Birmingham Community Healthcare NHS Trust
NHS / Health Body
Action Taken
A new protocol clarifies physical observations for prisoners, and IDTS nurses now complete the National Early Warning Score (NEWS). Healthcare staff were reminded on February 13, 2019, to ensure appropriate observations are carried out during physical examinations. (AI summary)
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Dear Mrs Hunt Response to Regulation 28 Report to Prevent Future Death dated 21 January 2019 Inquest touching the death of Neil Antony Black: 15-17 January 2019 Thank you for your Regulation 28 report relating to the death of Mr Neil Antony Black which we received from your office on 21 January 2019. Please do be assured that we have taken your concerns and findings very seriously _ We note that actions are required to be delivered by both Birmingham and Solihull Mental Health NHS Foundation Trust ("BSMH") and Birmingham Community Healthcare NHS Foundation Trust ("BCHC") This is joint response. The MATTERS OF CONCERN are as follows: B wing is the drug detoxification wing at Birmingham prison. Prisoners undergoing drug detoxification see IDTS nurses for drug needs and primary care nurses for health care needs. Prisoners on B wing often have complex mixed needs_ The evidence at the inquest confirmed there were no joint handovers despite the nurses being located very close to each other: Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach: 2 Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses. IN addition witnesses were unclear who should undertake what observations on prisoners and for what reason. Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations_ disability Better Care: Healthier Communities confident EMPLOYER NHS
3. Neil Black came into prison with a DVT in his right leg which was caused by IV use injecting into his groins. His groins sites and leg were not examined during his time at the prison. Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites_ This joint response by BCHC and BSMH has been prepared with the assistance of the Head of Healthcare at HMP Birmingham who holds that position jointly on behalf of both Trusts_ BCHC and BSMH have agreed the following: 1 _ JOINT HANDOVERS We commenced a process on 11 February 2019 whereby the Nurse in Charge for both the "B3" team (the primary, or physical, healthcare team employed by BCHC) and the "IDTS" team (the Integrated Treatment Service team employed by BSMH) have a verbal handover at the midday handover for any patients who are presenting as requiring joint care for both physical care and substance misuse treatment. The handover documents for both IDTS and B3 will be amended to ensure these patients discussed are recorded. This will be audited after one month to ensure the process is effective and any amendments to this process will be made 2 IMPROVING THE RELATIONSHIP BETWEEN THE TEAMS AND PROTOCOL FOR OBSERVATONS (a) Relationship between the teams_ Whilst we acknowledge there are challenges in the teams working relationships we can also cite a number of good practices and inter team working that we have initiated over the last year: We hold a Management/Leaders meeting every Monday morning where any issues are aired and can be immediately resolved to ensure problems are rapidly discussed and solutions implemented To further improve the teams working together we have established a Band 7 (Team Manager) meeting for all healthcare teams on a monthly basis. This meeting will provide an opportunity where any issues between the healthcare teams can be openly discussed and resolutions agreed at an appropriately senior level. We have also planned a series of more informal events to support inter team working these include "case busting" and team briefings. We will liaise with each Trust's Organisational Development Team to review if additional Organisation Development work would be beneficial: (b) Protocol for Observations In relation to the physical observations there is a new protocol which clarifies the process for physical observations on prisoners: IDTS nurses complete observations for people at risk of withdrawal which ensures people are experiencing a safe detoxification: drug Drug
IDTS also now complete the National Early Warning Score (NEWS) observation which results in a score and indicates the frequency of physical observations required (which IDTS continue to do). The NEWS score also indicates if any referral needs to be made to the 'B3" physical care team or GP and provides process to escalate concerns of a deteriorating patient: Physical care nurses B3 are responsible for taken a full set of physical observations if any patient is referred to their team: The requirement to do this was sent out to staff on 11 February 2019.
3. PROTOCOL FOR EXAMINATIONS OF INJECTION SITES AND DVT SITES We have carefully reviewed the national guidelines and our current protocols in relation to both the management of vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites_ We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out. We would like to thank you for drawing this matter to our attention and sincerely hope that the controls outlined above will help to prevent future deaths of this nature_ This response been approved by John Short; CEO, Birmingham and Solihull Mental Health NHS Foundation Trust
3. Neil Black came into prison with a DVT in his right leg which was caused by IV use injecting into his groins. His groins sites and leg were not examined during his time at the prison. Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites_ This joint response by BCHC and BSMH has been prepared with the assistance of the Head of Healthcare at HMP Birmingham who holds that position jointly on behalf of both Trusts_ BCHC and BSMH have agreed the following: 1 _ JOINT HANDOVERS We commenced a process on 11 February 2019 whereby the Nurse in Charge for both the "B3" team (the primary, or physical, healthcare team employed by BCHC) and the "IDTS" team (the Integrated Treatment Service team employed by BSMH) have a verbal handover at the midday handover for any patients who are presenting as requiring joint care for both physical care and substance misuse treatment. The handover documents for both IDTS and B3 will be amended to ensure these patients discussed are recorded. This will be audited after one month to ensure the process is effective and any amendments to this process will be made 2 IMPROVING THE RELATIONSHIP BETWEEN THE TEAMS AND PROTOCOL FOR OBSERVATONS (a) Relationship between the teams_ Whilst we acknowledge there are challenges in the teams working relationships we can also cite a number of good practices and inter team working that we have initiated over the last year: We hold a Management/Leaders meeting every Monday morning where any issues are aired and can be immediately resolved to ensure problems are rapidly discussed and solutions implemented To further improve the teams working together we have established a Band 7 (Team Manager) meeting for all healthcare teams on a monthly basis. This meeting will provide an opportunity where any issues between the healthcare teams can be openly discussed and resolutions agreed at an appropriately senior level. We have also planned a series of more informal events to support inter team working these include "case busting" and team briefings. We will liaise with each Trust's Organisational Development Team to review if additional Organisation Development work would be beneficial: (b) Protocol for Observations In relation to the physical observations there is a new protocol which clarifies the process for physical observations on prisoners: IDTS nurses complete observations for people at risk of withdrawal which ensures people are experiencing a safe detoxification: drug Drug
IDTS also now complete the National Early Warning Score (NEWS) observation which results in a score and indicates the frequency of physical observations required (which IDTS continue to do). The NEWS score also indicates if any referral needs to be made to the 'B3" physical care team or GP and provides process to escalate concerns of a deteriorating patient: Physical care nurses B3 are responsible for taken a full set of physical observations if any patient is referred to their team: The requirement to do this was sent out to staff on 11 February 2019.
3. PROTOCOL FOR EXAMINATIONS OF INJECTION SITES AND DVT SITES We have carefully reviewed the national guidelines and our current protocols in relation to both the management of vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites_ We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out. We would like to thank you for drawing this matter to our attention and sincerely hope that the controls outlined above will help to prevent future deaths of this nature_ This response been approved by John Short; CEO, Birmingham and Solihull Mental Health NHS Foundation Trust