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Form 6.2
Court Ref: DNF-B133-22 RESPONSE
to the
DETERMINATION OF SHERIFF SUSAN DUFF
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016 IN THE
INQUIRY INTO THE DEATH OF LINDA ALLAN
To: the Scottish Courts and Tribunal Service
Every post-operative patient should be seen by an ANP or a doctor and their presentation recorded in the observation notes on a daily basis. As part of that daily review, the medication prescribed to the patient should be considered and adjusted if appropriate. The observation record should narrate that the medication prescribed has been considered and narrate any changes.
NHS Fife will ensure that all patients will be reviewed the day following surgery. The average length of stay for trauma patients is less than 48 hours. Ideally this will be on a Consultant ward round, however there are times where it will be clinically appropriate for the patient to be seen by an ANP or a doctor in training. Due to the availability of workforce over weekends, there will always be a need to prioritise those patients who are immediately post op or have a clinical priority. Patients who are stable and greater than 48 hours post-op will only be reviewed at weekends if there is an immediate issue requiring clinical decision making input such as discharge from hospital, medication review or a change in clinical condition. It is vital that we use the clinical resource that we have wisely and to greatest benefit of our patients. All clinical reviews must be complemented by an appropriate entry in the health record. This, where clinically appropriate, should include a review of the prescribed medication. Any changes made to prescribed medication should be clear on the Drug Kardex and confirmed within the health record. Further detail on the work undertaken to improve record keeping is documented under recommendation 6.
The Orthopaedic Department will increase the weekend senior medical staff oversight of ward patients by adding an afternoon ward round, which will be criteria led depending on clinical need and acuity.
Due to current allocation of trainee doctors and funded ANP posts NHS Fife would not be able to fully comply with this recommendation. NHS Fife is currently undertaking a review of Orthopaedic Trauma services and as part of the review will consider the workforce requirements to meet this recommendation. A business case setting out the staffing shortfall would then need to be developed, which would equate to approximately 3 band 7 ANPs at the cost of £200,000.
Any patient who records a low pain score and at the next observation check records a high pain score should be the subject of an immediate referral to an ANP or a doctor.
NHS Fife currently has a pain assessment tool which records location of pain and specific actions for those patients who have epidural or spinal analgesia. Pain is measured using the Abbey Pain Scale. The local documentation will be updated to mandate the need for escalation and urgent clinical assessment should there be a sudden increase in the patient’s score. The updated guidance will be shared with ward staff via the Senior Charge nurses.
NHS Fife will develop an Acute Pain policy that will be the overarching governance for pain management in the Health Board.
The Fife Early Warning System (“FEWS”) Observation Chart should be revised to allow the site of pain to be recorded. Pain scores should be recorded from the point of admission into hospital until discharge.
A pain assessment is completed for all patients as part of the admission process and is documented in the Patient Care Assessment and Admission Record.
All patients are asked about pain twice daily and the outcome is recorded in the Daily Care Plan. Patients who require comfort rounding are also asked about pain and this is recorded in the Care and Comfort Clock.
NHS Fife has the facility to record and view pain scores (at rest and on movement) for all patients as part of the Early Warning Score (EWS) chart on the electronic system “Patientrak.” The EWS chart (soon to be moving to NEWS2) used in NHS Fife aligns with national guidance and cannot be amended to include the site of pain. However the site of pain should always be recorded within the Pain Assessment Tool and where appropriate the clinical notes.
A fluid balance chart should be maintained for every acute post-operative patient until they are ambulant
NHS Fife has a Criteria for Fluid Balance Chart Use document. This has been reviewed and updated ensuring that a fluid balance chart is in place for all patients that require their fluid intake and output to be monitored, including all post-operative patients until ambulant.
Senior Charge Nurses in each ward area within NHS Fife Acute Services undertake a bi-monthly care documentation audit; compliance with the completion of fluid balance charts is included within this. The result of the audits are reported on at the Acute Services Clinical Governance meeting along with relevant improvement plans.
Refresher training on the action points referred to in Mr Chesney’s email of 4 November 2020 should be given annually to all medical practitioners in orthopaedic wards. Records should be kept of who has received this training to ensure that all relevant employees receive it annually
There will be a twice-yearly focus on peri-operative care at the monthly Orthopaedic Clinical Governance meeting.
A post-operative review sticker ward round sticker is being developed. The aim is that this will ensure that there is a structured review to post-op patients. This will include a prompt for a medication review.
The Orthopaedic Department already has an established practice of reviewing the need for aperients with opiates in our hip fracture and elective ward.
The Orthopaedic Department will work with the Orthopaedic Pharmacist to develop an educational bundle to support safe and effective prescribing for all doctors in training and ANP’s. Training records are held by the individual within the TURAS system.
Documentation of the ward rounds will be supported by the Audit of medical records (please see response to Recommendation 6).
The lead trauma surgeon should continue to review a random selection of records on a monthly basis to ensure that ward rounds are being documented. Any failure to record a ward round should be raised with the doctor responsible for recording it to ensure that good practice is achieved and maintained.
The Clinical Governance Team (who are responsible for undertaking clinical audits across the organisation) will undertake an audit of inpatient health records, to look at the frequency and completeness of ward round documentation. This will be undertaken at four monthly intervals, rather than monthly to ensure the audit programme has meaningful data and can be sustainably embedded into the Board clinical audit programme. The output from the audits will be reviewed by the Clinical Lead for Orthopaedics (Trauma Lead) and the Clinical Director for Planned Care. The results of the audit will be discussed at the monthly Orthopaedic Department Clinical Governance meeting. Any areas for improvement will highlighted and be the focus of quality improvement activity. Any areas of concern will be reported to the Acute Services Clinical Governance Committee.
Where documentation of ward rounds is considered inadequate, this will be fed back to the responsible Consultant.
Annual refresher training should be given to all employees who implement the Boarding Policy on how it works, how patients should be assessed in relation to it and how the paperwork for the Boarding Policy should be completed. Records of who has received this training should be kept to ensure that all relevant employees receive the training annually.
The NHS Fife Procedure for Boarding Patients within the Acute Service Division is currently being reviewed and updated, which has included a wide reaching consultation, including Clinical Leads and Senior Charge Nurses. The procedure will be reviewed every 2 years through the Clinical Policies and Procedures Group with an extensive consultation and sharing process.
Once published the procedure will form part of the senior on-call manager training. The Hospital Capacity Team make most frequent use of the procedure and they will receive annual refresher training from their line manager. This will be recorded within the individuals TURAS portfolio.
Once published the revised procedure will be disseminated across the organisation to all clinical and ward teams via Clinical Leads and Senior Charge Nurses. It will be published on the NHS Fife ‘BLINK’ application, which will be supported by the input from the NHS Fife communications team.
The implementation of the procedure shall be the subject of a twice-yearly audit undertaken by the Clinical Governance Team with the output fed back through the departmental meetings, senior leadership team and Acute Service Clinical Governance Committee.
Annual refresher training should be given to the members of the Hospital at Night (“H@N”) team on the escalation process. Again, records should be kept of who has received the training to ensure that all relevant employees receive this training annually.
The Senior Practitioner for NHS Fife Advanced Practice is currently developing a programme of simulated practice dedicated to Advanced Practitioners, which will be delivered annually. A bespoke simulation training course will be developed for the Hospital at Night Team. This will focus on the management of the deteriorating patient and will be recorded on the practitioners training record in TURAS.
NHS Fife May 2023