Tameside NHS Foundation Trust

“Response Following detailed investigations, action has been taken to minimise the risk of inappropriate transfer occurring in the future. Training has been provided to doctors in the Orthopaedic Department to make them aware of the following: (a) That a patient's consultant or alternatively a senior member of the consultant's team must be involved in any decision to transfer a patient between specialties and / or ward areas and that the discussion about transfer and the decision taken must both be clearly”

“Page 8 of the Trust's internal investigation report confirms the outcome of the Trust's investigations; that at the time of handover from the Trauma Unit to Ward 41 the need for high-flow oxygen therapy and the skills to use that equipment should have been discussed and resolved before any transfer was completed. The on-call physiotherapist who was familiar with the equipment for high-flow oxygen attended the ward to review Mrs [name redacted] and was available to assist the nursing staff with it.”

“The Trust's internal investigation identified deficiencies in the record keeping in this case and is undertaking a review of its current training on record keeping standards. Such training will reinforce the need for clarity and completeness.”

“staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs [name redacted] was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained. Nurse staffing levels are being monitored through multiple assurance sources including the Trust Board Hard Truths paper. Additionally, the Trust's”

“The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration. In relation to the example given of a doctor who attended on Mrs [name redacted] at 2.30am and "guessed”

“Although, as addressed above, Mrs [name redacted] should not have been transferred to Ward 41 from the Trauma Unit it is certainly not the case that she was "written off'. Nevertheless, admittedly she was a very ill patient with a poor prognosis and this was supported by the Trust's commissioned independent expert report of Consultant [name redacted] which was sent to your offices prior to the inquest.”

“Develop a checklist to ensure all members of the Multidisciplinary Team (MDT) have engaged with patients and their family prior to discharge.”

“To ensure all patients and families have every opportunity to discuss plans and have a dedicated name and contact number for the social worker managing their discharge.”

“All patients returning home with care package will have their equipment needs assessed and documented in hospital.”

“All plans of care for patients must be shared with the patient and, with patient's consent, their next of kin and agreed before discharge.”

“A Pilot of "Sick Patients Home Other Plan" (SHOP) is in progress on two medical wards. This is to be escalated across the trust over the next 3 months and become embedded Practice.”