Rainer Wickens

St George’s Healthcare [A'/n ky

NHS Trust

St. George’s Healthcare NHS Trust
Blackshaw Road London SW17 0QT

Mr. Martin Fleming
Assistant Coroner for Surrey
Station Approach

Woking

Surrey GU22 7AP

16 May 2014

Dear Mr. Fleming
Re: Rainer Wickens Inquest 28 April — 2 May 2014

| write further to the above inquest which concluded on 2 May 2014. | have been informed of
your legitimate concerns about the delay in declaring and undertaking a Serious Incident (Sl)
investigation in this case, and also the doubts you expressed about the potential for the
completion dates for the SI panel’s recommended actions slipping. | am therefore writing to
provide some explanation which | hope will address your concerns.

The trust has already apologised sincerely 1 i... the sub-optimal care provided to
Mr. Wickens in Sept 2012 and also for the delay in undertaking the SI investigation. | would also
like to take this opportunity to apologise to you for the delay in declaring and undertaking this
internal investigation. | realise that this delay hindered your own investigation into Mr. Wickens’
death due to the time lapse between the incident and the inquest hearing, which meant that
witnesses were not able to recollect events clearly.

Incident reporting

The trust has a robust process for incident reporting and takes this element of patient safety
extremely seriously. All staff, including nursing, medical, allied health and administrative, are
aware of the trust's electronic adverse incident reporting system. Experienced staff in the Risk
Department review all reported adverse incidents rated severe or extreme, as well as those
flagged to the team as potential Serious Incidents. Those which meet the criteria for consideration
as a Serious Incident (in line with national guidance) are then discussed at the Serious Incident
Declaration Meeting (SIDM) every Monday.

The SIDM is chaired by me, and attended by key senior staff including the Chief Nurse, Director
of Corporate Affairs, Associate Medical Director, Head of Patient Safety and Corporate Risk and
Assurance Manager. Potential Serious Incidents (Sls) are presented to the SIDM for
consideration and declared as Sls as required. Sls are reported using STEIS (Strategic
Executive Information System), following which Wandsworth CCG and NHS England are notified.

Regrettably, in Mr. Wickens’ case, the delay in undertaking the CTPA was not reported on the
adverse incident reporting system as it clearly should have been. Although not entirely foolproof,
there is usually also another mechanism for picking up on unreported adverse incidents, in that
they could potentially have been recognised by either the Complaints team, had a family got in
touch with the hospital with any concerns, or by the Legal team, had any Coroner's office
requested statements from clinicians via the Legal office. Unfortunately, the Consultant who
initially reported Mr.Wickens’ death to the Inner West London Coroner's office provided a report
direct, and so another opportunity to recognise the delay in the CTPA as an adverse incident was
missed, until the Legal team started collating statements for your enquiry from mid-January 2014
onwards when it became apparent to the legal team that there had been a delay in undertaking
the CTPA which should have been reported as an adverse incident. The matter was then raised
at SIDM at the next available opportunity, the incident declared as an SI and a detailed
investigation was immediately commenced and expedited in order to ensure that both the family
and you were provided with the final report before your own enquiry commenced.

The failure to report this incident in a timely manner is most disappointing considering the systems
and processes the trust has in place to facilitate and actively encourage reporting of all adverse
incidents. The trust has one of the highest incident reporting rates nationally as evidenced by the
National Reporting and Learning System (NRLS) report and benchmarking which places the Trust
in the top quartile for reporting when compared with other similar organisations, which is indicative
of a positive safety culture.

Actions taken

| would like to take this opportunity reassure you of the actions taken at the trust to remind staff
again of the need to report all adverse incidents in a timely manner, and the consequences on
patient safety of failing to do so.

e | have personally discussed the missed opportunities for the early reporting of this incident
with each of the clinicians involved in Mr. Wickens’ care who potentially could have logged an
incident report.

e Ongoing training is being provided to all appropriate staff groups to ensure potential serious
incidents are recognised and reported to the Risk team immediately.

e New doctors on rotation are reminded of the trust’s patient safety agenda and adverse
incident reporting system

« There is a continuous organisation-wide effort to promote an incident reporting culture as
evidenced by a number of initiatives including the establishment of a regular staff safety forum
(led by myself, the Chief Nurse and Head of Patient Safety) where serious incidents are
discussed to ensure we have trust-wide learning and serve as a useful way of refreshing key
safety messages.

« Our participation in an annual patient safety week which, though a series of themed daily
events, raises awareness and helps to promote a culture where patient safety is seen as a
key trust priority.

e We are currently carrying out a patient safety week initiative enabling staff feedback on their
safety concerns. Themes from this will enable work on the issues identified to demonstrate
the trust's commitment to recognising and acting upon safety issues

e We also have a quality improvement strategy (signed off by the Trust Board) which describes,
using the three domains of quality (safety, experience and outcomes) how to improve the
standards of care and safety for our patients

SI Action Plan

As you are aware, the SI investigation highlighted a number of failures and missed opportunities
in the care provided to Mr Wickens. The SI investigation and the learning outcomes have since
been shared with the immediate teams who had looked after Mr. Wickens and will continue to be
disseminated through various patient safety initiatives as described above. You will also be
pleased to hear that we now investigate and undertake root cause analysis and disseminate the
learning on all cases of hospital acquired thrombosis.

The SI panel made a number of recommendations in the final report. All actions have been
assigned to senior staff to lead on implementation. Some of these actions have been completed
with the rest due for completion by 31 July 2014.

All actions are presented to the Patient Safety Committee and a regular audit of the actions
contained within any SI action plan is also presented to the committee on a bi-annual basis. The
Patient Safety Committee meets monthly and is a Trust Board sub-committee with the remit of
ensuring that actions are implemented and learning is shared.

| hope | have been able to convey, by way of this letter, the trust’s absolute commitment to
ensuring that patient safety remains central to everything we do, and in that regard we are
working continuously to promote a culture of early reporting of incidents and to ensure wider
learning opportunities are disseminated to all staff.

! would also like to provide assurance relating to your concern that the timelines for
implementation of the actions identified in Mr. Wickens’ case could slip. The trust does have
routine and stringent processes in place to ensure that all actions from all Sis are monitored and
audited, as described above. | will be very happy to provide you with an update of the actions in
August 2014.

If you require further information or assurance about this matter, please do not hesitate to contact
me.

Yours sincerely

Medical Director