University Hospitals Birmingham NHS Foundation Trust

“In December, two Tissue Viability Link Worker events focused on repositioning were held, with support from therapy teams using pressure mapping devices to identify pressure points and promote effective repositioning.”

“A weekly audit of repositioning practices in the AMU is now being conducted, with real-time feedback provided to staff.”

“The Wound Assessment Chart has been recently updated as part of the Wound Product Formulary review.”

“The investigation process will be revised to include individual statements from staff involved in care, ensuring that all aspects of care delivery are fully explored.”

“We have requested that the speciality use the three methodology coding scores recommended by the Learning from Deaths Team in line with the rest of the Trust and we have disabled the use of all other methodology coding fields on the software.”

“The Enhanced Care policy has been re-embedded into the ward and risks are discussed in the ward huddle following shift handovers.”

“Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review of acuity levels as part of the wider Trust review of acuity and dependency.”

“The nurse in charge currently identifies and discusses patients at risk of falls, as well as those requiring enhanced observations, with the Matron, prior to the 0800- touchpoint meeting.”

“We have recognised that the current layout of ward 19 can be challenging when nursing patients who are at risk of falls because of having only two 6 bedded bays and 13 side rooms positioned in a T shape within the ward.”

“Following the death of Mr [name redacted] the department is currently delivering falls training, which is provided by the Falls team and has been attended by qualified nurses and health care support workers. To date 42.5% of ward staff have completed training with a further 40% of staff booked on to the training for December 2024.”

“The witnesses and the investigation report did not address the central issue relating to the fall and this raises a concern about the quality of post death investigations being undertaken by the Trust.”

“The Trust will ensure that relevant staff are aware of this guidance and will ensure that it is disseminated to all staff managing acute surgical emergencies. Following Mrs [name redacted] death the following actions are being taken to share the learning from this incident: 1. Locally: Laminated posters of the joint statement will be displayed in acute surgical areas at all acute sites. A new trust policy that directly reflects the June 2023 guidelines will be published and disseminated to all clinical”

“We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors”

“we have rolled out our in-house electronic system, PICS to BHH. PICS has been in use in AMU at BHH since July 2021. PICS provides a paper-free electronic patient record system that allows for simultaneous access and entries to the record of a single patient by multiple clinicians. With PICS, it is easy to access and review patient records at any time. To ensure patients are seen without delay, there are time markers on the system which indicate when patients have been waiting to be seen for a period”

“immediately following the Inquest 5 zimmer frames were sourced internally and were made available for immediate use within the ED the same evening”

“We apologise unreservedly to the Coroner and Mr [name redacted] family that the evidence presented was inaccurate, but we are satisfied that this was a genuine error, which was in all probability influenced by the record indicating a need for blister packs.”

“A review has now been undertaken, and the content of the training package has been updated by our Speech and Language Therapy team (SLT) to reflect our standard operating procedures relating to 'dysphagia' and patients who are 'nil by mouth'. The training package is currently being developed and will be available for staff by 21 October 2019.”