Agenda item

Briefing Note of the Executive Director, People

Further to Minute 44/13, the Board considered a briefing note of the Executive Director, People which provided an update on the progress of the Mrs D Serious Case Review Action Plan. A copy of the action plan was set out at an appendix to the note.

The briefing note set out the background to the Serious Case Review which followed the death of Mrs D, a woman in her late 80s in the summer of 2011. The review had identified a number of recommendations and actions to improve practices which were detailed in the action plan. A key recommendation was focused on the referral into safeguarding of avoidable grade 3 and 4 pressure ulcers via the implementation of an effective pressure ulcer protocol. To raise awareness of the risk of pressure ulcers, the six month ‘Your Turn’ campaign was launched in May 2014. Reference was made to the considerable work undertaken to ensure that the protocol meant that safeguarding concerns were referred appropriately. This included the establishment of a Task and Finish Group who reported to the Coventry Safeguarding Adults Board on 3^rd December, 2014. In addition, from November, 2014 the number of cases reviewed and frequency of quality checks had been increased by undertaking regular in-house peer reviews on a rolling programme basis.

The Board were informed that all single actions included on the action plan had been completed and there were no outstanding actions. The two non-specific multi-agency recommendations would continue to be monitored by the Safeguarding Board.

Members questioned the officer and responses were provided. Matters raised included:

·  Whether lessons had been learnt from previous Serious Case Reviews and the reasons behind the increasing problems around tissue viability issues  

·  Details about the number of pressure ulcer alerts

·  Further information about the introduction of sticky labels on hospital patient records to highlight information that staff need to be aware of

·  Clarification that all actions had been completed and the lessons learned had been shared with all relevant organisations

·  The arrangements for awareness training for staff in the partner organisations

·  The consistency of standards when dealing with pressure ulcers

·  The importance of ‘on the job’ vocational training and the requirement to ensure that patients feeling cared for

·  Staff recruitment and retention

·  The levels of quality and consistency of GP care in the city.

RESOLVED that:

(1) The Dean of Life Sciences, Coventry University and the Dean of the Medical School at Warwick University, or their representatives, be invited to attend a future meeting of the Board to present an item on clinical training linked to the education sector, including the vocational nature of courses. Consideration to be given to the recruitment and

retention of staff.

(2) The Quality and Audit Sub Group of the Safeguarding Adults Board be informed of the Board’s recommendation that consistent standards are validated and in place for dealing with pressure ulcers.

(3) The Board’s sympathies be conveyed to the family of Mrs D in any final correspondence to be sent to the family.

(4) Board members to be provided with detailed information on the number of pressure ulcer alerts.