Anne Sandever

Hinchingbrooke Health Care INHS|

NHS Trust

Dr Samuel Bass

Assistant Coroner, South and West Cambridgeshire
The Coroner's Office

Lawrence Court

Princes Street

Huntingdon

PE29 3PA

29 October 2014

Dear Sir

Requlation 28 regarding Anne Elizabeth Sandever

| write in response to your letter of 03 September 2014, enclosing your Regulation 28 report to
Prevent Future Deaths, following the Inquest into the death of Mrs Anne Sandever.

Coroner’s Concerns

In relation to the four matters of concern listed in the Regulation 28 letter, | provide a response to
each, below [adopting your numbering]:

1. There was a lack of nursing care afforded to Mrs Sandever. She was not seen by
any nurse or medical staff from 10.30 until 16.10 whilst on the ward.

Please see the full response to concern 4, below, which advises that we have conducted an
investigation of these events, incorporating information gained via medical records and factual
accounts and evidence given in your Inquest, including the family's account of events. Our
investigation has confirmed that observation and engagement with Mrs Sandever between
10.30 and 15.00hrs on 4 February 2104 was limited, and this resulted in a failure to identify
that IV fluids had run out and needed a timely response. Our review also recognised that a
failure to respond to Mrs Sandever's daughter's request for a discussion with staff was a
missed opportunity to become alerted to concerns.

We have taken action as a result of this issue, developing and implementing a Trust-wide
action plan to address the deficits highlighted in this case. In relation to this specific issue,
actions have included the introduction of spot checks undertaken on wards, which include a
review of the number of patient interactions, call bell response times and completion of
required risk assessments, as well as the delivery of a specific training programme for all staff,
in the recognition of a deteriorating patient, the importance of Modified Early Warning Scores
(MEWS) and the importance of monitoring urine output as part of the MEWS system. This
includes clear triggers and routes for escalation, including input from the Critical Care
Outreach team.

This training programme has commenced and is due to be completed by 31 March 2015. We
will also conduct a Trust wide audit to ensure completion of the course, alongside a review of

Hinchingbrooke Health Care INHS|

NHS Trust

incident data to identify any failure to treat incidents, as part of monitoring effectiveness of the
training.

2. Communication and handover was poor. No-one on the ward knew Mrs Sandever

was diabetic or took appropriate care of her diabetic control

Our internal investigation also identified that the handover from AAU to Walnut Ward did not
ensure that all relevant staff who would assume responsibility for Mrs Sandever were made
aware of her presence on the ward. In addition, the handover did not adequately cover the
relevant medical history, including that Mrs Sandever had diabetes, nor did it explain the
treatment plan to manage hydration.

The recommendations coming from our internal investigation on this issue were that the ward
transfer policy and the SBAR chart [which documents the key information at transfer] should
be reviewed and updated and that this update would specifically include a requirement to
ensure and document that a face to face handover has occurred at the point of transfer from
one Clinical area to another. All patient transfers would also be risk assessed and any patients
who have a MEWS score of 23 will be transferred by a nurse who knows the patient.

This work is already under way, with the revised policy implemented, and we have a target
date of the end of December 2014 for all related actions to have been put in place. This will
then be monitored for effectiveness via internal audit.

3. She was left without intravenous fluids for many hours despite having renal failure

Please see the response to concern 1 above, as the actions incorporate this issue. In
addition, the investigating team recommended specific work around raising awareness of
Acute Kidney Injury (AKI) in chronic renal patients. We have, therefore, re-circulated NICE
guidance and a subsequent ALERT around AKI to all nursing and medical staff, through which
we are raising awareness of the significance of a lack of urine output and fluid replacement in
patients with Chronic Renal Failure in an acute episode. Minutes of Critical Care meetings
have confirmed circulation and we will include AKIs in our review of incidents.

4. There has been no SUI inquiry and the hospital has not investigated this sufficiently
to ensure that this does not recur and has not taken the necessary steps to assure

me of this.

As mentioned above, following the Inquest the Trust instigated an investigation into the care
provided to Mrs Sandever, to identify both positive practices and learning points for the Trust,
to form part of our programme of continuous improvement.

In addition to the above issues, we identified a need for all agency nursing staff to be provided
with a more robust induction pack, incorporating information about MEWS, escalation and the
SBAR process.

We also identified a need to enforce and reiterate the Trust’s, and the wider NHS’,
expectations in relation to documentation. Specifically, to emphasise the requirement of timed
and dated entries, clear recording of the name and role of the person making the entries, and
the use by medical staff of personalised stamps with their GMC numbers on. We also
recommended that this should be followed up via a Trust wide documentation audit to identify
hotspots and areas for targeted learning and enforcement.

Additional actions also include the need to highlight the importance of seeking and listening to
relatives’ views and concerns during episodes of care, and the need to apply good

Hinchingbrooke Health Care INHS|

NHS Trust

communication techniques in those interactions. Service excellence training has been
developed and is available for staff but the Trust is also identifying a means of wider cascade.
We will monitor communications issues via complaints received, and feedback specifically
sought on communication.

The Trust’s Serious Incident process is also being revised as part of a wider quality
improvement programme.

Finally, we have presented this case, in an anonymised form, as part of the lessons learned
section of a Clinical Governance Day, to make more staff aware of the issues identified and,
especially, the core learning around safe handover and the recognition of, and response to,
deteriorating patients.

| hope that the above information provides you with suitable assurance of the seriousness in
which the findings of the Inquest are held. It is my great regret that Mrs Sandever and her
family did not receive the high quality of care and communication to which we aspire and |
fully recognise the additional distress this will have caused her family. | sincerely hope that the
steps taken by the Trust in response, the work carried out to put actions in place to avoid a
recurrence and the ongoing monitoring to assess the effectiveness of these actions goes
some way to assuring you, and Mrs Sandever’s family, of our recognition of the impact of the
deficits in our care and communication and our commitment to improvement.

Yours faithfully

yu blL-

Hisham Abdel-Rahman
Chief Executive Officer/ Clinical Chairman
Hinchingbrooke Healthcare NHS Trust