Pennine Care NHS Foundation Trust
NHS / Health Body
Action Planned
Pennine Care NHS Foundation Trust will circulate a 7-minute briefing to raise awareness of physical health and acute illness management training, and staff's responsibility to maintain compliance. The training covers assessment of deteriorating patients, including airway management and oxygen administration. (AI summary)
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Dear Mr Wells,
RE: Allan William Cunliffe
Thank you for your Regulation 28 Report dated 22nd April 2020 and for bringing to my attention the concerns you have after hearing evidence at the inquest of Allan William Cunliffe. Your concerns have been reviewed and Pennine Care’s response is outlined below:
Concerns: “The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.”
Response: Pennine Care’s Physical Health Policy for Mental Health and Learning Disability Service Users (CL042) identifies that the NEWS2 has now received formal endorsement from NHS England and NHS Improvement to become the early warning system for identifying acutely unwell patients in hospitals in England. Completion of the NEWS2 scoring system can help to recognise sepsis, raise the alarm quickly to a senior colleague or health care professional. The NEWS2 should be completed more frequently if the service user shows signs of deterioration, commenced on antibiotics, prescribed certain medication (e.g. rapid tranquilisation) and/or placed on neurological observations. The policy goes onto say that, if there is indication that physical health is deteriorating or a service user is complaining of physically unwell, nursing staff should ensure, where possible, that observations are recorded and that a National Early Warning Score is calculated. Other tests may be carried out depending on the patient’s presentation. Observations should be recorded and reported as agreed with the doctor to ensure effective ongoing
monitoring. The observations and communication with the doctor must be recorded in the service user’s hospital notes. This policy along with Pennine Care’s Resuscitation Policy (CL009) indicates staff must ensure that all communication is in line with SBARD principles. These principles and its associated documentation are taught within the ILS courses and NEWS2 training across the organisation.
Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A memo has been sent to all staff members reiterating the importance of ensuring that NEWS2 scores are calculated accurately and signed appropriately. All refusals of observations or escalations of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance that quality standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:
a) Help to recognise that a patient is deteriorating b) Support clinical judgement (whilst not replacing it) c) Help secure appropriate help, including transfer for emergency treatment d) Aid communication by providing a common language.
The parameters of each physiological observation are discussed along with how to score these on the NEWS2 chart. Attendees are provided with a copy of the NEWS2 and guided In terms of the completion of this. It is reiterated that all observations need to be completed in order to obtain an accurate NEWS2 score. At the end of the course a number of scenarios are used to ensure attendees understanding of the tool and the need for escalation as required. Attendees are also made aware of the signs of sepsis.
The use of the SBARD tool is widely recognised within Pennine Care. However, it is acknowledged that this is difficult to evidence as this communication is often verbal. To assist in the documentation of the handover provided in the event of a physical health concern and/or medical emergency it is envisaged that an A4 document will be produced which will, not only prompt staff members in relation to the principles of SBARD, but also serve as a log of the information that has been handed over. This can then be added to the clinical record. It is hoped that this piece of work will be complete by August 2020.
In addition to the above a series of meetings have taken place this year between the Older People’s Mental Health Service and the Digital Health Team which is part of Tameside Integrated Care Foundation Trust (ICFT) to explore ways of providing a holistic and consistent approach to accessing timely specialist advice in relation to the physical health needs of older people on the inpatient mental health unit at Tameside Hospital who often have complex co-morbid physical and mental health needs.
Both organisations are progressing towards an agreement to work together which would allow the clinical inpatient teams on Summers & Hague Wards to access further specialist advice and guidance from the Digital Health Team to aid care and treatment of patients who are experiencing a decline in their physical health ensuring patient assessments are safe and effective resulting in early identification of a deteriorating physical health status.
By accessing the Digital health Team it is hoped that attendance at A&E for patients from Summers & Hague Wards can be reduced as the Digital health Team will be able to signpost to more appropriate services or arrange direct admission to the ICFT if clinically safe and indicated.
I am aware that you heard evidence from a Pennine Care member of staff which caused concern regarding their knowledge relating to the administration of oxygen and their awareness of the mandatory training provided by the Trust. The administration of oxygen is covered in the Immediate Life Support training that it is mandatory for all registered nursing staff working on in-patient wards in Pennine Care. This details that, in the event of an emergency, high flow oxygen should be administered via a non-rebreathe mask. It further details the use of airway adjuncts and a bag valve mask if the patient’s presentation indicates such.
More recently Pennine Care now also provides Acute Illness Management training for both registered and unregistered nursing staff. A workshop covering the systematic approach to assessing a deteriorating patient is delivered. During this airways and breathing are discussed and includes how to assess, and take action (inclusive of oxygen), in the event of an emergency. A demonstration/simulation is also delivered. The course details why a person needs oxygen to survive and the consequences of our body not receiving enough whilst also detailing normal and abnormal signs relating to the airway and breathing.
Attendees are advised, in the event of a medical emergency and having assessed a person’s oxygen saturations, oxygen should be administered through a reservoir (non-rebreathe mask) mask at a rate of 15 litres per minute. Reservoir masks are stored with the emergency equipment in the resuscitation grab/bags/trolley on the in- patient wards along with a bag-valve mask that is used for patients whose respirations have fallen below 10 respirations per minute. Acute Illness Management handbooks are given to all staff attending the course and are also available on each ward for reference.
Those attending the course aimed at unregistered staff are advised that they can take a person’s physical observations (including oxygen saturations) and recognise when oxygen therapy is necessary but must rely on the registered staff to administer it as per Pennine Care’s Standard Operating Procedure on the safe administration of oxygen to patients of the Trust (SOP 0029).
A 7 minute briefing will be circulated to raise awareness of the content of this training and staff’s responsibility of maintaining compliance with such.
I hope this response assures you that the Trust has taken your concerns seriously and is taking measures to address the concerns raised.
RE: Allan William Cunliffe
Thank you for your Regulation 28 Report dated 22nd April 2020 and for bringing to my attention the concerns you have after hearing evidence at the inquest of Allan William Cunliffe. Your concerns have been reviewed and Pennine Care’s response is outlined below:
Concerns: “The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.”
Response: Pennine Care’s Physical Health Policy for Mental Health and Learning Disability Service Users (CL042) identifies that the NEWS2 has now received formal endorsement from NHS England and NHS Improvement to become the early warning system for identifying acutely unwell patients in hospitals in England. Completion of the NEWS2 scoring system can help to recognise sepsis, raise the alarm quickly to a senior colleague or health care professional. The NEWS2 should be completed more frequently if the service user shows signs of deterioration, commenced on antibiotics, prescribed certain medication (e.g. rapid tranquilisation) and/or placed on neurological observations. The policy goes onto say that, if there is indication that physical health is deteriorating or a service user is complaining of physically unwell, nursing staff should ensure, where possible, that observations are recorded and that a National Early Warning Score is calculated. Other tests may be carried out depending on the patient’s presentation. Observations should be recorded and reported as agreed with the doctor to ensure effective ongoing
monitoring. The observations and communication with the doctor must be recorded in the service user’s hospital notes. This policy along with Pennine Care’s Resuscitation Policy (CL009) indicates staff must ensure that all communication is in line with SBARD principles. These principles and its associated documentation are taught within the ILS courses and NEWS2 training across the organisation.
Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A memo has been sent to all staff members reiterating the importance of ensuring that NEWS2 scores are calculated accurately and signed appropriately. All refusals of observations or escalations of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance that quality standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:
a) Help to recognise that a patient is deteriorating b) Support clinical judgement (whilst not replacing it) c) Help secure appropriate help, including transfer for emergency treatment d) Aid communication by providing a common language.
The parameters of each physiological observation are discussed along with how to score these on the NEWS2 chart. Attendees are provided with a copy of the NEWS2 and guided In terms of the completion of this. It is reiterated that all observations need to be completed in order to obtain an accurate NEWS2 score. At the end of the course a number of scenarios are used to ensure attendees understanding of the tool and the need for escalation as required. Attendees are also made aware of the signs of sepsis.
The use of the SBARD tool is widely recognised within Pennine Care. However, it is acknowledged that this is difficult to evidence as this communication is often verbal. To assist in the documentation of the handover provided in the event of a physical health concern and/or medical emergency it is envisaged that an A4 document will be produced which will, not only prompt staff members in relation to the principles of SBARD, but also serve as a log of the information that has been handed over. This can then be added to the clinical record. It is hoped that this piece of work will be complete by August 2020.
In addition to the above a series of meetings have taken place this year between the Older People’s Mental Health Service and the Digital Health Team which is part of Tameside Integrated Care Foundation Trust (ICFT) to explore ways of providing a holistic and consistent approach to accessing timely specialist advice in relation to the physical health needs of older people on the inpatient mental health unit at Tameside Hospital who often have complex co-morbid physical and mental health needs.
Both organisations are progressing towards an agreement to work together which would allow the clinical inpatient teams on Summers & Hague Wards to access further specialist advice and guidance from the Digital Health Team to aid care and treatment of patients who are experiencing a decline in their physical health ensuring patient assessments are safe and effective resulting in early identification of a deteriorating physical health status.
By accessing the Digital health Team it is hoped that attendance at A&E for patients from Summers & Hague Wards can be reduced as the Digital health Team will be able to signpost to more appropriate services or arrange direct admission to the ICFT if clinically safe and indicated.
I am aware that you heard evidence from a Pennine Care member of staff which caused concern regarding their knowledge relating to the administration of oxygen and their awareness of the mandatory training provided by the Trust. The administration of oxygen is covered in the Immediate Life Support training that it is mandatory for all registered nursing staff working on in-patient wards in Pennine Care. This details that, in the event of an emergency, high flow oxygen should be administered via a non-rebreathe mask. It further details the use of airway adjuncts and a bag valve mask if the patient’s presentation indicates such.
More recently Pennine Care now also provides Acute Illness Management training for both registered and unregistered nursing staff. A workshop covering the systematic approach to assessing a deteriorating patient is delivered. During this airways and breathing are discussed and includes how to assess, and take action (inclusive of oxygen), in the event of an emergency. A demonstration/simulation is also delivered. The course details why a person needs oxygen to survive and the consequences of our body not receiving enough whilst also detailing normal and abnormal signs relating to the airway and breathing.
Attendees are advised, in the event of a medical emergency and having assessed a person’s oxygen saturations, oxygen should be administered through a reservoir (non-rebreathe mask) mask at a rate of 15 litres per minute. Reservoir masks are stored with the emergency equipment in the resuscitation grab/bags/trolley on the in- patient wards along with a bag-valve mask that is used for patients whose respirations have fallen below 10 respirations per minute. Acute Illness Management handbooks are given to all staff attending the course and are also available on each ward for reference.
Those attending the course aimed at unregistered staff are advised that they can take a person’s physical observations (including oxygen saturations) and recognise when oxygen therapy is necessary but must rely on the registered staff to administer it as per Pennine Care’s Standard Operating Procedure on the safe administration of oxygen to patients of the Trust (SOP 0029).
A 7 minute briefing will be circulated to raise awareness of the content of this training and staff’s responsibility of maintaining compliance with such.
I hope this response assures you that the Trust has taken your concerns seriously and is taking measures to address the concerns raised.