University Health Board
Action Planned
The health board has incorporated actions into a formal plan with clear timescales and responsibilities for monitoring Mr Redmore's neurological state, acting upon NEWS observations, and undertaking observations in line with guidance. An advisory group will help deliver improvements. (AI summary)
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Dear Mr. Barkley, Inquest The late Dennis Redmore write further to your correspondence dated gth August 2017 regarding the above and the Regulation 28 notification issued_ The Regulation 28 was issued as a result of the inquest completed on 3rd August 2017 which concluded that Mr Redmore died as result of the effects of a head injury which he sustained when he fell in hospital. The evidence did not reveal a clear cause for the fall but it is likely that his medical condition, both acute and chronic, contributed. You detailed your concerns in respect of: Failure to monitor Mr Redmore neurologically Failure to act upon NEWS observations Failure to undertake observations in line with local and national guidance Lack of appropriate management of the nurse responsible for undertaking the observations Please find below a resume of the actions we are currently undertaking and those planned. These are described in detail in the attached action plan. Chaiman/Cadeirydd: Andrew Davles Interim Chief Executivel Prif Weithredydd: AJoxandra Kowells ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot SA12 7BR Telephone: (01656) 752752 Bwrdd lechyd ABM Y enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board Is the operatlonal name of Abertawe Bro Morgannwg University Local Health Board WWW: abm wales nhs,uk J0
Action PlanlActions Undertaken The following have been incorporated into a formal action plan with clear timescales and responsibilities assigned to key individuals in undertaking and monitoring of the required actions as follows: Staff to be reminded of the need to adhere to the ABMU neurological guidelines Ward sister to reiterate to the nursing team on AMU the Leadership and delegation responsibilities of the nurse in charge of each shift For the month of October 2017 documentation to be reviewed (audit) on all patients who have sustained a fall on AMU which will include compliance with neurological observations Learing from the above audit to be shared with staff in AMU and actions agreed for implementation Outreach team are currently auditing NEWS compliance across all acute wards in a rolling programme Training Needs Analysis (TNA) to be undertaken in relation to need for ALERT and Beach training in AMU Feedback from review of current Falls Policy and revised documentation currently on trial in Princess of Wales Monitor this action plan monthly to ensure compliance and adherence to timescale In addition, the above actions will be reviewed by the Unit Nurse Director and Unit Medical Director and summary report will be provided to the Quality and Patient Safety Committee in April 2018. On the 10th March 2017 a Spot the Sick Patient Steering Group was set up which meet on bi-monthly basis: One of the aims of the Group is to improve the recognition, treatment and outcome of deteriorating patients In hospital. Enclosed is a copy of the Terms of Reference of the Group for your information. trust that the action plan to address the matters of concern raised in the Regulation 28 notice are to your satisfaction and provide with the required level of assurance.
Action PlanlActions Undertaken The following have been incorporated into a formal action plan with clear timescales and responsibilities assigned to key individuals in undertaking and monitoring of the required actions as follows: Staff to be reminded of the need to adhere to the ABMU neurological guidelines Ward sister to reiterate to the nursing team on AMU the Leadership and delegation responsibilities of the nurse in charge of each shift For the month of October 2017 documentation to be reviewed (audit) on all patients who have sustained a fall on AMU which will include compliance with neurological observations Learing from the above audit to be shared with staff in AMU and actions agreed for implementation Outreach team are currently auditing NEWS compliance across all acute wards in a rolling programme Training Needs Analysis (TNA) to be undertaken in relation to need for ALERT and Beach training in AMU Feedback from review of current Falls Policy and revised documentation currently on trial in Princess of Wales Monitor this action plan monthly to ensure compliance and adherence to timescale In addition, the above actions will be reviewed by the Unit Nurse Director and Unit Medical Director and summary report will be provided to the Quality and Patient Safety Committee in April 2018. On the 10th March 2017 a Spot the Sick Patient Steering Group was set up which meet on bi-monthly basis: One of the aims of the Group is to improve the recognition, treatment and outcome of deteriorating patients In hospital. Enclosed is a copy of the Terms of Reference of the Group for your information. trust that the action plan to address the matters of concern raised in the Regulation 28 notice are to your satisfaction and provide with the required level of assurance.