Maureen Ellett

Brighton and Sussex INHS|

Your co University Hospitals
Our Ref: NHS Trust

Miss V Hamilton-Deeley, HM Senior Coroner The Royal Sussex ¢ ounty Heepital
Coroner's Office, Woodvale Eastern Road
Lewes Road Brighton
BRIGHTON BN2 5BE
BN2 3QB | Te:
12 January 2015 |

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Dear Miss Hamilton-Deeley

The Late Maureen Ellett, date of birth: 07 January 1948
NHS No:

Thank you for your letter and enclosure of 31 October 2014, and for drawing
your concerns to our attention in detail. As you know, we are always willing
to review our practices, in order to identify improvements which can be
made in the light of experience. Thank you also for agreeing an extension of
time for provision of this detailed response. We have chosen to respond
jointly to the issues you have raised, reflecting the way we work closely
together within this Trust to address concerns.

Using the same numbering as in your letter, we would make the following
comments on the issues you have raised:

1. We agree that there were shortcomings in the record keeping when Mrs
Ellett first arrived in the Emergency Dept. Since then, several changes
have been made. Agreement has been reached with the South East
Coast Ambulance NHS foundation Trust (SECAMB) that they will start
calculating National Early Warning Scores (NEWS) and the triage nurse
will note this when the patient arrives. We agree that the term Acopia
is inappropriate and misleading, and should not be used to describe the
condition of a patient on arrival to the Emergency department. We are
continuing to educate staff about avoiding this term, while recognizing
that it may be used by other people outside this Trust. We are aware
that it may be repeated by junior medical staff on occasion, as in this
instance, to describe what has been reported to this Trust as the
condition ascribed to the patient by other people before arrival to the
hospital.

We do not believe it is appropriate for any decision about whether or
not blood is to be taken to be based on the mode of transport by which
they arrive (ambulance, own transport etc). We agree that Mrs Ellett’s
blood should have been taken for testing, and confirm that while blood
may be taken by medical or nursing staff, it is the responsibility of the
doctor to ensure that appropriate blood has been taken and
appropriate blood tests ordered. The doctors’ induction programme has

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been amended to emphasize to the new doctors in the department that
it is their responsibility to ensure appropriate blood tests have indeed
been taken.

. We believe the A&E consultant’s failure to date and time his signature
on the transfer documentation, while not best practice, is not relevant
to the clinical care of Mrs Ellett. However, we agree that she should
not have been transferred until an appropriately detailed plan for her
management had been agreed and summarized in a series of bullet
points in the documentation, and the clinical shift leader had
confirmed his agreement by signing the proforma. All the consultants
and the relevant shift leaders have been reminded of the importance of
this aspect of their duties.

. We agree that it is particularly important for senior staff to be vigilant
when working with less experienced agency junior staff. All the
Emergency Department consultants and other senior doctors in the
department have been asked, in the light of these events, to reflect
upon their current approach, practice and vigilance. These clinicians
have been strongly reminded that extreme caution should be taken if a
patient is not being seen in person by them, after assessment by any
locum staff who are not familiar with the department or any locum not
previously known to the senior clinician.

. We have established that the triage nurse to whom you refer handed
over to her colleague starting the next shift that there were several
outstanding assessments to be completed and documented for Mrs
Ellett. We deeply regret that this next member of staff, who had newly
come on duty, did not complete these tasks as he should have done.
We have not been able to take this up with him in the light of your
comments as he had already left the Trust before Mrs Ellett’s inquest
took place. Arrangements have been made for further training on
documentation to be included in both the departmental nurse induction
programme and also in the nurse development training days held in the
department.

We do not believe the failure to complete and document these
outstanding assessments arose from the length of shifts being worked
by the staff. While we acknowledge that there are recognized risks
associated with staff working these long shifts, the Trust’s Chief Nurse
agrees with the national view that these risks are counter-balanced by
the benefits associated with such shifts. In particular, the continuity of
care for individual patients is preferred by most patients and many
staff. Such continuity makes it easier to detect what may be subtle
changes in a patient’s condition, as the same clinical member of staff
has direct contact with the patient over a longer period. We are also
aware that it is at handovers between staff that there is a particular
risk of miscommunication, and by reducing the numbers of handovers in
a 24 hour period, there is a reduction in this risk.

. The Emergency Department has 5 electrocardiograph (ECG) machines.
One of these is allocated for sharing between the Clinical Decisions

Unit (CDU) and the neighbouring Short Stay Ward (SSW) - effectively
the small adjacent male and female ward areas within the Emergency
Department for patients who are asked to stay in the department for a
longer period. We believe this provides sufficient access for ECGs to be
requested and performed safely in both areas, and that it is not
necessary to have a dedicated ECG solely for the 7 female patients in
the SSW.

6. Astamp has been devised for use in the Emergency Department on ECG
print outs so that doctors can document, sign and date on it their
interpretation of the ECG and any associated plan for the patient’s
management.

7. While we do not accept that it is necessarily clinically appropriate for
every patient to be reviewed in person by a doctor if a decision is taken
that a further ECG should be taken after an interval, we do agree that
continuity of care is desirable (see 4, above). However, we are not
convinced that it is always safest to insist that a particular doctor
reviews a second ECG, especially in a busy Emergency Department. This
reflects both the risks inherent in interrupting a doctor who may be in
the middle of some other complex patient assessment, and also the
recognized advantage of using fresh eyes to assess a new heart trace.

8. The agency staff nurse who worked that shift in the SSW is a very
experienced nurse, with plenty of experience of working on different
types of wards as well as undertaking regular part time NHS
employment in an endoscopy unit. We have no reason to doubt her
clinical skills in caring for patients in a setting such as the SSW, while
acknowledging the difficulties which will always be associated with
working in any unfamiliar ward or department, for example, locating
equipment or completing local documentation which may be in an
unfamiliar format.

This nurse was closely supported by the senior charge nurse in the
Emergency Department who was responsible for the SSW and other
areas on the night shift. He had been fully involved in the decision-
making for Mrs Ellett to be moved to the SSW, had discussed the
management plan for her with the consultant and had assured himself
that she met the criteria for such a move before it took place. He also
made sure that the agency nurse received a formal induction to the
department and the SSW at the start of her shift. He himself visited the
agency nurse several times on the shift to ensure she was not
experiencing difficulties, and he offered her an earlier break during the
shift. She chose initially to have some refreshment without leaving the
unit, and to carry on working until later in the shift. On reflection, we
agree that it would have been preferable for her to have been
encouraged more strongly to take an earlier break, even though we
have no reason to think that the clinical care of any patient was
compromised by her commitment to continuing their care without
taking a formal break for several hours.

9. We agree that a hands on approach to patients is important, and
believe that the experienced nurse caring for her did interact with Mrs
Ellett on several occasions, for example when helping her to reposition
to make sure that she was comfortable, and when helping her to have a
drink. This provided her with opportunities to take into account what
the policy you refer to describes as the “look, listen and feel” of Mrs
Ellett. These interactions did not initially give her cause for concern,
and she described a sudden change in Mrs Ellett’s condition later in the
night.

10. The observations policy requires trained staff to review and countersign
the findings, if taking the observations has been delegated to a health
care assistant, however experienced that health care assistant may be.
The agency staff nurse gave evidence to you that she had reviewed the
first set of observations taken on the CDU and satisfied herself that the
NEWS score was zero. What she failed to do, and acknowledged she
should have done, was to countersign to indicate that she had carried
out this check. We do not believe this documentation oversight at
21.55 had any adverse effect on Mrs Ellett’s clinical assessment, but we
appreciate - as does the agency nurse herself - that detailed
documentation of this kind is nevertheless important.

The nursing and medical staff in the Emergency Department, as well as the
locum staff involved in the care of Mrs Ellett, and we ourselves have taken
very seriously all the issues you have raised, and changes have been made to
improve different aspects of the quality of care. As an over-arching step,
individual named emergency consultants have recently been given
responsibility for each of the Short Stay Ward and Clinical Decisions Unit, in
order to provide visible senior medical leadership in each area and to seek
ways of improving the quality of care. This will include regular audit to
ensure proformas are being used correctly.

Thank you once again for raising your concerns. Finally, please pass on our
condolences to the family and friends of Mrs Ellett on their sad loss.

Yours sincerely

Matthew Kershaw ‘EME Governance Lead Pt
Chief Executive on behalf of| » Matron,

Lead Consultant, Emergency Dept
Emergency Dept |

*« [ERR is currently away, but has been actively involved in
investigation of the issues raised and has contributed information contained
in this letter. JE has confirmed’the accuracy of the finalized text in
relation to the Emergency Dept

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