Margaret Walker

Dear Mrs Leeming, Re: Mrs Margaret Walker deceased Thank you for letter dated 26 March 2014 with regards to your findings into the death of Mrs Margaret Walker and the directions given under Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 The Trust takes the matters described within the letter extremely seriously and hopes this response addresses the concerns you have raised: In addition we hope we are able to demonstrate to your satisfaction the learning within the Trust as a result of your correspondence_ Taking your points in turn can confirm the Trust have completed the following: Information Concerning Medication The Trust recognises the vital importance of the recording and sharing of accurate information with regard to medication This is covered within our core training programme on our medicines policy As a result of this case we have reviewed our policy and processes and will be issuing further guidance to raise awareness of the medicines reconciliation process and particularly the specific responsibilities of staff with regard to this_ Your letter states that Mrs Walker was admitted on 4 March 2012; however would like to confirm that Mrs Walker was admitted as a detained patient on August 2012_ note your concerns in the apparent delay in obtaining an accurate medication regime. 6 August 2012 was Monday and while it was significant (up to 48-hours after admission) , it was the earliest possibility at that time for obtaining GP practice held information needed to complement other information sources to establish an accurate medication regime Recently members of the Medicines Management Team have gained access to the electronic Summary Care Record for patients; this links to GP practices and provides access to the Better View_. of mind & body Our delay

GPs record of the patient's medication in most cases; however, it will not provide clinical details or blood test results or required ranges_ Routine access to the Summary Care Record is included in the work plan for the Trust's new Clinical IT system (RiO) Specifically this will improve medicines reconciliation out of routine working hours The Medicines Management Team provide services on our in-patient wards daily (Monday- Friday) to support a number of functions including medicines reconciliation: The team's work is audited regularly and the accuracy of their work is assured. The Trust has developed and in place process to regularly audit and to report any failings in the medicines reconciliation process_ Our data shows almost 100% of admissions have a medicine reconciliation completed; the small number that don't represent inpatient admissions lasting less than one daylone week- end: ii) Recording of Information in Clinical Notes would Iike to reassure you that processes and systems are in place to ensure that records are kept in line with Trust policies and procedures_ There are Trust approved documents for recording of vital signs and charts for the monitoring of Blood Glucose In this instance the staff involved in this case did not follow policies and procedures and did not record the clinical information they had in the correct place_ The competency of these staff to undertake the accurate and timely recording of information within clinical notes has been addressed through supervision and additional training: In addition, the Trust has also introduced care quality records audits for each named practitioner _ which is undertaken by the ward leadership team. The audits enable managers to identify the level of completeness and to address any areas ofconcern, including incomplete assessments. Record keeping audits and re-audits are undertaken by the Trusts Records Team and identified improvements from these audits are communicated and actioned by the Team Managers The Trust has also produced a number of Managers Briefing Notes (MBN's) , circulated Trust wide, reinforcing the importance of recording information in clinical notes, these include: MBN circulated 20 June 2013 reinforcing the requirement of completing and documenting physical health checks_ As part of the work stream to improve physical health assessment and monitoring, an MBN was issued January 2014 providing guidance re the completion of Charts for recording Blood Glucose Monitoring, Glasgow Coma Scale assessment;, Fluid InputIOutput recording, Hydration Assessment and Open Wound Assessment in Mental Health and Learning Disability Services _ An MBN was issued in April 2014 regarding the Physical health competency declaration within the (staff's) Personal Development Review process for all nurses, assistant practitioners and health care assistants_ key improvement in 2013-14 has been the development of the physical health competencies process, including competency self-declaration process linked to performance reviews and training needs identification, to ensure that our staff understand the 2 Better View_. of mind & body put

elements of managing patients with co-morbid physical health problems All Trust policies and procedure for clinical skills and physical health assessments have been updated and there is a dedicated page on the intranet containing this and other useful information_ We are also piloting a Modified Early Warning System (MEWS) for the deteriorating patient on both our adult and older people's wards with the aim of rolling this to all in-patient areas_ iii) Cardio-Pulmonary Resuscitation and the use of a Defibrillator In line with National Patient Safety Agency (NPSA) RRRO1O Resuscitation in Mental Health and Learning Disability inpatient settings" (November 2008) and Resuscitation Council UK (RCUK) requirements, all medical staff and registered nurses working within inpatient settings are expected to be competent to the standard of Immediate Life Support (ILS) AlI support workers are expected to be competent to the standard of Basic Life Support (BLS) BLS and ILS training is mandatory for all staff within our inpatient settings. The training curriculum for BLS and ILS was in line with RCUK 2010 standards_ This covers effective cardiopulmonary resuscitation including: Knowing what actions to take in the event of a medical emergency Knowing how to summon the emergency paramedic service_ Basic Life Support maintenance and management of the airway, CPR, immediate management of anaphylactic reaction, management of the choking patient: Immediate Life Support management of a collapsed casualty, BLS, use of emergency oxygen, use of an automated external defibrillator; insertion of an airway_ Medical and nursing staff are required to demonstrate and achieve the required level of competency before approved: In this case, while the staff involved in the incident were compliant with their mandatory training requirements they had not appropriately followed the Trust approved Resuscitation policy and procedures in relation to the use of the automated external defibrillator_ would like to reassure you that this has been addressed with the staff in question who has undergone specific Trust processes in relation to their competency: In line with NPSA and RCUK guidelines, it is recommended that services undertake practice drills to support further learning within the clinical environment: The Trust operates an annual practice drill schedule that includes use of an automated external defibrillator. Practice drills are undertaken by the Trust resuscitation trainers to ensure correct standards of practice are demonstrated. Staff are assessed against the RCUK competency framework during practice drills; the outcomes of practice drills are documented to identify areas of good practice and areas requiring improvement Local actions plans are agreed to address any areas of concern: Records are available which evidence that Sephton Ward have had 4 practice drills completed between November 2012 and January 2014. The Trust approved Resuscitation policy and procedures requires local services to undertake daily checks of the resuscitation equipment including the automated external defibrillator: These checks are documented; and are subject to annual audit: The outcomes of the annual audit are scrutinised by the Trust Resuscitation Steering Committee as part of the annual work programme. Further to the completion of the Serious Untoward Incident report in relation to this case, an action plan was developed by the Business Manager: can confirm that these actions have been completed and led to the implementation of Trust wide initiatives in relation to the 3 Better View__. of mind & body key out being

management of physical health and diabetes within the Trust in patient facilities. Examples of this activity include; Development of Diabetes guidelines to support delivery of inpatient diabetes care by nursing staff Diabetes Link Nurses/Associates This initiative was introduced across the Trust and identified both qualified and non-qualified staff to act as Diabetes leads within their teams Hospital at Home service This is a partnership initiative between the Trust and Wrightington; Wigan and Leigh NHS Foundation Trust that provides direct input from physical health services at Leigh Infirmary site to the wards at Leigh_ If can be of any further assistance or you require further information about the steps we have taken please do not hesitate t0 contact me