PFD report

Rose Workman · Prevention of Future Deaths report

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Issued 6 Jul 2017•Gloucestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
21

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Insufficient monitoring of patients’ ongoing conditions by the district nursing service
    Part of recurring concern: Unreliable district nursing assessment and monitoring of patients
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.16

  1. Action

    Operate a capacity-and-demand model to allocate community nursing patients and time appropriately.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 July 2017.
  2. Action

    Issue weighing scales to each locality for pressure-ulcer and malnutrition assessment.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 July 2017.
  3. Action

    Run monthly professional development sessions covering pressure-ulcer risk and malnutrition screening.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 July 2017.

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

Insufficient monitoring of patients’ ongoing conditions by the district nursing service

Wider context from the report

“Whether the district nursing service employs sufficient measures to ensure that patients are effectively monitored of their ongoing condition(s). ”

Is this part of a recurring concern?

Yes — Unreliable district nursing assessment and monitoring of patients.

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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 a capacity-and-demand model to allocate community nursing patients and time appropriately.

Verbatim wording from the response

“Workload capacity and its effective management within our clinical services also needs to be satisfactory for patients to be effectively monitored. A “capacity and demand” model was introduced into Community Nursing service in October 2016. This was developed by clinicians and supports the planned and timely allocation of patients who receive care. This resource allocation tool supports suitable time allocation for wound care and colleagues have been strongly advised to apply a rating score and work to a standard operating procedure that supports patient care.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

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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

Issue weighing scales to each locality for pressure-ulcer and malnutrition assessment.

Verbatim wording from the response

“Weighing scales have been issued to each locality and where a patients weight cannot be obtained to calculate the MUST score the ulnar measurement is used as advocated by Trust policy.”

Source location

Rose-Workman-Response
Page 4 · response
Published 6 July 2017

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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

Run monthly professional development sessions covering pressure-ulcer risk and malnutrition screening.

Verbatim wording from the response

“Our Professional Leads for Community Nursing run monthly Continuous Professional Development sessions for community nurses across the localities; the Braden Risk”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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

Undertake refresher training on the National Early Warning Score.

Verbatim wording from the response

“Refresher training for the National Early Warning Score (NEWS) is being undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward a “deteriorating patient” quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non-qualified clinical workforce to be able to detect a deterioration in a patient’s health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in a standardised way using this evidence based approach for patient care.”

Source location

Rose-Workman-Response
Page 2 · response
Published 6 July 2017

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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

Ratify the combined National Early Warning Score and sepsis policy and use it as cascade teaching material.

Verbatim wording from the response

“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location

Rose-Workman-Response
Page 2 · response
Published 6 July 2017

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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

Double Professional Lead and Senior District Nurse capacity for the Gloucester locality.

Verbatim wording from the response

“Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally). The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care. We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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

Create a combined National Early Warning Score and sepsis management policy.

Verbatim wording from the response

“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location

Rose-Workman-Response
Page 2 · response
Published 6 July 2017

Open published response

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 an unscheduled-care ledger with daily shift-lead oversight of workloads and urgent care demands.

Verbatim wording from the response

“An ‘unscheduled care’ ledger (on SystmOne) was also introduced to reduce the impact on those workloads associated with unplanned visits which are referred into our nursing team for an urgent patient contact. This ensures that there are nurses holding the position of shift lead each day and who have an overview of all colleagues’ workloads, demands and unpredicted care requirements.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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

Employ an additional District Nurse to support workload and patient care for the relevant team.

Verbatim wording from the response

“Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally). The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care. We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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 Clinical Lead to embed consistent deteriorating-patient practices across services.

Verbatim wording from the response

“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location

Rose-Workman-Response
Page 2 · response
Published 6 July 2017

Open published response

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

Drive a deteriorating-patient quality improvement programme to strengthen detection and communication of clinical deterioration.

Verbatim wording from the response

“Refresher training for the National Early Warning Score (NEWS) is being undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward a “deteriorating patient” quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non-qualified clinical workforce to be able to detect a deterioration in a patient’s health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in a standardised way using this evidence based approach for patient care.”

Source location

Rose-Workman-Response
Page 2 · response
Published 6 July 2017

Open published response

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 planned nurse attendance at GP practice meetings and daily links with affiliated practices for complex and high-risk patients.

Verbatim wording from the response

“To enhance communications nurses are now supported to attend GP practice based meetings on a planned basis to discuss those patients with more complex needs and those that are identified to be an unplanned hospital admission risk, as well as those at the end of their life. In addition all teams have a process for linking with their affiliated GP practice at least daily, either by telephone or in person. We are also progressing with having more scheduled multidisciplinary cluster meetings which will act as an open forum for nurses, physiotherapists and occupational therapists to discuss and care plan for particular patients on their caseloads.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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

Embed Braden, MUST and physical top-to-toe assessments in records, issue clinical guidance and review completion through quality assurance visits.

Verbatim wording from the response

“Braden, MUST and physical top-to-toe assessments are now incorporated fully into our clinical record system (SystmOne). For example, for documenting wound care the improved record system provides the facility for wounds to be better described including the date the wounds started, were reviewed and healed. Another example is the top-to-toe assessment which is a question-prompt template with blank boxes for different parts of the body which are required to be completed. Clear professional guidance has been issued to all nurses regarding the need to conduct these assessments at admission to the caseload and re-assessed at a frequency according to need. This clinical practice is now reviewed as part of quality assurance visits across all localities to ensure it is carried out.”

Source location

Rose-Workman-Response
Page 4 · response
Published 6 July 2017

Open published response

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

Implement re-engineered electronic records with structured assessments, care planning, deterioration reporting, non-adherence prompts and NEWS/sepsis prompts.

Verbatim wording from the response

“Firstly our electronic clinical patient record “SystmOne” has undergone extensive re-engineering with all our community multidisciplinary integrated team “units” (sections of the record split into localities). This re-engineering was clinically led, including”

Source location

Rose-Workman-Response
Page 1 · response
Published 6 July 2017

Open published response

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

Produce and operate a structured handover procedure with protected handover time, standard formats and electronic recording.

Verbatim wording from the response

“A Standard Operating Procedure for handovers was produced in August 2016, two months after RW’s death. This now provides structure and expectation for handovers within each of our community nursing teams. Time to complete the handover is applied to the SystmOne ledgers previously mentioned and colleagues are strongly encouraged to attend them. A quality review visit has identified that occasionally due to operational pressures nurses have not been able to attend some handovers. However, this is currently being actively monitored by our operational managers to determine whether this is a significant issue.”

Source location

Rose-Workman-Response
Page 5 · response
Published 6 July 2017

Open published response

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

Appoint a Clinical Lead for deteriorating-patient practice.

Verbatim wording from the response

“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location

Rose-Workman-Response
Page 2 · response
Published 6 July 2017

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

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. 1

    Provide specialist degree- and masters-level practitioner training to support District Nurse qualification and succession planning.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 July 2017.
  2. 2

    Implement pressure-ulcer awareness and prevention improvement actions across services.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 July 2017.
  3. 3

    Discuss the scope of a sustainable district nursing service specification with the Clinical Commissioning Group.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 July 2017.
  4. 4

    Discuss the response and inquest learning at the Trust Quality and Performance Committee.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 July 2017.
  5. 5

    Progress scheduled multidisciplinary cluster meetings for shared discussion and care planning.

    Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 July 2017.

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 specialist degree- and masters-level practitioner training to support District Nurse qualification and succession planning.

Verbatim wording from the response

“We also continue as an organisation to provide specialist Practitioner Training for nurse colleagues at degree and masters level in order for them to achieve their District Nurse qualification - this is a long term approach with regards to our succession planning i.e. growing staff within.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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

Implement pressure-ulcer awareness and prevention improvement actions across services.

Verbatim wording from the response

“It should also be noted that pressure ulcer prevention and awareness is a recognised risk for the organisation and is one of our quality priorities for 2017-18. A quality improvement group to address this is in place. Since May 2017 we have moved towards implementing a range of actions to raise awareness of pressure ulcers and their prevention across services. We are currently observing an increase in the reporting of grade 1 (very low grade pressure ulcers) which indicates a growing awareness of the risks of developing pressure ulcers and the need for early detection.”

Source location

Rose-Workman-Response
Page 4 · response
Published 6 July 2017

Open published response

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

Discuss the scope of a sustainable district nursing service specification with the Clinical Commissioning Group.

Verbatim wording from the response

“In addition, constructive discussions are currently in place with Gloucestershire Clinical Commissioning Group to determine the scope of a new district nursing service specification that is both sustainable and coherent with the plans and vision of the “One Gloucestershire” Service Transformation Programme (STP).”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response

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

Discuss the response and inquest learning at the Trust Quality and Performance Committee.

Verbatim wording from the response

“This response and the issues and learning that have been highlighted from the inquest, will be discussed at the Trust Quality and Performance Committee on 31 August 2017. This is a Trust Board sub-committee, chaired by a Non-Executive which examines the performance, quality and safety measures of all aspects of the Trust’s performance, holding managers and leaders to account in order to ensure where identified, actions and improvements are completed.”

Source location

Rose-Workman-Response
Page 5 · response
Published 6 July 2017

Open published response

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

Progress scheduled multidisciplinary cluster meetings for shared discussion and care planning.

Verbatim wording from the response

“To enhance communications nurses are now supported to attend GP practice based meetings on a planned basis to discuss those patients with more complex needs and those that are identified to be an unplanned hospital admission risk, as well as those at the end of their life. In addition all teams have a process for linking with their affiliated GP practice at least daily, either by telephone or in person. We are also progressing with having more scheduled multidisciplinary cluster meetings which will act as an open forum for nurses, physiotherapists and occupational therapists to discuss and care plan for particular patients on their caseloads.”

Source location

Rose-Workman-Response
Page 3 · response
Published 6 July 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026