Ronald Ellwood

Burton Hospitals hE
NHS Foundation Trust
Queen's Hospital

Belvedere Road
Burton Upon Trent

Medical Director: _

Staffordshire
28 October 2013
Mr A Haigh

HM Senior Coroner
Coroner's Office

No. 1 Staffordshire Place
Stafford

ST16 2LP

Dear Mr Haigh
Rule 43 - Ronald Sidney Ellwood (deceased)

Thank you for your letter dated 3 September, addressed to Ms Ashley, which has
been passed to me to respond.

In response to the request for information regarding the supply of fresh air in Critical
Care areas in relation to the death of Mr Ronald Ellwood, | am replying as follows.

While the experience of fresh air will add to an individuals feeling of wellbeing, there
are certain areas within a hospital where it is not recommended.

The guidance for the design and operation of air systems in health care
establishments comes from: Health Technical Memorandum 03-01: Specialised
ventilation for healthcare premises. Part A - Design and validation from the
Department of Health published 2007.

The Health Technical Memorandum specifies that ventilation in Critical Care should
be regarded as a critical system and as such requires annual verification of
performance.

The difference between ventilation and air-conditioning is made clear within this
document on Page 5, 1.27- 1.24. The areas that full air-conditioning is required are
indicated on Page 9, 2.19.

From this rationale “fresh air” from open windows for example, being introduced into
an air-conditioned system will negate air-conditioning.

Air conditioning will have tolerances within which it works, e.g. on a very hot day in
an area where there are large windows with sun beating on them, as is the case in
critical care areas within Burton Hospitals, will put a strain on the system. These
tolerances as defined in the document on Page 83, with 10 changes of air per hour
maintaining a temperature of 18-25 Celsius (in practice this will be maintained at the
uppermost levels as patients will have little coverings in Critical Care).

The rationale for using air conditioning in this area is highlighted on Page 46, 7.5
and here lies the paradox of fresh air; in the days of rampant tuberculosis, as you will
know fresh air treatment in sanatoria was the only management with any chance of

success. Fresh air was preferable to the infected environment of tuberculosis and
Infectious Disease wards. Today by air changing so frequently, the risk of build up of
air borne bacteria will be minimised. Open windows will allow fresh air in but may not
remove pockets of infected air. The research indicates that fresh air will only
penetrate a maximum of 6 metres into a space; please refer to Page 8, 2.7. of Health
Technical Memorandum 03-0. in addition it should be noted that windows on the
Critical Care Unit have limited opening of 10 cm in order to comply with Health and
Safety legislation and penetration of any fresh air will be much more limited than for a
fully open window.

The guidance does not indicate that microbiological testing is necessary.

However, there is no evidence to suggest that there is environmental air
contamination in the Critical Gare Unit either at present or since February 2013. The
environment is surveyed when there is evidence of linked cases of the same
organism occurring in more than one patient. This was last done on the 11th
February 2013. It was found that there was minor contamination with a solitary
species of bacteria specifically spread by direct and indirect contact rather than being
related to air or the air conditioning.

A literature search has not revealed new guidance relating to the need to carry out
survey routinely.

| am aware of no other nationally published/adopted evidence to suggest that
windows should/could be open or closed. | would make the simple observation that
opening the windows will detrimentally affect air conditioning.

The critical care unit has a full fresh air system with no recirculation of air. The air
conditioning is a conventional system with heating and cooling and was installed
when the hospital was built. The extract air and supply air being separate frorn each
other.

The system is designed to operate with all windows closed so that the temperature
can be controlled. In 2001 when the High Dependency Unit was added to the
hospital, additional supplementary cooling was added to the critical care unit suite,
again with 100% fresh air.

Set points for the system are set with a general supply temperature of the Air
Handling Unit (AHU) of 18°C. When external temperature is below 18°C the extract
air goes through a heat exchanger for energy savings. Reheat batteries are set to
operate when the room temperature falls below 21 °C. The supplementary cooling
system is set to operate when temperature's rise over 23°C. The room temperature is
controlled as average between two room thermostats within the critical care unit.

The AHU is served by a G4 Filter as per HTM 20/25 when designed as apposed to
the current design guide (HTM 03) for F7 filters.

The systems are subjected to annual maintenance by the estates staff and this was
last carried out in March 2013. The ventilation duct work and systems were cleaned
and systems pressures and volumes were externally assessed by Total
Environmental and Mechanical Services (TEAMS) in July 2010 and there is no
requirement for alterations to the system before the next revalidation checks in 2015.

Following on from your letter the estates department has requested the filter
manufacturer to carry out a survey of the ITU system to look at the possibility of

converting the AHU to accept the more efficient F7 filter, but this is likely to result in a
decreased air flow to the areas served by this system and the Trust will take a view
on this change when further technical information is available for consideration.

A refurbishment of the Air Conditioning Systems units within the hospital is currently
planned to commence with the next years capital program. At this time the current
environmental conditions within the hospital will be re-evaluated and the system
designed to control the environment with the additional heat loads within the building,
especially within the ITU unit where the advancement in medical equipment has
substantially increased the heat loadings within ITU.

The Trust can demonstrate that the Critical Care Unit conforms to the applicable
guidance and memorandum for specialised ventilation. By opening the windows, it
makes this system less efficient and compromise air changes that may lead to
increased environmental air contamination. The system is appropriately maintained
and checked.

Although there may be a perception that the environment would be more comfortable
with more fresh air it must be balanced by the fact that comfort for staff and relatives
may come at a price that must be paid by the patient in terms of safety and exposure
to additional organisms. For these reasons the Trust considers that it would be to the
detriment rather than benefit of patients in the Critical Care Unit to compromise the
specialised ventilation system by opening windows and so the Trust will continue to
ensure that windows remain closed on the Critical Care Unit.

| greatly regret that I ouna the Critical Care environment unpleasant at a
time of great personal stress and while we accept that no system can be perfect we
believe that our air-conditioning system delivers the safest environment for our
patients and hope this reassures yourself and [i

if you require any further information please do not hesitate to contact me.

Yours sincerely

Medical Director