Place of dying and working in palliative care during COVID

In this blog to mark Dying Matters Awareness Week 2021, Katie Versaci, who is Head of Community Nursing at St Peter’s Hospice discusses working in palliative care during the pandemic and how ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) was used by her and her team to support meeting patient wishes…

I work for a hospice and my role is focused on patients and carers in the community.

At the beginning of the pandemic we prepared to support people dying of COVID-19 in the community, anticipated an overwhelming demand on services, medication and staff shortages. As a team we have had very little involvement in supporting people dying of COVID-19. However the impact of the pandemic on the people that we are used to working with – those living with and dying from life limiting illnesses – has been profound. Negotiating an already complex healthcare system has been hugely challenging for them.

All the things that I love about working with people in their homes- that you are a guest, that there is very little that you can control became things that made it more complicated when we looked at how we could go into people’s homes in a way that was as safe as possible for  patients, families and the team.

Overcoming challenges

We have got used to the barrier of wearing PPE. How it affects your presence with people at one of the most challenging times of their lives. Not being able to touch people apart from through gloved hands. Patients and families not being able to properly see your face apart from the picture pinned to your arm. We have learnt little things that make a difference like not putting your mask on until the person has opened the door and seen your face.

For patients having to contemplate the end of their life, where they want to be cared for and die is hard enough without the added consideration of visiting restrictions in care homes and the hospice. For families understanding that by the patient choosing to be at home, in most situations, they are then committed to providing the majority of the person’s care.


The pandemic bought into sharp focus our continued need to understand the appropriate plan for a patient in an emergency, and the ReSPECT process has been a really useful tool in supporting us to communicate this.

During lockdowns there have been times when there are lots of family available to support patients at home. However at some point most patients and families benefit from care. Some have felt very worried about people coming into their home and that it might put the patient or other vulnerable family members at greater risk.

We have learnt lots about the possibilities of telephone and video assessment and the skills needed but also its limitations and the risk that it can leave patients feeling alienated and abandoned.

We have all had our own experiences of living through the last year and have all been affected in one way or another. I find it hard to imagine what it is like to know that you are in the last months of your life in a pandemic and the impact it has had on those last months.  ReSPECT has helped us understand our patients’ wishes and work to ensure they are met.

Find out more about ReSPECT here.

RESTORE2 is supporting Ella and her team to provide appropriate and timely care

Ella Redler is a team leader for the Brandon Trust at their Hampstead Road residential home which cares for people with a complex learning disability. Ella and some of her team attended our free RESTORE2 training in late 2020. The whole team of 23 staff are now trained. 

In this blog Ella’s shares her views on what the training has meant to her, her team and the care they deliver: 

Using RESTORE2 to observe changes to a resident

Being trained to use RESTORE2 has made a huge difference to the care and support we deliver in the home. For example, we recently faced a challenge with a resident (who we shall call X) who had no NEWS2 score (New Early Warning Score) but the way they presented and their soft signs gave us some concerns. Therefore we went ahead and contacted the GP.  X was subsequently admitted to hospital with the early signs of an infection confirmed by a blood test. By using the RESTORE2 tool and our new found confidence in recognising soft signs of deterioration (such as changes to eating and drinking in this case) we were able to act swiftly.

Working collaboratively with GPs

We also have a better relationship with our GP now we use RESTORE2. We can now speak a common language with the clinicians; we are now able to clearly communicate our observations and concerns when we ask for a GP home visit, and the GP better appreciates the complexity of needs of residents living in the home. Furthermore, the GP now proactively calls the home every week to check on the residents, looking at their soft signs, because our residents are vulnerable and at risk of deterioration due to associated health needs. This proactive monitoring is making a positive difference.

Boosted confidence

The staff team feel confident in understanding and using what we learnt at the RESTORE2 training; it is useful to deliver day to day on this basis. We now use RESTORE2 frequently and have a “grab bag” in the office which contains necessary requirements to support an appropriate response and escalation of concern about any of our residents. We can check the resident’s vital signs and staff now feel more confident knowing that everything they need is kept in that one bag and they haven’t got to spend time finding the correct paperwork. This enables us to focus the much needed attention on the resident.

Looking forwards

Overall the RESTORE2 training and use of the tool has been really beneficial. It has made such a difference that we are now looking forward to additional training to enhance our knowledge and skill, in order to continuously improve the quality of care we provide and the confidence with which it is provided.


Adopting care bundles to improve patient safety

Mark Juniper is a consultant in respiratory and intensive care medicine at the Great Western Hospital in Swindon. He also works as a clinical lead at the West of England AHSN. Over the last year, when clinical commitments have allowed, he has been working on our adoption and spread safety improvement programme. This is part of a national programme led by NHS England and Improvement using a collaborative approach between acute hospitals helping to deliver improved care for patients with tracheostomies and respiratory problems.

In this blog, Mark talks through this expanding programme as we mark Patient Safety Awareness Week 2021.

How can we deliver reliable, high quality care?

Working in a complex environment is challenging and can sometimes feel overwhelming. When there are so many things to remember, it’s easy to overlook one small thing. How many of us have forgotten where we put the car keys when we’re in a hurry and taken longer to arrive at our destination as a result? Even at its simplest, the reliable delivery of healthcare is complicated. The COVID-19 pandemic has made the healthcare environment even more challenging. As individuals, our practice can vary each day, and there is often variation in practice between individuals and organisations. This can compromise patient safety. How can we improve this?

Improved safety can be achieved by improving the reliable delivery of care.  Many of us are now familiar with the use of checklists used for example to ensure that the correct patient receives the correct treatment. A care bundle is a group of evidence-based interventions known to improve a specific outcome. This effectively creates a ‘checklist’ that gives structure to how care is provided. This can improve the reliability of care, resulting in improved outcomes.

Structuring care in this way allows us to measure how consistently each element of a bundle is delivered. Measuring performance can also provide a focus on which areas require improvement. Working collaboratively with teams from other organisations helps to bring fresh ideas which can help to solve problems, often in simple but effective ways.

West of England AHSN Adoption and Spread Safety Improvement Programme

I’ve been lucky to work on programmes that involve the clinical areas on which I focus. We have adopted a number of care bundles which I’ve outlined below that improve the reliability of care and have spread their use across the West of England. This work is ongoing and additional programmes are being introduced shortly.

Tracheostomy care

The surge in intensive care admissions due to COVID-19 has been well publicised. The increased number of patients needing prolonged ventilation in ITU resulted in a greater number of tracheostomies to aid weaning from ventilation. In a system already under stress it was important to ensure that tracheostomy care was as safe as possible. A care bundle including the use of bed head signs and standardised bedside equipment can reduce harmful events due to tracheostomy emergencies. Use of a daily checklist has even been shown to help reduce length of stay. Resources to deliver improved tracheostomy care are available from The National Tracheostomy Safety Project. Our tracheostomy project ensured that these bundle elements were in use in all hospitals in the West of England during the pandemic.

COPD readmissions

COPD is a frequent cause of hospital admission with a high incidence of readmissions within 30 days of discharge. A care bundle developed by the British Thoracic Society in 2016 was designed to reduce readmissions but had not been reliably implemented. A collaborative project ensured that all hospitals began measuring their performance, and sharing ideas on how to improve use of the bundle. This project will continue until April 2022.

Asthma care

Despite effective treatments for asthma, some patients still experience emergency admissions and some still die from this disease. From April 2021, the British Thoracic Society asthma discharge bundle will be introduced across the West of England region. This work will build on the learning from the COPD collaborative and aims to standardise the care received by patients who come to hospitals with acute asthma exacerbations. This includes more reliable arrangements for follow up in both primary and secondary care. This should also reduce emergency admissions with asthma and improve safe care.

Bringing people together is at the heart of what the AHSN does and by sharing learning we can improve patient safety, I encourage anyone to get involved in our adoption and spread safety improvement programme. There’s nothing better than working with experts and enthusiasts to deliver improvements in the care for our patients!

Patient safety in a pandemic year

In this blog to celebrate Patient Safety Awareness Week, our Maternal and Neonatal Clinical Lead, Ann Remmers, reflects on her experiences during a pandemic year.

Little did we know this time last March what was in store for us in 2020/21 and many of us would have been very surprised to find out that we would still be in the grip of a pandemic a year later. Patient Safety Awareness Week 2021 provides a time for reflection on how much has been achieved and to look forward to the next year.

The pandemic has certainly brought patient safety to the fore and touched people’s lives in different ways. Our front line NHS staff and key workers are among those who have borne the brunt of COVID-19, often at great personal sacrifice.

The impact of COVID-19 has been far and wide and has caused us to look at new and inventive ways to communicate and support each other.

Gone are the large face-to-face conferences where we would meet up for one or two days to share ideas, listen to experts and patient stories, helping us to improve outcomes and experience for patients. The last two in-person Maternity and Neonatal events I attended were in March last year within a week of each other. One was Better Births: four years on and the other was the Maternity and Neonatal Safety Collaborative final event of the three-year programme. Both events took place in Manchester and entailed long and crowded train journeys. It seems hard to imagine that now.

Large events aside, we have been unable to meet together (even in small groups) and have become adept at using Zoom or Teams.

In the first wave resources were understandably diverted to dealing with the immediate consequences of the pandemic. Clinical staff found themselves moved to areas where they were most needed. This sometimes meant that some services which were not considered essential (to the pandemic response) were greatly reduced. Carbon monoxide monitoring ceased due to concerns of infection risk which took away a significant tool to reduce smoking in pregnancy (one of the national ambitions is to reduce still births and neonatal deaths by 50% by 2025).

We were left wondering how we could continue with our maternity and neonatal safety and improvement work. Staff have found innovative ways to continue to support women to stop smoking in pregnancy like the Maternity Healthy Lifestyles Pod in the foyer of Gloucestershire Royal Hospital.

In the first wave, we were very fortunate in the South West not to experience the high numbers of cases and deaths that some other parts of the country did but even so it felt that we would have to pause a lot of our safety work.

Prior to the pandemic we were about to launch our PERIPrem care bundle which would provide premature babies with expert care and interventions that would greatly improve their outcomes. The project would build on our successful national roll out of PReCePT in 2019. Two amazing consultant neonatologists came to us (as part of our Evidence into Practice call) with the idea to introduce the care bundle: Professor Karen Luyt (the clinician behind PReCePT) and Dr Sarah Bates.

The PERIPrem team were ready to start supporting trusts with quality improvement methodology, resources and tool kits to launch the project – that’s when the pandemic hit. Surely this would mean putting the project on hold? It was disappointing but necessary to wait until the clinical staff in the maternity and neonatal units had the capacity to launch the project.

We decided to ask them what they wanted to do. The overwhelming response was they wanted to be part of the project and felt it was a positive thing to do at a time when things were so difficult in the health service. We would need to provide them with what they needed without overwhelming them. It was clear this would be a launch like no other! We enlisted the experts, including parents, in our teams to help us develop online tool kits and videos. The PERIPrem perinatal teams have been amazing and we have seen some real improvements in the use of the elements of the care bundle.

PERIPrem has given us a real head start in the West and South West to fulfil one of the three key ambitions of the national Maternity and Neonatal Safety Improvement Programme to improve outcomes for pre-term babies.

We have found that trusts and Local Maternity and Neonatal Systems have been keen to continue with this important improvement work despite the pressures of the pandemic. We have established our Maternity and Neonatal Patient Safety Network to support these national ambitions bringing together all the people, systems and organisations involved in caring for mothers and babies.

The MatNeo Patient Safety Network, which held its latest meeting on 17 March, brings together midwives, doctors, neonatal nurses, ambulance services, Maternity Voice Partnerships, safety champions, Local Maternity and Neonatal Systems, families, primary care and other networks to bring some real focus to sharing and learning how to continually improve maternity and neonatal services. This collaborative way of working is not only supportive but provides the opportunity to enquire and learn from others. There are 15 such Patient Safety Networks across England hosted by their respective AHSNs.

This pandemic has highlighted existing health inequalities; in addition there are some pretty stark statistics about outcomes and experience for black and brown women and their babies.

For example, while stillbirth rates have reduced by over 16% and neonatal mortality has reduced by 11% between 2013 and 2018, “rates of death are falling more slowly among [Black and Asian] babies compared to White babies” and thus initiatives to reduce baby loss are “failing to reach many women from higher risk ethnicities”.  (MBRRACE-UK, 2018, Perinatal Mortality Surveillance Report for 2018)

Stillbirth rates for Black and Black British babies are over twice those for white babies and neonatal mortality rates are 45% higher. (MBRRACE-UK, 2020, Perinatal Mortality Surveillance Report Summary)

Looking at outcomes for all those who receive maternity and neonatal care and understanding why these outcomes and experiences are so different is an essential part of our framework for improving safety.

I am looking forward to the next year as hopefully our lives start to get back to some sort of normality. I am particularly looking forward to increasing our service user and Maternity Voice Partnership involvement and making an impact on health inequalities.

Together with all the people in our West of England maternity and neonatal networks we will continue our focus on learning together and improving outcomes and experience for all.

Reflections on hosting virtual interactive workshops

In this Q&A our West of England Academy Project Managers Kate Phillips and Vardeep Deogan share their reflections on the delivery of the Academy’s recent Quality Improvement (QI) Summer Series. They led 10 hours of online interactive workshops and delivery of QI theory by 12 different facilitators to around 60 delegates per session from across the West of England region and beyond. The Academy team have also compiled a series of slides with their top tips on hosting virtual learning.

Vardeep talks about virtual learning

  1. What did you enjoy about the QI Summer Series?

Vardeep: Every part of our workshops had a purpose, so being creative and thinking outside the box with activities without making them complicated was really important. Supporting our guest facilitators was a pleasure too. After our fifth session, we really felt a sense of achievement, and we cannot wait to deliver future online workshops.

Kate: An unanticipated pleasure was coaching our guest facilitators. Vardeep and I were the main hosts, but wanted the series to reflect the wealth of knowledge and range of experiences of working with QI across the West of England. We also figured that our voices might be a bit dull for two hours straight! Considering that online training was a fairly new concept, this meant that Vardeep and I mentored our guest facilitators to deliver their 25 minute activity. The feedback from the guest facilitators was lovely – they felt challenged by the experience but also supported. I think they were all very proud of themselves which was great to see.

The overwhelmingly positive response to the sessions has also been wonderful. Vardeep and I cooked these sessions up, combining our knowledge and experiences and we seemed to have stumbled upon a winning formula!

“Exceeded my expectations – I learnt so much.”

    2. What are the differences between online and face-to-face delivery?

Vardeep: When delivering face to face it’s much easier to ‘read the room’ for non-verbal communication and how people interact with each other, and as a facilitator you respond accordingly. We had to think differently about how to get this feedback during and throughout each workshop. This involved designing activities and including opportunities for feedback using functions like slido, the chat box and voting.

We also considered different learning styles and made certain to include activities that reflected these. Using liberating structures supported this.

Kate: The whole experience is different- quite often I’d be looking at only one or two faces in the corner of my screen, but knowing I was talking to 50+ delegates who had prioritised our training over other work, it’s a bit of a barmy experience really! I think delivering online sessions brings a different type of nervous energy…the adrenaline flows!

   3. Can you tell us about your biggest ‘aha’ moment?

Vardeep: As the series progressed, even though we may have been delivering our fourth or fifth session (and at times felt we were repeating ourselves with instructions for activities etc.) we kept in mind that this may be someone’s first experience on zoom or of virtual learning. I realised the value of clear instructions from the positive feedback we received where our clarity was praised. This was a key learning point.

Kate: For me, a lovely moment during our second session was when Vardeep asked a delegate to turn their mic on and share their experiences verbally with the entire group. We regularly asked delegates to share feedback via the Zoom chat box, but giving individuals the platform to voice their thoughts brought the session alive. It did mean having to relinquish some control, but it was worth it every time. Sharing the platform was important.

“I think I’ve learned more in this two-hour online session than any other face-to-face course I’ve attended!”

    4. Have you learnt any new skills with online facilitation/delivery?

Vardeep: I’ve learnt you have to be even more adaptable and fluid when delivering online. Anything can happen at any time (tech issues!) and you have to be able to step in and pick up anything, whether this is the delivery of a session or an aspect of facilitation. Every member of the team needs to be able to pick up any role and this really stretched me and took me out of my comfort zone – we survived a few hairy moments.

Kate: I had delivered a few online webinars before, but they were very much ‘chalk and talk’ style. I’ve loved learning about, and using, Liberating Structures to keep delegates engaged and to facilitate interaction between them. I’ve also enjoyed thinking creatively to convert traditional face-to-face QI training for online delivery.

   5. Have you learnt anything about yourselves during this project?

Vardeep: Working alongside Kate to plan every session in detail, really enabled me to be fluid and agile to the needs of others, particularly guest facilitators. I’ve learnt that with the right team around you, you can adapt to any last minute change and for it to still feel under control and most importantly – fun.

Kate: I’ve learnt that my happy place is extremely organised and where I’m in control. Fortunately Vardeep is very good at making me feel safe enough to step outside of that and allow space for spontaneity and discussion, and that’s where the magic happens! On the flip-side, I’ve learnt to value the skill of organisation and I don’t think we could have pulled off this series without it.

“Really good workshop today – best I’ve attended during this whole pandemic, so thanks to you and your colleagues”.

  6. What has been the biggest challenge?

Vardeep: You never truly know how you’re being received online until you read the feedback.  Over the five sessions I got used to smiling and talking to a camera instead of being able to make eye contact and responding to non-verbal cues. That often felt odd but it’s vital to the person the other side of the screen.

Kate: At the start I was overwhelmed with the task that lay ahead of us, thinking about all the details. Fortunately I work with brilliant colleagues who made this series a true team effort. I was able to focus on planning and delivering the sessions in a step-by-step way, knowing that the event logistics and marketing of the series were being expertly handled. Breaking down the roles, tasks and working as a team was crucial.

 7. Do you have any top tips for online delivery?

Vardeep: Plenty….

  • As a facilitation team agree a way of communicating with each other behind the scenes (such as Whatsapp). This allows you to adapt, adjust or abandon as you go along.
  • Plan your sessions with timings in mind. This is invaluable and is a skill – things often take longer virtually. This also includes prepping any guests.
  • Allow time for a team pre-brief and de-brief after each session. Kate, Shomais and I always spent time reflecting on what went well, what didn’t go so well and we also captured new ideas to incorporate for the next session on ideaz boards or jamboards.

Kate: I think one of my favourite phrases from this series was “team work makes the dream work”. We couldn’t have delivered such a slick series without the designated online technical support that our colleague Shomais provided. Having clear roles and responsibilities in the team was important, e.g. being clear on who is responding to questions in the chat box, who is co-ordinating break-out rooms and who is introducing facilitators and welcoming delegates back from breaks. I think the clarity of roles and knowing we could depend on each other, created a safe space to do each of our jobs really well.

Thanks to Kate and Vardeep for sharing their experiences.

Further information about the West of England Academy’s online resources and future events can be found here.

Quality Improvement in the age of COVID – launching PERIPrem

Noshin Menzies, Senior Project Manager, shares her experiences of launching a Quality Improvement programme during COVID.

If you’d told me 4 months ago we would be where we are today with PERIPRem, I’d have wondered what planet you were from. This exciting, ambitious care bundle, the vision of two extraordinary neonatologists, was going to launch in April and change the way that perinatal care is delivered across the entire South West region. It was a seed reliant on collaboration. However, 2020 had other plans…

The fundamentals of PERIPRem – nurturing a regional clinical community dedicated to improving outcomes for our most vulnerable babies and working side by side with women and their families – were, in an instant, stopped in their tracks.

Pre-COVID, I had been lucky enough to attend the Royal College of Obstetrics and Gynaecology’s “Let’s Talk about Race” event for International Women’s Day. The stories I heard further cemented the commitment we had to reducing inequalities.  We could not deliver a perinatal quality improvement project without ensuring that we were actively listening – and considering how to chip away at the barriers that result in Black and Minority Ethnic women being 5 times more likely to die in childbirth and their children to experience poorer outcomes. This was even before we knew the increased risk of COVID to people of colour and the raised chance of preterm labour for those women unfortunate enough to contract the virus whilst pregnant.

Just as we finalised plans for launch, and to get out into the communities and find every opportunity to involve those who lives are imprinted by the experience of preterm birth, COVID hit. Our PERIPRem teams were now on the battle lines, and we were nestled behind our laptop screens, shell shocked. Our ability to be agile and adapt to novel ways of working mattered now more than ever.

I’ll admit, I was sceptical how we could launch what was still a seedling of a programme to twelve units across the whole of the South West, when we were unable to leave our kitchens, let alone realise our plans to provide fertile ground for the creation of a regional PERIPRem clinical community. Without a physical launch, how could we provide space for those small but mighty moments, that when cultivated, have more of an impact than any toolkit or presentation?

I often struggle when I have to describe QI; in my experience it is much bigger than a framework or a process by which you can input your problem and wait for gold-standard results. For me, QI has its foundations in the people, the team and the culture. It is the introductions to new faces, teams huddled together around meeting tables, clinicians whispering to colleagues they had not seen for years and the camaraderie brewed alongside the substandard coffee.  We grow highly functioning teams, and the most exciting part of any QI project, on these blocks. It was boom or bust but I needn’t have worried.

We have formed strong bonds as a PERIPRem team; we have even managed a team social. My treasured counterpart in the South West AHSN and I have never met, we joke that we do not know what each other look like from the shoulders down. We have bonded over the many cameos from the PERIPRem teams’ children – or Assistant QI Coaches as they are now known.

Most importantly, the PERIPRem perinatal teams have flourished. Whilst in the pressure cooker of the pandemic, we gave space and time to focus on delivering patient care – when they got a handle on what it meant for them as clinicians, they came back raring to go.  We have digitised all of our resources and are now holding webinars on each of the bundle elements – they are so well attended we cannot fit on a screen!

People have pushed through discomfort to record themselves sharing the clinical fundamentals and to provide the presence (all be it through a screen) we all miss. We are exploring new ways to engage with the women we were so keen to meet and listen to, and we are forever indebted to our patient representatives who are now pillars of our PERIPRem team.

The takeaway message from that tired trope of “these unprecedented times” is that we are stronger than we think. At the end of each exhausting day, when we have had our fill of fighting for bandwidth with Xboxing teenagers, with tired mouths from calmly saying, “you’re on mute”, we have been and will continue to be successful. More significantly, we have supported frazzled teammates, butted horns and laughed until we cried.

There is a sense of freedom this way of working has granted us. Whilst before, there was a tendency to stick to the tried and tested method of engaging and working with our clinical communities, COVID allowed us to think again. We used technology to enable hospital teams scattered across the entire southwest to meaningfully engage in PERIPRem without ever having to leave their wards. I was worried connecting through screens and keyboards would reinforce the distance between us all, but I am surprised to realise that it has in fact accelerated relationships and in turn progress.

Having to rely on the written word in email has meant that tone and intonation have been more carefully considered and the periods of chat offered through video calls means each sentence really counts. Of more significance, is a flattening of the hierarchy within our team. Each person no matter what their seniority is vital in keeping the PERIPRem wheel turning – be it because they know how to record a MS Teams meeting, or because they have the complex clinical knowledge of a perinatal intervention.  It is not that we did not appreciate this before, but the situation forced us to see beyond the limitations of a job description.

I have reflected on whether, upon return to ‘normality’, if we as a team will revert to the pre-COVID way of working. Whilst I would like to think there would be a time when we are able to sit in offices and meet with units, I do not think that is the whole question. I can honestly say I hope we do not – I do not want to forget our swift response to the restrictions placed on us, or our unwavering faith in our ability to make improvements.

I believe that we have fundamentally changed the way we will approach projects such as this in the future. We are braver in our ways of facilitating community, we have lived experience of delivering change programmes utilising technology rather than travel and we know that when needed, we can free ourselves of the legacy of traditional and more restrictive ways of working.