Queen Elizabeth Hospiatl Kings Lynn NHS Trust
NHS Trust
Action Taken
AI-generated response summary
• A new electronic referral system for the Tissue Viability Nurse service will be implemented in the first week of next month. • A weekly Documentation Task and Finish Group, led by the Chief Nurse, commenced business on 21st August 2019. • Training for core and clinical induction now covers record keeping, and a roll-out of new standardised blue folders for nursing medical records has commenced in acute medical wards.
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Dear Mrs Lake Inquest Carol Anne Jennings (deceased) Regulation 28 Report In response to your Report under Regulation 28 of the Coroner's Rules wish to set out our reply below. You raised two concerns, the first being about patient referrals to our Tissue Viability Nurse (TVN) service and the second relating to the completion of nursing records. Referrals to the TVN service new electronic referral system will be in place during the first week of next month: As compared with the previous system involving telephone referrals and the practice of answering machine use, which is being discarded, there is now new e-form which must be used in all cases The e-form must only be emailed to the TVN nurse as indicated and the referral form'$ design means that correct and accurate information about the patient must be included so that the referral and response is efficiently conducted by the TVN. A copy of that form is attached for your information: Nursing documentation We have number of initiatives in relation to nursing documentation as a result of our recent CQC inspections and these changes are being overseen by our Conditions Notices and Oversight Group. Under the heading of nursing documentation the key improvements put in place are: The Department responsible for the area in which Mrs Jennings was treated has a new divisional leadership team (Division 2) which has been in place since August. King
25 September 2019 The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust A weekly Documentation Task and Finish Group was set up and commenced business on 21st August 2019. The Chief Nurse is the executive lead and has oversight of this meeting and it is attended by the Matrons and Ward Managers. The weekly documentation and risk assessment audits are to be maintained and for Division 2 overall the most recent recorded compliance rate is 90.5%. The Stop the Clock and SBAR (Situation, Background, Assessment, Recommendation) campaign continues within Acute Medicine_ "Stop the Clock is an initiative started by our Assessment Zone nursing staff which advocates stopping the time to gain situational awareness of risk pertaining to task. It allows staff to check and challenge potentially unsafe practice when transferring and receiving patients before it happens This is enhanced by using the SBAR tool as prompt to ensure that appropriate information is relayed: understand that Mrs Jennings was moved twice within the Acute Medicine Department and that loss of continuity may have been factor in the problems with the associated record keeping: Training for core and clinical induction now covers record keeping alongside the NEWS2 early warning system: The Rapid Assessment Team has introduced a checklist for aiding communication among the acute medical teams and this will be in use in October. Our acute medical wards have started a roll-out of new standardised blue folders which contain the most active parts of the nursing medical records: This encompasses our most acute clinical areas, including the Acute Medical Unit and the Assessment Zone. Wound assessment documentation also falls within the scope of this change. In addition; bespoke training on the ward is given to new staff who may be unfamiliar with the blue folder documentation: The intention is that standardisation means that regardless of the patient'$ movement through the Acute Medicine Department; the documentation will be continuous and consistent
25 September 2019 The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust A weekly Documentation Task and Finish Group was set up and commenced business on 21st August 2019. The Chief Nurse is the executive lead and has oversight of this meeting and it is attended by the Matrons and Ward Managers. The weekly documentation and risk assessment audits are to be maintained and for Division 2 overall the most recent recorded compliance rate is 90.5%. The Stop the Clock and SBAR (Situation, Background, Assessment, Recommendation) campaign continues within Acute Medicine_ "Stop the Clock is an initiative started by our Assessment Zone nursing staff which advocates stopping the time to gain situational awareness of risk pertaining to task. It allows staff to check and challenge potentially unsafe practice when transferring and receiving patients before it happens This is enhanced by using the SBAR tool as prompt to ensure that appropriate information is relayed: understand that Mrs Jennings was moved twice within the Acute Medicine Department and that loss of continuity may have been factor in the problems with the associated record keeping: Training for core and clinical induction now covers record keeping alongside the NEWS2 early warning system: The Rapid Assessment Team has introduced a checklist for aiding communication among the acute medical teams and this will be in use in October. Our acute medical wards have started a roll-out of new standardised blue folders which contain the most active parts of the nursing medical records: This encompasses our most acute clinical areas, including the Acute Medical Unit and the Assessment Zone. Wound assessment documentation also falls within the scope of this change. In addition; bespoke training on the ward is given to new staff who may be unfamiliar with the blue folder documentation: The intention is that standardisation means that regardless of the patient'$ movement through the Acute Medicine Department; the documentation will be continuous and consistent