Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 20
Action
Deliver 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.
Stated by Department of Health and Social Care Stated plannedThe respondent said that this action was planned when they made their response on 5 June 2020. View source
Action
Provide financial support grants to eligible nursing, midwifery and allied health professional students, including additional support for childcare and shortage areas.
Stated by Department of Health and Social Care Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Develop and improve NHS-owned staff banks, including collaborative banks, to provide flexible staffing and reduce agency reliance.
Stated by Department of Health and Social Care Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
Stated by Department of Health and Social Care Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Maintain enhanced falls oversight through care reviews, live documentation audits, bay tagging, senior nursing checks, intentional-rounding projects, and falls-equipment compliance monitoring.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide enhanced induction and senior nursing support for new and temporary staff, including local clinical-area induction.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Review out-of-hours skill mix and training needs and coordinate regular senior nursing deployment meetings with escalation of staffing concerns.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Audit falls-risk assessments and policy compliance through ward, hot-spot, Matron, Trust-wide, and annual accreditation reviews.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Review Ward 6 workforce establishments and progress collaborative workforce redesign with therapy leads to align staffing and skill mix with rehabilitation needs.
Stated by Manchester University NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Relaunch staff competency checklists and falls-management prompts across WTWA to identify training needs and support guided reflection.
Stated by Manchester University NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Amend the falls policy to require documented 24-hour review of individualised additional interventions, obtain ratification, and disseminate the update across the Trust.
Stated by Manchester University NHS Foundation Trust Stated plannedThe respondent said that this action was planned when they made their response on 5 June 2020. View source
Action
Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Operate falls harm-review and Harm-Free Care meetings to investigate falls, identify learning, implement preventative measures, and monitor compliance.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide Ward Managers with falls-risk-reduction checklists and prompts to support consistent assessment, care planning, and management.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Use the updated falls policy, electronic risk-assessment records, Ward 6 and hospital falls action plans, and multidisciplinary task groups to coordinate falls prevention.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Recruit registered and unregistered nurses, appoint Ward 6 leadership and patient-flow staff, and recruit additional Nursing Assistants to strengthen staffing capacity.
Stated by Manchester University NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Deliver falls-risk training and support, including Hot Topic sessions, face-to-face education, and mandatory interactive e-learning for clinical staff.
Stated by Manchester University NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source See 17 more actions
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to follow falls risk policy
Wider context from the report “4. The inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross.
” Is this part of a recurring concern? Yes — Inadequate control of falls risks .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficiently detailed clinical documentation
Wider context from the report “3. During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a clear system of regular orthogeriatric consultant reviews
Wider context from the report “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.
” Is this part of a recurring concern? Yes — Delays in consultant review of patients .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Delays in arranging suitable community care packages for discharge
Wider context from the report “2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to escalate deterioration to a consultant
Wider context from the report “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of sufficient and appropriately experienced ward staffing
Wider context from the report “1. The inquest was told that the ward in question had been short staffed for a number of months . As a result there was a reliance on agency staff and less experienced staff . The trust was now seeking to resolve the issue but it was still not fully resolved . It reflected a wider issue of a national shortage of nurses.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.
Verbatim wording from the response “However, we of course accept we need to do more and that is why on 18 December 2019, the Government announced a commitment to deliver 50,000 more nurses in our NHS by 2025. We will do this through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide financial support grants to eligible nursing, midwifery and allied health professional students, including additional support for childcare and shortage areas.
Verbatim wording from the response “This Government has already taken steps to deliver this commitment through our recently announced financial support package for eligible students. Eligible pre-registration nursing, midwifery and most allied health professional students on courses at English universities from September 2020 will benefit from grants of at least £5,000 per academic year. There will be up to £3,000 additional funding for some students to help with childcare costs or who choose to study in regions or specialisms struggling to recruit, including with priority given to shortage groups that are key to delivering the NHS Long Term Plan². None of this funding will have to be paid back.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and improve NHS-owned staff banks, including collaborative banks, to provide flexible staffing and reduce agency reliance.
Verbatim wording from the response “We recognise that to fully eliminate unnecessary agency spending, the Department and the NHS need to support trusts in developing a viable alternative source of flexible staffing in the form of in-house Staff Banks. Having reduced the rate of agency spending, we are now entering a new phase of work, focusing on the creation and improvement of staff banks, wherein existing NHS staff, who choose to work flexibly, can do so through an NHS owned bank, as opposed to a privately-owned agency. In the context of staff shortages in the NHS, in-house staff banks, and especially collaborative banks, create a larger pool of flexible staff, ensuring better quality and continuity of care, and reducing unnecessary agency spending by avoiding expensive commission.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
Verbatim wording from the response “During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain enhanced falls oversight through care reviews, live documentation audits, bay tagging, senior nursing checks, intentional-rounding projects, and falls-equipment compliance monitoring.
Verbatim wording from the response “A number of initiatives are already in place at Trafford General Hospital to ensure oversight of falls across the hospital including Matrons/Lead Nurse completing their enhanced care reviews three times per week as per policy, live documentation audits, relaunching the Bay Tagging initiative on hot spot areas and firmly challenging staff who do not adhere to policy, quality improvement projects in relation to intentional rounding and increased daily senior nursing on clinical areas to ensure correct adherence to Enhanced Observations of Care Policy and proper use of falls sensor equipment.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
Verbatim wording from the response “In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local ‘Discharge Policy for Adult Inpatients (excluding Children and Maternity)’, implemented May 2019, a copy of which is enclosed (Appendix 1). At the Trust’s WTWA site this policy is overseen by the Integrated Discharge team. The policy is applicable to all Trust staff who are involved in the assessment, planning and monitoring of patient discharges. It also applies to staff from other health/social care organisations involved in the discharge” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide enhanced induction and senior nursing support for new and temporary staff, including local clinical-area induction.
Verbatim wording from the response “Induction for new recruits is provided on the Trafford General Hospital site, and the Head of Nursing now supports this with the welcome and introduction session. This provides an additional opportunity for staff to engage with Senior Nurses who give feedback and provide ongoing support.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review out-of-hours skill mix and training needs and coordinate regular senior nursing deployment meetings with escalation of staffing concerns.
Verbatim wording from the response “A review of the skill mix and roles and a Training Needs Analysis for the Out of Hours team has also been undertaken. This is to ensure that the clinical contribution is maximised, and the correct level of professional leadership is provided to teams at Trafford General Hospital in the out of hours period.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit falls-risk assessments and policy compliance through ward, hot-spot, Matron, Trust-wide, and annual accreditation reviews.
Verbatim wording from the response “As part of the Monthly Matron Review proforma, a sample of patient assessments are audited to monitor the ongoing completion of Falls Risk Assessments. Results of these audits are highlighted at the Monthly Matron Confirm and Challenge meetings with Ward Managers.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Ward 6 workforce establishments and progress collaborative workforce redesign with therapy leads to align staffing and skill mix with rehabilitation needs.
Verbatim wording from the response “The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine safe staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and January 2020. The outcome of this data collection was utilised to inform the establishment review process, which was completed for Ward 6 in March 2020. Further workforce redesign is being progressed collaboratively with Therapy Leads for Ward 6, to reflect the requirements of the rehabilitation service at Trafford General Hospital.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relaunch staff competency checklists and falls-management prompts across WTWA to identify training needs and support guided reflection.
Verbatim wording from the response “In addition to these assurance processes, senior nursing teams across WTWA are being asked to relaunch both the Staff Competency Checklist for the Risk Reduction and Management of Inpatient Falls, and the Falls Risk Reduction and Management Prompts, to ensure staff feels comfortable and confident in falls risk assessment and care planning; and that additional training needs are highlighted appropriately. This process also allows for staff managing individuals involved in falls incidents to consider their competency level and ensure guided reflection is appropriately provided.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the falls policy to require documented 24-hour review of individualised additional interventions, obtain ratification, and disseminate the update across the Trust.
Verbatim wording from the response “When a nursing review of Mrs Ross’ care was undertaken prior to the Inquest, it was identified that the individualised additional intervention section of the falls care plan were not reviewed every 24 hours. It was noted however that at the time there was a discrepancy in the Trust falls policy which did not specifically refer to a requirement to undertake this, and document this review every 24 hours. Subsequently, the Falls Specialist Nurse was made aware of the discrepancy in the falls policy. This amendment to the policy has been incorporated with further updates to the policy (to reduce the need for multiple policy revisions being shared with staff intermittently, and to provide one comprehensive update).” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
Verbatim wording from the response “Training is provided to all clinical staff in respect of documentation in clinical records. As part of the mandatory induction of all staff, Trust training is provided in respect of Information Governance, which covers accurate and clear record keeping. This is also covered in the mandatory training updates which all staff are required to undertake every two years. All staff also receive a local induction in their own area of work which comprehensively covers all areas of documentation and records keeping relevant to the individual staff member’s role. The Trust retains records of all staff training undertaken Trust-wide, including mandatory training.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate falls harm-review and Harm-Free Care meetings to investigate falls, identify learning, implement preventative measures, and monitor compliance.
Verbatim wording from the response “Falls resulting in patient harm are presented to the monthly Falls Accountability meeting. Thematic analysis is considered in order to establish learning arising out of patient incidents in respect of falls and to implement preventative measures to improve patient safety.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Ward Managers with falls-risk-reduction checklists and prompts to support consistent assessment, care planning, and management.
Verbatim wording from the response “Each individual Ward Manager has been provided with a checklist to support falls risk reduction, as well as falls reduction and management prompts.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the updated falls policy, electronic risk-assessment records, Ward 6 and hospital falls action plans, and multidisciplinary task groups to coordinate falls prevention.
Verbatim wording from the response “Prior to Mrs Ross’ admission, the Trust had recently, in April 2019, implemented a new Trust-wide updated Falls Management Policy and I enclose a copy of this for your information (Appendix 2). I am very sorry to hear that there was evidence that aspects of the falls policy were not adhered to in Mrs Ross’ case.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit registered and unregistered nurses, appoint Ward 6 leadership and patient-flow staff, and recruit additional Nursing Assistants to strengthen staffing capacity.
Verbatim wording from the response “Since April 2019, a number of International Recruitment (IR) Registered Nurses have been recruited to wards at Trafford General Hospital in addition to successful domestic recruitment to Registered Nursing posts across Trafford General Hospital. A substantive appointment was made for a new Ward Manager that joined the team in January 2020, in addition four experienced Band 6 Registered Nurses have been appointed to Ward 6 specifically. A Band 3 Patient Flow Coordinator role has also been developed and successfully appointed to on Ward 6.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver falls-risk training and support, including Hot Topic sessions, face-to-face education, and mandatory interactive e-learning for clinical staff.
Verbatim wording from the response “As of April 2020, the Matron for Quality Improvement and Patient Experience’s compliance audit for falls risk assessment completion and falls care plan implementation was 90%. Hot Topic Sessions covering falls risk reduction and management have been launched in June 2020. So far this month across Trafford General Hospital 30 members of staff, including six members of staff from Ward 6, have attended the training, with several further sessions to take place this month to capture further staff.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
Verbatim wording from the response “As stated above, a Patient Flow Coordinator role has been developed and successfully appointed to Ward 6 at Trafford General Hospital. In addition, the Hospital Discharge Service is available and responsible for supporting wards in the discharge process of patients, and their input is routinely sought for instance in respect of patients who require special considerations or who may have complex support needs on discharge. The discharge service will assist the ward staff to plan and identify the supporting needs of the patient for discharge.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.
Verbatim wording from the response “The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily at the morning Board Rounds and all patients are discussed and followed up to Consultant level as needed. If clinical concerns are raised in respect of an individual patient’s case, a member of the Senior Medical team (Consultant or Registrar) will review the patient.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health Education England leads national workforce education, training and workforce supply arrangements.
Verbatim wording from the response “In terms of the health and care workforce overall, Health Education England (HEE) provides leadership for the education and training system at a national level. HEE ensures that the workforce has the right skills, behaviours and training, and is available in the right numbers.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.
Verbatim wording from the response “It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. Discharge arrangements from hospital should start before a patient is ready for discharge and the hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE falls guidance provides the relevant framework for identifying and addressing inpatient environmental and individual fall risks.
Verbatim wording from the response “Finally, with regard to falls prevention, the National Institute for Health and Care Excellence (NICE) has published a clinical guideline on Falls in older people: assessing risk and prevention (CG161³) that includes guidance on preventing falls in older people during a hospital stay. The guideline says:” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts are responsible for determining staffing numbers, staff types and agency staff use.
Verbatim wording from the response “Individual NHS Trusts are responsible for the number and type of staff they employ and they must ensure that there are sufficient staff and that those staff are trained and competent to carry out their duties. This applies equally to the usage of agency staff, which is a local decision for individual employers.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.
Verbatim wording from the response “In line with usual practice in secondary care, patient discharges from hospital are in some cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions by other bodies such as Local Authorities; for instance assessments in respect of any ongoing package of care required in the community, as well as other bodies in the Social Care sector. It is the Trust’s responsibility to undertake such liaison where applicable to ensure arrangements are in place so that the Trust can effect a safe patient discharge to the community. Given the Trust’s dependence on other parties in respect of this, delays can occur, and this is unfortunately an NHS-wide issue not unique to our Trust. Safe discharge requires teamwork across many people and organisations.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.
Verbatim wording from the response “centre placement was declined by the Local Authority; in order for the clinical team to progress her discharge, as I am sure you will appreciate, there was a limitation on further actions the Trust was able to take to address this issue, due to its dependence on actions by In-reach, Social Care and other bodies.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust concluded that regular Consultant reviews occurred and junior doctors escalated clinical concerns as required in Mrs Ross’ case.
Verbatim wording from the response “Having undertaken a comprehensive review of the entries in Mrs Ross’ clinical notes, the Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case there were in fact regular Consultant reviews, in line with required standards, and there was no issue in respect of junior doctor escalation, which as documented in the clinical notes took place as required. I apologise if the evidence you heard at the Inquest did not accurately convey this.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Open published response
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 5 1 Support health and care organisations during the COVID-19 pandemic to maintain capacity for people affected by the virus.
Stated by Department of Health and Social Care Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source 2 Operate the Trafford General Hospital Quality and Patient Safety Group and improvement programme with defined responsibilities, performance indicators, and monthly monitoring.
Stated by Manchester University NHS Foundation Trust Stated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source 3 Realign Ward Managers’ roles to provide increased clinical time and more visible professional leadership.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source 4 Use a Quality and Patient Experience Matron post to monitor patient feedback, incidents, training, and ward-specific quality-improvement projects.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source 5 Strengthen Trafford General Hospital’s senior nursing leadership structure through revised responsibilities, additional Lead Nurse and Matron appointments, and a patient-safety Matron secondment.
Stated by Manchester University NHS Foundation Trust Stated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support health and care organisations during the COVID-19 pandemic to maintain capacity for people affected by the virus.
Verbatim wording from the response “During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Trafford General Hospital Quality and Patient Safety Group and improvement programme with defined responsibilities, performance indicators, and monthly monitoring.
Verbatim wording from the response “In order to strengthen its governance, accountability and assurance framework, in January 2020 the Trust established a Quality and Patient Safety Group at Trafford General Hospital to lead the development and implementation of an overarching quality improvement and transformation programme. The Group is chaired by the WTWA Deputy Chief Executive/Director of Finance in order to oversee the delivery of Trafford General Hospital’s Quality Improvement and Transformation Programme and Quality and Patient Safety objectives. The Group reports directly to the WTWA Quality and Patient Safety committee, in addition to the Hospital Management Board. The Group has patient safety and quality improvement objectives, aiming to have a measurable impact by way of positive outcomes for patients, carers and their families.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Realign Ward Managers’ roles to provide increased clinical time and more visible professional leadership.
Verbatim wording from the response “Ward Managers’ roles have been realigned to allow for increased clinical time (15 hours’ management time and 22.5 hours’ clinical time per week) and therefore also provide more visible clinical professional leadership for ward teams, patients and visitors.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a Quality and Patient Experience Matron post to monitor patient feedback, incidents, training, and ward-specific quality-improvement projects.
Verbatim wording from the response “In addition, a Quality and Patient Experience Matron post has been seconded to Trafford General Hospital for 12 months, in order to prioritise and monitor patient feedback, incident themes, training and supporting the implementation of ward-specific Improving Quality Programme (IQP) projects. The Matron has for instance overseen the development of the above-referenced Training Needs Analysis document specific to staff on Ward 6 at Trafford General Hospital, to identify and prioritise ongoing staff training and development. IQP” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen Trafford General Hospital’s senior nursing leadership structure through revised responsibilities, additional Lead Nurse and Matron appointments, and a patient-safety Matron secondment.
Verbatim wording from the response “Prior to Mrs Ross’ admission, in April 2019 a new Head of Nursing commenced at Trafford General Hospital, who has undertaken and completed a review of the nursing leadership structure. These include changes to areas of responsibility and line management, and further appointments made to the post of Lead Nurse in addition to four Matron posts. To further strengthen the Senior Nursing Leadership team at Trafford General Hospital, a Matron for Quality Improvement and Patient Safety has been appointed on a 12-month secondment. This has established a new experienced Senior Nursing Leadership team at Trafford General Hospital, supporting a robust professional governance structure, providing clear lines of assurance and accountability directly to the WTWA Director of Nursing.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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