Henry Powell

Dear Mrs Brown, Re. Henry Denis Whitwell POWELL Further to your report dated 18 February 2015,in accordance with paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 offer the following response We have investigated the matters you raised in your report, relating to concerns about discharge care planning, the conflict currently between the policies governing transfer arrangements between University Hospitals of Leicester NHS Trust (UHL) and Leicestershire Partnership NHS Trust (LPT), the inadequate co-ordination between services, and the communications between stakeholders in the provision and ordering of bed rail equipment: Please note that the scope of our response relates to adults over the age of 18 years each concern is addressed in turn below: The LPT Action Plan that follows from our responses is at the Annex and will be monitored by Board"s Quality Assurance Committee The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff: Health care professionals working for LPT will discharge patients with bed rails and order bed rails where assessed as appropriate: This takes place predominately in community in-patient services It may also occur in Mental Heallh Services for Older People (MHSOP) , Adult Mental Health and Learning Disability Services Our health care professionals working within an in-patient setting are trained in the appropriate use of bed rails through the essential t0 role falls training , All staff working within these areas have undertaken a clinical workbook that incorporates falls training: The clinical workbook is being replaced with a continuous roll out training programme for all healthcare professionals Currenlly compliance records for falls training is held locally on each ward. We are in the process of establishing how training compliance can be reported on divisionally t0 enable wider scrutiny: Chair; Professor David Chiddick CBE Chiet Executive: Dr Peter Millet Town and Lou/ 2 21548149

2015 falls training will be included on the Trust's centralised training database (ulearn) system giving a more systematic approach to recording and monitoring of compliance t0 falls training. The correct use of bed rails is included within the staff induclion; and also in the annual update mandatory moving and handling training for all our healthcare staff: The Integrated Community Equipment Service (ICES) will be providing essential training for staff that are able to assess patients for bed rails and order bed rails, especially when transferring from hospital to community environments When this training becomes available LPT will support staff to attend; is a conflict currently between the policies governing transfer arrangements between hospital (UHL) and community (LPT) and the provision ordering of equipment which can now be done directly by the hospital: Our Lead Nurse for Community Services, Community Health Service division is leading the development of a shared policy for the safe use of bedrails: Representatives from LPT, UHL, ICES and West Leicestershire Clinical Commissioning Group have met and agreed (he areas for development and wider consideration; draft combined policy will be available for each organisation to adopt by the end of April 2015. A standardised assessment and risk assessment flowchart t0 determine the appropriateness of bedrails for individual patients has been devised for use in all organisations. This will ensure that patients will be assessed for the safe use of bed rails using the same process regardless of the environment in which they are cared for. The risk assessment will be used in conjunction with a standardised care plan for patients assessed as suitable for use of bed rails These will be available within the shared policy and as separate workable documents. The development of a standardised approach t0 risk assessment and care planning will aid communication and transfer arrangements of patients Co-ordination between services is inadequate, resulting in equipment being ordered by the hospital, but not thereafter being followed Up or assessed in the community: The newly devised shared policy for (he safe use of bedrails will include the responsibilities of staff when transferring patients, stating when and who will provide on-going risk assessments: For patients discharged from healthcare services with an on-going need for bed rail use with formal or in-formal carers a minimum standard of information will be provided The local authorities have been involved t0 determine the most appropriale transfer of care arrangements for those patients who do not have a continued health care need. The ICES will be including a message within their newsletter to alert all staff t0 the need t0 share bed rail assessments; risk assessments and Ihe (ype of bed rail provision on discharge: The communication from ICES will be delivered t0 all healthcare professionals across (he organisations including LPT $ healthcare professional staff that are able to order equipment; Equipment is supplied by a single gatekeeper, NRS Healthcare, and an alert system is intended to ensure communication has taken place between all Chair; Professor David Chiddick CBE Chief Executive: Dr Pcter Millcr 0 01548149 From May There and The out( 0

stakeholders, but was advised that this system has not been implemented; early implementation would assist in resolving the current difficulties: An alert on the NRS Healthcare ordering system has been put in place The alert requires the healthcare professional ordering the equipment to confirm that full assessment and risk assessment has been completed that supports the bed rails are a safe and appropriate for the individual patient: The system will not allow the order for bed rails t0 be placed if the risk assessment is not confirmed. LPT takes these concerns very seriously and trust that you will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again. Yours_ sincerel Dr Peter Miller Chief Executive Annex: LPT Action Plan Chair: Professor David Chiddick CBE Chict Executive: Dr Petcr Millcr Lour, 0 1 015404t9

8 8 2 b 6 0 li 0 0 9 12 L ] ] 8 Hx 8 8 6 1 V 1 1 L 2 2 0 2 1 9 ] I 2 0 1 #5 Ju 8 1 j 1 I 8 1 I 8 g 3 I J H g g Mh 6 U | 8 1 L 1 8 1 8 I Je L 8 93 2 ! H 5 8 8 HHI 2 8 8 1 5 J 2 @ I 0 h 8 JU @ # 1 U 8 g 8 8 1 ] Mi 1 1 9 Ju 0 6 6 2 1 1 2

0 8 I I 7 8 Jb 8 1 8 1 8 3 2 l I ] 8 L 2 8g2 I g 1 1 8 8 IL 8 < { Ji 2 28 5 1 7 8 81 1 2 1 1 2 H 1 2 9 W [ 1 L 8 W L# 6 H 23 B 1 8 [ 8 2 Iuh 6 1 1 HH 1 8 U 2 Ihi 1 Hmh 3 2 2 9 8 23 8 0# He V 8 2 ! 1 Iu "6 2 1 g 8 28 g 1 1 0 g3 g 2 I i 8 1 8 1 g 8 1 32 8 1 8 7 7 8 1 2 Hl EZe 1 2

Dear Mrs Mason Re: Henry Dennis Whitwell Powell write further to your Regulation 28 sent to us on 18 February 2015, and am now in a position t0 respond. note that the matters of concern are as follows - The discharge care planning is felt to be inappropriate with misunderstanding regarding the appropriate use of bed rails. There was felt to be a conflict between the policies governing transfer arrangements between my Trust and the Community Services and the provision and ordering of equipment: Co-ordination between services provided by UHL and LPT was felt to be inadequate Implementation of an alert system to ensure communication between all stakeholders has not been implemented. Since the conclusion of this inquest can report that we have taken steps to strengthen our processes light of what occurred in this case our Lead Discharge Nurse has met with all staff working in the Trust, who are authorised to order bed rails for discharge, to ensure they are up to date with the procedure for ordering bed rails and to ensure they fully understand how to use the bed rail risk assessment matrix for patients who are at risk of slipping, sliding or rolling out of bed: She has used this case t0 emphasise the importance of strictly University Hospitals of Leicester NHS Trust ineludes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: WWW leicesterhospitalsnhs.uk Chairman: Mr Karamjit Singh Chicf Executive: Mr John Adler

adhering to the approved process for discharge including when bed rails are to be provided. Supported by our Acting Chief Nurse, she will ensure that training is provided to relevant staff on the Trust's processes for discharge and this will include training on bed rails risk assessment: All staff authorised to order bed rails are all now aware of their responsibility to forward a copy the risk assessment and care plan undertaken by UHL staff to the person responsible for the patient's care in the community setting following discharge from UHL and the information will also be recorded on the electronic transfer letter on ICE and audited: In addition, our Acting Chief Nurse will ensure that the Manual Handling Team will review the manual handling training undertaken by Ward staff, t0 ensure they are able to understand and interpret the risk assessment matrix, to aid their decision making; for the use of bed rails for patients who are at risk of slipping, sliding rolling of bed in the hospital setting: This case has been discussed at the recent CMG Health and Safety Board and it was agreed that details of bed rail risk assessments will be recorded in the metrics that we collect and which provide an indication of current concerns within the clinical setting: particular we will be strengthening our guidance on the meaning of patient mobility to improve the quality of our bed rail risk assessments Our Acting Chief Nurse will ensure that all of the above action will be completed by June 2015. On your second and third concerns am pleased to be able to confirm that my Trust and Leicestershire Partnership Trust are working together to remove any conflict between our respective bed rail policies. Our Lead Discharge Nurse working collaboratively with representatives from community hospitals , community nursing NRS to agree a joint working policy for the safe use of bedrails. The working group have met twice to agree the process of assessment; development of a care plan and handover arrangements following transfer from hospital. A further meeting is scheduled for 10th April 2015, to make final adjustments to Ihe policy, before this is sent for ratification. Our Acting Chief Nurse will ensure that this work , will have occurred by May 2015. In addition, our Discharge Policy will be reviewed and will advise staff to consult the joint policy for the safe use of bedrails. This work will be completed by the end of June 2015. In addition, to ensure Trust-wide learning, this case will be discussed at UHL's Falls Group which is chaired by a senior clinician and also at the next meeting of the Trust's Nursing Executive Team which is chaired by our Acting Chief Nurse On your fourth our Lead Discharge has confirmed that an alert system is now in place on the electronic ordering system to prompt staff to consider a bed rails risk assessment: If this information is not completed, then the system will prevent bed rails being ordered, University Hospitals of Leicester NHS Trust includes Glenfield Hospilal, Leicester General Hospital Leicester Royal Infirmary Website: WwW_leicesterhospitals nhs_uk Chairman; Mr Karamjit Singh Chief Executive: Mr John Adler out and point anc

trust that this response provides you with the assurance that we take these matters seriously. If you would Iike any further information please do not hesitate to contact me.