South London Maudsley NHS Trust
NHS / Health Body
Action Planned
The Director of Nursing will issue a safety alert, and ward managers will hold learning conversations with nurses regarding observation practices. The Therapeutic Engagement and Observation Policy will be reviewed, and new nurses and nursing trainees will receive a "Learning the Lessons" presentation. Six-monthly audits will be commissioned to establish compliance, and a timeline is being developed for transforming observations into an e-observation framework. (AI summary)
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Dear Ms Henrietta Hill Re: Prevent future deaths Mr William Dickens This letter responds to the Prevent Future Deaths report issued to South London and Maudsley NHS Foundation Trust on & May 2018 in relation to the death of Mr William Dickens on 10" May 2017 whilst in our care_ In the PFD report you set out five matters of concern that relate to how nurses observed Mr Dickens, how and when the observations were recorded and how effectively observations records are used to maintain the safety of Mr Dickens. You have directed Trust to take action to eliminate or reduce the risk of death created by the Way our nurses carried out and recorded observations for Mr Dickens_ actions we will take are: The Director %f Nursing to use the case a8 the basis of an internal safety alert 'Blue Light Bulletin' to be sent out to all registered nurses to reinforce the practice standards To be completed by 6/07/18
2) All Ward Managers to be directed to have learning conversation with inpatient registered and non-registered nurses about the practice To be completed by 31/07/18
3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to clarity of practice standards and the implementation of the policy: the The the
Underway, to be completed by 31/08/18 From September 2018 the cohort of newly registered nurses to receive a "Learning the Lessons' presentation_ using this case a8 the basis, of the importance of timely observation and recording in preserving safety and confidence in those We care for. Commencing September 2018 and annual thereafter. From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for, Commencing September 2018 and annual thereafter:
6) Report the PFD and the actions taken to the Board of Directors as a part of the quarterly public learning lessons report Completed by November 2018 The Director of Nurslng as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into e-observation framework This is a long term project that is complex to deliver; a time frame is difficult to reliably commit the aim will be scoping from January 2019.
8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate: trust that these actions address the five concerns that are set out In section 5 of the preventing further deaths report; am happy to answer further questions or provide further information should that be necessary_
2) All Ward Managers to be directed to have learning conversation with inpatient registered and non-registered nurses about the practice To be completed by 31/07/18
3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to clarity of practice standards and the implementation of the policy: the The the
Underway, to be completed by 31/08/18 From September 2018 the cohort of newly registered nurses to receive a "Learning the Lessons' presentation_ using this case a8 the basis, of the importance of timely observation and recording in preserving safety and confidence in those We care for. Commencing September 2018 and annual thereafter. From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for, Commencing September 2018 and annual thereafter:
6) Report the PFD and the actions taken to the Board of Directors as a part of the quarterly public learning lessons report Completed by November 2018 The Director of Nurslng as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into e-observation framework This is a long term project that is complex to deliver; a time frame is difficult to reliably commit the aim will be scoping from January 2019.
8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate: trust that these actions address the five concerns that are set out In section 5 of the preventing further deaths report; am happy to answer further questions or provide further information should that be necessary_