Leicestershire Partnership NHS
NHS / Health Body
Action Taken
The Partnership NHS Trust reviewed the case, assessed the nurse's competence, and arranged medicines management and emotional resilience training along with additional clinical supervision. They are also implementing a mobile working solution for community staff. (AI summary)
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Dear Mrs Mason Re: Labhuben Amarshi VAGHADIA Thank for your letter, dated 6 September 2013, with the enclosed Regulation 28: Report to Prevent Future Deaths; would t0 reassure you, and Mrs Vaghadia's family, that Leicestershire Partnership NHS Trust have carefully considered the concerns you have raised, and put actions in place t0 respond to them: Your concems am aware that you are concerned that: Mrs Vaghadia was visited Community Nurse who administered prescribed anti-coagulant injection despite evidence 0f bleeding from the site of the previous injection; and Nurse reported the Out Hours service that Mrs Vaghadia was experencing abdominal pain;, but did not inform them of the bleeding: Whilst these actions were not causative of Mrs Vaghadia'$ death; you are concerned that these actions were inappropriate demonstrated a lack of professional insight, training and experience and that they could Iead to a death in the future. Response The death of Mrs Vaghadia has been reviewed by the following: Community Health Services (CHS) Division Senior Clinical Team CHS Divisional Head of Nursing CHS Clinical Directors Chair; Prolcasor David Chiddick CBE Chicl Executive: Dr Peter | ler LeicesteR SouTH! CITY & LeiceSTERSHIRE CORONERS DISTRICT RECEIVED you like
CHS Lead Nurses CHS Head of Governance CHS Nurse Consultants Chief Nurse of Leicestershire Partnership NHS Trust (LPT) The CHS leadership has also considered the current practice of the Community Nurses when they attend a patient t0 administer prescribed medication: It is recognised that it is vital that the Community Nurses ask the right questions t0 ensure that it is still appropriate to administer the prescribed medication . It is the responsibility of any nurse t0 work within their Nursing and Midwifery Council (NMC) Code of Conduct: With specific reference t0 the administration of medicine nurses are required t0 follow the NMC Standards for Medicines Management; which clearly sets out under Standard Ihe standards for practice in administering medications. These standards include: understanding the therapeutic uses of the medicines being administered; its normal dosage; side effects; precautions and contraindications; administering or withholding medications according to the patient's condition; and contacting the prescriber or another authorised prescriber where contraindications are discovered or where the patient develops a reaction to a medication. The CHS has Standard Operating Protocol (SOP) for administration of medicines in the community that aligned the NMC guidance CHS Division Community Nurses administer subcutaneous Iow molecular weight heparin only the prescription prescriber. Usually the prescriber will be a doctor; such as the patients GP or the prescriber may be non-medical prescriber such as a Advanced Nurse Practitioner. The responsibility for the prescription ultimately lies with the prescriber. In the case of non-medical prescribing, nurses, who prescribe under this auspice do so only within their competency- can confirm that if it appears that the administration of the prescribed medication may be contra-indicated the Community Nurses should seek second opinion from Nurse Prescriber or Doctor before administering the medication Full details of all the symptoms should be provided to professionals to enable appropriate decisions to be made. This applies anti-coagulant medication where there evidence bleed; and otner prescribed medication: Actions_Taken It is accepted fully that part of health professional s responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professiona responsibility regarding this issue via system of email cascade Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health: All CHS nurses will be re-issued with the SOP and the Divisional Clinical Director will ensure Inat this communication process S completed by the end of December 2013. All pertinent nursing staff in CHS will be re-issued with the SOP and the matter topic at the team meetings CHS lead staff will als0 be sharing the learning points from the case with nursing clinical colleagues in all clinical divisions of LPT , For further assurance advise that within CHS division they are implementing mobile working solution allowing all community nursing and therapy staff_to access the patients' notes in their own homes Many GP practices are linked via this IT solution allowing them the ability t0 communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for Chair; Professor David Chiddick CBE Chiet Executive: Dr Miller 01548149 other and our Pelet 1
the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA. Community Nurse_ We have taken a number of steps to address your concerns regarding Nurse These include: Two independent assessments of the nursing practice of Nurset The Lead Nurse in the Community Health Service Division; The Clinical Education Lead in the Community Health Service Division: Nurse clinical skills and competencies were assessed using the Leicestershire Competency Assessment Test (LCAT) that is also used by other NHS organisations The Divisiona Clinical Director and Lead Divisional Lead Nurse personally interviewed Nurse with regard t0 this matter As a result of this process Nurse is judged to be competent in all areas of clinical practice assessed. However in response t0 the concerns raised a programme of training has now been arranged for Nurse which includes medicines management training and emotional resilience training In addition she will participate in additional clinical supervision on a monthly basis for six months and undertake reflective practice assessment; the sum of which is to strengthen her clinical decision making skills:
CHS Lead Nurses CHS Head of Governance CHS Nurse Consultants Chief Nurse of Leicestershire Partnership NHS Trust (LPT) The CHS leadership has also considered the current practice of the Community Nurses when they attend a patient t0 administer prescribed medication: It is recognised that it is vital that the Community Nurses ask the right questions t0 ensure that it is still appropriate to administer the prescribed medication . It is the responsibility of any nurse t0 work within their Nursing and Midwifery Council (NMC) Code of Conduct: With specific reference t0 the administration of medicine nurses are required t0 follow the NMC Standards for Medicines Management; which clearly sets out under Standard Ihe standards for practice in administering medications. These standards include: understanding the therapeutic uses of the medicines being administered; its normal dosage; side effects; precautions and contraindications; administering or withholding medications according to the patient's condition; and contacting the prescriber or another authorised prescriber where contraindications are discovered or where the patient develops a reaction to a medication. The CHS has Standard Operating Protocol (SOP) for administration of medicines in the community that aligned the NMC guidance CHS Division Community Nurses administer subcutaneous Iow molecular weight heparin only the prescription prescriber. Usually the prescriber will be a doctor; such as the patients GP or the prescriber may be non-medical prescriber such as a Advanced Nurse Practitioner. The responsibility for the prescription ultimately lies with the prescriber. In the case of non-medical prescribing, nurses, who prescribe under this auspice do so only within their competency- can confirm that if it appears that the administration of the prescribed medication may be contra-indicated the Community Nurses should seek second opinion from Nurse Prescriber or Doctor before administering the medication Full details of all the symptoms should be provided to professionals to enable appropriate decisions to be made. This applies anti-coagulant medication where there evidence bleed; and otner prescribed medication: Actions_Taken It is accepted fully that part of health professional s responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professiona responsibility regarding this issue via system of email cascade Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health: All CHS nurses will be re-issued with the SOP and the Divisional Clinical Director will ensure Inat this communication process S completed by the end of December 2013. All pertinent nursing staff in CHS will be re-issued with the SOP and the matter topic at the team meetings CHS lead staff will als0 be sharing the learning points from the case with nursing clinical colleagues in all clinical divisions of LPT , For further assurance advise that within CHS division they are implementing mobile working solution allowing all community nursing and therapy staff_to access the patients' notes in their own homes Many GP practices are linked via this IT solution allowing them the ability t0 communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for Chair; Professor David Chiddick CBE Chiet Executive: Dr Miller 01548149 other and our Pelet 1
the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA. Community Nurse_ We have taken a number of steps to address your concerns regarding Nurse These include: Two independent assessments of the nursing practice of Nurset The Lead Nurse in the Community Health Service Division; The Clinical Education Lead in the Community Health Service Division: Nurse clinical skills and competencies were assessed using the Leicestershire Competency Assessment Test (LCAT) that is also used by other NHS organisations The Divisiona Clinical Director and Lead Divisional Lead Nurse personally interviewed Nurse with regard t0 this matter As a result of this process Nurse is judged to be competent in all areas of clinical practice assessed. However in response t0 the concerns raised a programme of training has now been arranged for Nurse which includes medicines management training and emotional resilience training In addition she will participate in additional clinical supervision on a monthly basis for six months and undertake reflective practice assessment; the sum of which is to strengthen her clinical decision making skills: