Stanford Bell

Dear Mr Fleming

Re: Prevention of Future Deaths (PFD) Report: Mr Stanford Bell: DOB: 24/05/1935: DOD: 02/03/2018 Your Ref: MDF-HK/811-2018

Following my letter to you of 3 August, acknowledging receipt of the Prevention of Future Deaths (PFD) Report you issued to the Trust under Regulation 28 of the Coroners Rules, I am pleased to share as requested, the Trust's response to the area of concern highlighted in your report. Our responses are contained within the enclosed action plan describing improvement actions, both taken and planned; identified leads and timeframes for these actions.

The local monitoring of the actions along with assurance of sustained compliance is the responsibility of the Emergency Governance Group, with escalation of non-compliance through the Trust governance structures.

Within the Trust, from a Corporate Governance and Assurance perspective, the actions along with evidence of embedding will be received at the Risk & Compliance Group with assurance provided to the Board of Directors.

The Trust is fully committed to learning and improving the patient experience, to ensure we provide high standards care for our patients. I hope that this information will demonstrate to you that the Trust has responded both positively and actively to your ruling and expressed concern.

However, if you do require any further information, please contact me and I will assist in any way I can.

Dear Mr Flemming

Re: Regulation 28 Report to Prevent Future Deaths

Further to the Regulation 28 Report provided to myself Mrs Rosina Parkinson at Riverview Nursing Home, Stourton Road, Ilkley, LS29 9BG, please find below my response together with a copy of a 'Falls Protocol' introduced following a review of our response to any falls on site at Riverview Nursing Home.

During the immediate period following the incident resulting in the sad death of Mr Bell Riverview Nursing home had reviewed its policies and procedures following any untoward incident including falls and staff had been prompted to ensure they completed all documentation appropriately.

In responding to your Regulation 28 request we have however taken a more direct 'Lessons Learnt' approach and additional measures and have now been introduced with a specific 'Falls Protocol' including specific procedures to be followed for any resident fall (including falls which may result in head injury). The lesson learnt was that we could be, and will be, much more pro-active in our response to any resident fall.

This work has been undertaken with support from an independent clinical advisor together with further external validation by an independent medical practitioner (who in addition to being a senior medical practitioner is an experienced Medical Educator (advanced life support) and an Expert Medical Witness)).

The protocol guidance includes a flow chart, specific observation checklists (for any type of injury post fall) and specifically a neuro-observation chart to be used should head injury be suspected. The protocol also includes further guidance on completion of the neuro-observation chart (including the Glasgow Coma Scale). Riverview/Coroner Reg28/August 2018

The protocol also allows and encourages continuation of observations beyond the first 24 hours post fall concerns however if observations taken raised concerns at any time the advice of a medical professional would be sought.

The protocol also requires a 999 'bluelight' emergency call should seizures or fitting occur following a fall either pre or post hospital attendance.

In addition to the 'Falls Protocol' Riverview Nursing Home is signed up to and is participating in the Local Authority and CCG 'Red Bag' pathway ((in line with NICE NG27: Transition between inpatient hospital setting and community or care homes).

This supports the process of ensuring correct information and documentation is sent with the resident should transfer to hospital be required. The pathway is monitored and audited externally by the CCG. The service has transferred two residents to hospital during the summer period and has utilised the 'Red Bag' pathway on both occasions (however I should confirm that neither transfer was related to a fall). The Falls Protocol also requires that should a resident attend hospital following a fall and subsequently return to the service within 24 hours, Riverview staff will 'pick up' observations from the point of return and continue to record until at least 24 hours post incident unless told to cease or continue further by a medical practitioner.

Training has been provided for all staff in completing the Falls Protocol however the protocol is written in a way to direct staff completing it in a step by step process. In response to your request for a timetable for action, the new protocol was introduced and went live at Riverview Nursing Home on 15th August 2018 (as a final draft awaiting external validation as we believed it offered a safer and improved response to resident falls). The Protocol was fully (externally) validated on 23rd August 2018.

The Reg Bag pathway was introduced during the spring and was utilised for two transfers during July 2018 (as mentioned above).

A copy of the Falls Protocol and my response to you has been submitted to the CQC who requested I complete this no later than 26th August 2018 (following my Regulation 18 submission to them as per Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).

I have also submitted a copy of the Falls Protocol to the Local Authority (Bradford) with whom we work closely.

Should you have any further questions please do not hesitate to contact me and I will respond as a matter of urgency. Riverview/Coroner Reg28/August 2018