Agnes Sansom

Dear Mr Chipperfield Re: Agnes Gwenlllan Sansom am writing in response to Regulation 28 Report To Prevent Future Deaths, which you issued to County Durham & Darlington NHS Foundation Trust on 6th January 2020." You raised two matters of concern that create the risk of other deaths and will respond t0 each in turn; Existing patient record systems fail to ensure that important and urgent infonation Is brought; in & timely way, t0 the attention of those who neod it The root cause analysis report has been reviewed and we have concluded that a misleading choice of words have been used as follows: "The matron advised that nursing staff primarily utilise Nervecentre (an electronic patient record) accessed by & hand held device &8 the main source of information during & shift rather than the patient"s paper health record". It is not factual t0 describe Nervecentre a8 an electronic patient record: The Trust does not have an electronic patient record in place. Nervecentre is an electronic observations system which ig also used for some patient risk assessments; including falls risk assessment and mobility gallery: Detailed patient care records are multi-disciplinary and in paper format within the Trust: Both nursing and physiotherapy records, along with medical entries are recorded contemporaneously within the paper record, In relation to Ms Sansom the physiotherapist had recorded within the paper record, placed mobility advice above the bed and handed over this advice verbally to the nursing staff. On further discussion with the nursing staff they have confirmed that this is the accepted procese, however; have also said that as Nervecentre Is a hand held device they will on occasion refer to the mobility gallery within Nervecentre also. safe compassionate . joined-Up care

NHS] County Durham and Darlington NHS Foundation Trust To address this issue physiotherapists now record in the mobility gallery in Nervecentre if they identify change in mobility or change in interventions required This does not replace the detailed paper record but ensures that all staff are aware of this whether accessing paper records or Nervecentre: "vulnerable patients are obliged to share walking aids on hospital wards" During traditional working hours walking aids are provided by physiotherapists following assessment of the patient We have implemented a buffer stock of walking aids in the hospitals to ensure there is an adequate supply out of hours. Ideally the buffer stock should not be used as it is preferable that patients requiring a walking aid have a physiotherapist assessment first;, however, if someone presents who does require a walking frame out of hours we have ensured that there is a buffer stock available for emergency use_ hope that you find actions taken by the Trust to be adequate to address the issues that you have raised, but please do not hesitate t0 contact me if you require further information_