Sari Keen

LUTON &
DUNSTABLE

UNIVERSITY

HOSP TAL

Our ref: PMP/ams

Lewsey Road Luton LU4 0DZ
Tel: 91552 49 12.66 www. idh.nhs.uk

12 June 2014

Mr T Osborne

HM Senior Coroner
The Court House
Woburn Street
Ampthill

MK45 2HX

Dear Sir

Inquest touching the death of Sari Marlene KEEN
Inquest held on 19 March 2014 at Coroner’s Court, Ampthill

| am writing in response to your Regulation 28 Report, dated 16" April 2014, in response to
the death of Mrs Sari Keen.

The Trust has considered three issues:

1) medical and nursing staff numbers;
2) the ability of staff to escalate their concerns; and
3) the role of the Crash Team

Medical and Nursing Staff Numbers

Nursing Staff establishments are reviewed every six months using a number of different
approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty
matron and ward manager who have greater insight into the local clinical need and context
of each ward setting. The establishments are also reviewed in the context of the wider
quality performance of the ward which includes key nursing quality indicators, patient
experience scores and workforce indicators such as sickness and turnover rates. In fact
following our most recent establishment review the actual numbers of nurses on ward 22 at
night has been increased.

In addition to the agreed staffing numbers per shift, operational meetings are held three
times a day, led by the Chief Nurse, Deputy Chief Nurse or Matron to review the staffing
numbers on a shift by shift basis using a risk assessment process. This includes all clinical
wards across the Trust. Decisions are made, if required, to move nurses across clinical
settings to ensure that all areas are safely staffed.

Out of hours, doctor ward cover is provided by the on-call surgical team. For General
Surgery, this includes a junior surgical doctor in training (FY2), a senior surgical trainee
(SpR/middle grade) and the on-call consultant. Additional cross-cover is provided by the
Orthopaedic on call team (similar team structure), and this can be called upon if necessary.

Sp

er Colvin Luton and Dunstable University Hospita

©, Pauline Philio NHS Foundation Trust

The Divisional Director for Surgery has confirmed the processes are in place to ensure that
adequate medical staffing numbers are in place and adhered to.

The ability of staff to escalate their concerns

On the night of the 23" of October 2013 the nurse in charge of the shift did not escalate to
the senior night nurse for support or advice as the House Officer was already on the ward
for the majority of the night and the senior nurse felt, at the time, that the House Officer was
managing the situation accordingly. In hindsight, the staff recognise that they should have
escalated to the senior nurse regarding the nursing workload as it was extremely
challenging for the nurses to manage this level of acuity.

The following actions have been undertaken to minimise the risk of this happening again:

e The ward manager has raised this issue with her staff and stressed the importance of
early escalation when the existing nurse staffing is insufficient to cope with the
unpredicted patient acuity. This is discussed at the daily ‘safety briefs’.

* We have introduced a more robust process for identifying the patients who are
particularly unwell/at risk of deteriorating by providing the senior clinical sister on night
duty with an up to date list. This enables patient reviews to be prioritised.

For doctors, in cases where a deteriorating patient requires specialist input, escalation is by
the surgical on-call team to the Medical registrar, the ITU registrar, ITU outreach (during
their hours of operation 08.00 — 22.00) or the link anaesthetist. If they foresee that they will
be unable to respond within an appropriate timescale, it is their duty to inform the referring
doctor of this at the time, to allow additional assistance to be sought.

We acknowledge that there is a culture within the L&D whereby some junior medical and
surgical staff do not like to disturb senior colleagues out of hours, despite being told
explicitly during their induction that it is their duty to do so where they have concerns for
their patients. There is an ongoing dialogue with junior staff about senior doctors’
expectations with respect to being notified about a deteriorating patient, and it has been
made clear to all consultants that they are expected to respond appropriately to all juniors
requests for support.

e The requirement to escalate is also reinforced by the Director for Medical Education as
part of the junior doctor's training programme.

In addition in HDU, we have adopted a policy a few months ago that empowers nursing staff
to escalate concerns regarding a deteriorating patient directly to the consultant if they feel
that appropriate action is not being taken quickly enough, and we will look at the feasibility
of extending this to all ward areas. This has worked well.

All members of staff have a professional accountability to escalate concerns about their
patients, and they should never feel unable to do so. This is reinforced at induction and
ongoing junior doctor training.

Further actions include:

e Improving the management of the deteriorating patient. This is a key quality objective for
2014/15 and a dedicated steering group has been set up with a key focus on identifying
the barriers to the effective management of the deteriorating patient.

e Arevised Root Cause Analysis (RCA) process for investigating all cardiac arrests has
been introduced which is now being led by the Consultant responsible for the patient
rather than the former process which was led by the resuscitation officer.

e Arevised observation and escalation process is currently being piloted on 4 wards. A
key change is the introduction of registered nurses to undertake the observations of all
patients who require observations more than 4 hourly. Health Care Assistants also
undertake observations but it was noted that the registered nurse has a greater ability
and opportunity to identify other factors that might indicate deterioration where a Health
Care Assistant would not be skilled enough to identify the patient during the actual
observation process. Early indications are that there is a more timely escalation from
nurses at the earlier signs of deterioration.

e Re-launch of the standard communication tool - SBAR (Situation, Background,
Assessment, Recommendations.) Analysis of the RCAs for cardiac arrests has identified
the importance of communicating in a clear and concise way. The drive to standardise
the communication is being led by the Critical Care Outreach Team and this should
provide clearer details regarding the deterioration of the patient. This in turn will promote
a more timely medical response and enable the medical staff to prioritise their workload
more effectively.

¢ The Trust has aiso undertaken a review of the clinical support available at night across
the Trust. Further work is underway to develop a revised ‘hospital at night’ model to
meet the national strategy requirement of a robust 24/7 service.

The role of the Crash Team

We have very clear and specific protocols for activation of the cardiac arrest process, which
every member of staff is expected to be conversant with. It is taught through basic life
support, which is an element of mandatory training for all clinical staff.

in addition, we nave a separate “Medical Emergency Team’ policy, designed to be activated
in situations where a patient is deteriorating but is not yet in cardiac arrest. This involves
activation of the bleeps of the medical registrar and the ITU registrar by switchboard with a
message asking the medical emergency team to go to ward X immediately.

For patients deteriorating between 8am and 10pm, we have the third option of summoning
the ITU Outreach team to review the patient. This can be initiated by either medical or
nursing staff, and results in a review by a nurse trained in assessment of critically ill patients
who can then escalate to either the medical team or the ITU team as appropriate.

It is unacceptable that any member of staff feels that an “unrecordable blood pressure’ is
not a medical emergency, and this will need to be addressed across the whole Trust.

* The process of escalating to the Medical Emergency Team was widely publicised at
its inception, and its availability is being emphasised to all staff groups during basic
life support mandatory training.

e Evaluation of the current training for nurses and doctors on the identification of the
deteriorating patient is in progress with a proposal to improve the content as reflected
in the learning from Root Cause Analysis of cardiac arrests.

e This case will be presented at the Grand Round, Trust Patient Safety Meetings and
Senior Nurse meetings so that learning can be shared.

| trust the information contained in this letter will provide you with the assurance that we
have taken appropriate in response to your Regulation 28 Report.

Yours sincerely

Pauline Philip
Chief Executive Officer