The role of the CQC & Inspection methodology

The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to inspect whether or not the fundamental standards are being met.

Our current regulatory approach involves inspectors considering five key questions. They ask if services are Safe; Effective; Caring; Responsive; and Well Led. Inspectors use a series of key lines of enquiry (“KLOEs”) and prompts to seek and corroborate evidence Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA

Telephone:

Fax: 03000 616171

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and reassurance of how the provider performs against characteristics of ratings and how risks to people are identified, assessed and mitigated. Sources of evidence for the KLOEs can be found on our website along with our KLOEs and characteristics of ratings.

The regulatory framework includes providers being required to meet fundamental standards of care, standards below which care must never fall. These standards are contained in Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the 2014 Regulations”).

Background

On 18 June 2020, from South Manchester Coroners’ Court contacted CQC to advise us of the unexpected death of Mr Philip Taylor at Stepping Hill Hospital on 6 January 2020 and inform us that this matter was being investigated. Due to a technical issue the provider had completed a statutory notification, but this had not been submitted and received by CQC. Following the information received on the 18 June 2020 a copy was immediately provided to the CQC inspector and this was submitted on 7 July 2020 by the registered manager at Bamford Close. The statutory notification stated that Mr Taylor began to show signs of declining health on the 2 January 2020 and a visit from the doctor was undertaken that day where advice was to encourage food and fluids. Mr Taylor’s health continued to decline the following day and the home contacted the doctor for further advice and subsequently called an ambulance. Mr Taylor was admitted to Stepping Hill Hospital on the 3 January 2020 and sadly passed away three days later on the 6 January 2020.

Further discussion was undertaken with the registered manager and CQC was assured that the provider and registered manager had taken appropriate action to support Mr Taylor as his health declined and seek medical advice as required.

Regulatory History

Borough Care Ltd were registered to carry on a regulated activity at Bamford Close on 18 January 2011. Mr Taylor was admitted to the care home on 4 April 2019. The last comprehensive inspection of the service was undertaken shortly after this in June 2019. The service was rated as good with no breaches of regulations being identified. Bamford Close is a residential care home and is registered to accommodate a maximum of 40 people. Bamford Close is registered for the regulated activity of ‘Accommodation for person who require nursing or personal care’ and a condition of their registration is that the register provider does not provide nursing care at this location.

At the time of Mr Taylor’s death there were 38 people living at Bamford Close and staffing levels were in line with the service dependency assessment. Staffing included care assistants, senior care assistants, the deputy manager and registered manager together with auxiliary staff including domestic and kitchen staff.

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Bamford Close is not a location that offers nursing services and so retains no nursing staff.

Matters of concern for CQC

The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.

In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (both being Registered Persons for CQC purposes) to decide.

Registered Persons have a duty under Regulation 14 of the 2014 Regulations to ensure adequate nutrition and hydration for service users. The specific wording under Regulation 14(4)(a) refers to “receipt by a service user of suitable and nutritious food and hydration which is adequate to sustain life and good health”.

CQC does not publish detailed standards and expectations about specific conditions. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE - see below). We expect Registered Persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations. Information on the CQC website to signpost providers on meeting Regulation 14 is available. This includes links to a variety of best practice guidance including Diet, nutrition and obesity (National Institute for Health and Care Excellence) which is deemed relevant to all service providers. Other specific guidance to adult social care service included links to BAPEN (British Association for Parenteral & Enteral Nutrition): BAPEN: Malnutrition universal screening tool; Malnutrition Universal Screening Tool (MUST) explanatory booklet; Nutrition for specific groups (Royal College of Nursing); Nutrition support in adults (National Institute for Health and Care Excellence); Nutrition support in adults (NICE); Nutritional care and older people (Social Care Institute for Excellence, March 2009). CQC also includes information on hydration in the Frequently Asked Questions section of its website. This section provides a general overview of some of the issues around hydration that Providers may need to consider when formulating and reviewing their policies and practices. In conjunction with the links to external sources provided (see above), CQC expects Providers to be able to find the information they require to support the hydration needs of their Service Users.

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Other sources of guidance available in the public domain include: Getting it right every time (fundamentals of nursing care at the end of life) (Royal College of Nursing, 2015); SCIE guidance Nutrition for older people in care homes: Dignity in care videos; Dehydration in the elderly - British Nutrition Foundation; and Hydration and older people in the UK: Addressing the problem, understanding the solution (International longevity Centre UK, 2014). These provide examples of how to meet the nutritional and hydration needs of older adults. It should also be noted that research indicates that the signs and symptoms commonly used to detect dehydration are often ineffective in doing so in care home residents and that nursing and care staff focus should instead be on supporting older people to drink well (Effective hydration care in older people living in care homes; Nursing Times, 2019). Like many care homes, Bamford Close supports care staff to complete the Care Certificate. There are 15 standards to the Care Certificate and standard 8 relates to fluid and nutrition. This standard covers the importance of good nutrition and hydration; the signs and symptoms of poor nutrition and hydration and how to promote adequate nutrition and hydration. Training records indicate that the majority of staff completed the care certificate or had other relevant qualification where this was pertinent to their role. One of the KLOEs for answering ‘Is this service Effective’ asks: How are people supported to eat and drink enough to maintain a balanced diet? Inspectors explore the arrangements in place to manage people’s nutritional and hydration needs, how people are involved in what they eat and drink and how risks to people with complex needs are managed. All KLOEs were reviewed following CQC’s inspection methodology during the inspection of the service in June 2019 (report published 18 July 2019), at which Bamford Close was rated Good.

The death of Mr Taylor was reviewed as part of our regulatory duties, to assess whether there was any evidence of failings by a Registered Person that amounted to a breach of the Regulations. The conclusion of the initial review found that there was insufficient evidence of a breach of the Regulations. Mr Taylor had a nutrition and hydration care plan in place, along with a variety of other appropriate and relevant care plans. These were being reviewed on a monthly basis. An assessment of Mr Taylor’s nutrition needs had also been recently reviewed in December 2019. Daily records were being completed and included food and fluid charts. The latter records both fluid offered and fluid taken by Mr Taylor, which would have assisted with auditing to ensure appropriate fluid levels were maintained. The meal chart is a similar mechanism for ensuring appropriate food intake.

The fluid charts indicate that overall support to maintain adequate fluids levels was good but there had a reduced intake at times, possibly due to declining health and Mr Taylor’s diagnosed chest infection. This is particularly notable on 3 January 2020, the day Mr Taylor was admitted to hospital.

In order to ensure that that this risk is minimised to the lowest possible level and to ensure service users are not placed at risk at Bamford Close, we are continually monitoring the service and liaising with the local authority to review any ongoing risks and feedback.

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In summary, the requirement is placed on Registered Persons to ensure that they are delivering care in a safe and effective way and doing all that is practicable to mitigate any risks. CQC will continue to review through its inspection processes the systems and processes being operated by those services it regulates and will challenge and, if appropriate, take enforcement action against a Registered Person where it finds that care is being provided in an unsafe way.

Should you require any further information please do not hesitate to get in touch.

Dear Ms Mutch,

Thank you for your letter of 17 December 2020 about the death of Philip Taylor. I am replying as Minister with policy responsibility for adult social care.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Taylor’s death and the lengthy delay Mr Taylor experienced at the Emergency Department at the Stepping Hill Hospital, part of the Stockport NHS Foundation Trust. If you have the opportunity, please convey my condolences to Mr Taylor’s family. Your report describes care that falls short of the high standards we expect from the NHS, and that the NHS strives to deliver, and it is important that we take the learnings from Mr Taylor’s death to improve the quality and safety of care.

I am informed that the Stockport NHS Foundation Trust has provided you with information about its use of NEWS2, the National Early Warning Score for adults, and actions it has taken to strengthen oversight of patient acuity in the Emergency Department and processes for the escalation of care, among others. I understand the Trust has reduced its nursing vacancies and there is senior level oversight of nursing rosters.

I am aware that this is not the first Prevention of Future Deaths report you have issued concerning the pressures experienced by the emergency department at Stepping Hill Hospital, Stockport during the winter period of 2019/20. It is right that the Trust, and its health system partners, reflect carefully on the concerns you have raised and take the necessary action to improve the safety and quality of urgent and emergency services in Stockport.

As you will know from the Department’s responses to previous PFD reports raising these concerns, regulatory action was taken by the Care Quality Commission (CQC) after it identified similar concerns during an inspection at Stepping Hill Hospital in early 2020.

The CQC found that people were not always kept safe and were at high risk of avoidable harm during periods of heavy demand on urgent and emergency care services. Emergency care was consistently unable to be provided in a timely way; and there were significant issues with the flow of patients through the emergency department and the Hospital. The report of the CQC’s inspection is available on its website1.

Following the CQC’s inspection, health system partners in Stockport formed a system improvement board, that has representation from the CQC and NHS England and NHS Improvement (NHSEI), to oversee the implementation of an improvement plan.

I am assured that progress is being closely monitored by the Trust Board and the CQC. Furthermore, I am informed that the issues at Stockport NHS Foundation Trust have been escalated within NHSEI national governance structures, including to the Executive Quality Group (EQG), chaired by , National Medical Director, and , Chief Nursing Officer, and the Joint Strategic Oversight Group with senior representation from the CQC, where progress is regularly monitored. I have asked my officials to bring your report to the attention of NHSEI.

Turning to the specific matters of concern in your report, you ask the Department to address two issues, the first, in relation to the Pathfinder clinical assessment tool; and the second about the availability of national guidance on recognising and responding to the risk of dehydration.

In preparing this response, my officials have taken advice from health system leader, NHSEI; the independent regulator for care quality, the CQC; and the National Institute for Health and Care Excellence (NICE).

I am advised by the North West Ambulance Service (NWAS) that Pathfinder is a clinical presentation-based, triage tool based on the Manchester Triage System, which is used worldwide by emergency clinicians and by a number of ambulance services in the UK. It may be helpful to clarify that Pathfinder is not mandated for use nationally and it remains a decision for individual ambulance services as to which clinical triage tools they use.

I understand that Pathfinder was developed by the Manchester Triage Group, with involvement from NWAS, as a tool to support ambulance clinicians prior to them undergoing training on the full Manchester Triage System. The Pathfinder tool contains the main general discriminators of the Manchester Triage System, as well as some specific discriminators, however, whereas the full Manchester Triage System has 53 presentational charts, Pathfinder has just two; Medical and Trauma.

I am informed by NWAS that a review of the ambulance response to Mr Taylor identified the point on Pathfinder that the paramedic at the scene would have reached based on Mr Taylor’s clinical presentation, specifically, a NEWS2 score of above five and a reduced level of consciousness. Both these clinical factors elicit the ‘red priority response’, ‘Stabilise and immediate transportation to ED’. NWAS advises that it was therefore clear from Pathfinder that an immediate transfer to hospital was required. I am further advised that NWAS investigation of the ambulance response to Mr Taylor identified other factors that impacted on the length of time taken to transfer Mr Taylor to hospital, including the need to stabilise and obtain the contextual history.

I am assured by the NWAS that having considered the concerns you have raised carefully, it believes that changes are not required as a result of this incident and that Pathfinder remains a safe and effective assessment triage tool.

You may wish to note that during the review of this incident, those responsible for the Pathfinder tool identified two improvements (not directly related to this incident) that will be put forward for action. These are an amendment to the Pathfinder chart to include guidance on timeframe for transfer to all red priority boxes; and to include ‘possible sepsis’ as a red priority outcome to ensure that where a patient’s clinical presentation is triggering on a sepsis screening tool, that it is also captured in Pathfinder as a failsafe where patient observations fall outside the NEWS2 parameters.

In relation to the national guidance that is available to care home staff on recognising and responding to the risk of dehydration, I am advised that in its response to you, the CQC has provided a detailed explanation of the guidance and best practice materials that are available. I will not repeat the detail here. However, you may wish to note that Departmental officials have made enquiries with NICE, which has confirmed that appropriate guidance is available, issued by NICE itself and others.

For example, National Guideline 148: Acute Kidney Injury acknowledges that there can be practical difficulties in patients with dementia (recommendation 1.1.12) which may make becoming dehydrated more likely. In addition, NICE guideline, Older people with social care needs (NG223), identifies the need to maintain hydration for such patients and includes specific recommendations relating to hydration with regard to care in care homes (recommendation 1.5.13) and training for health and social care practitioners (recommendation 1.7.2). I understand guidance has also been issued by the Social Care Institute for Excellence (SCIE); British Nutrition Foundation and others.

The Care Certificate4, that has 15 standards that define the knowledge, skills and behaviours expected of roles in the health and social care sectors, includes a standard (Standard 8) relating to fluid and nutrition.

Registered providers have a duty to deliver care safely and effectively. In particular, to ensure adequate nutrition and hydration for their service users; and that they employ suitably qualified, competent and experienced staff, that are supported with the right training, professional development and supervision necessary for them to carry out their role and responsibilities. Registered providers are expected to adhere to and implement national guidance and standards to ensure high standards of care. As well as signposting the guidance available, the CQC website provides information on issues around hydration that registered providers may need to consider when formulating and reviewing their local policies.

I am aware that the CQC has advised in its response to you that it identified no breach of the Regulations when it reviewed the death of Mr Taylor. Mr Taylor had a nutrition and hydration care plan in place; an assessment of Mr Taylor’s nutrition needs had recently been made; and daily food and fluid records were being completed. Training records at the Home indicated that the majority of staff had completed the Care Certificate or had other relevant qualifications pertinent to their role. In line with its regulatory responsibilities, the CQC will continue to monitor the Home.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

HELEN WHATELY