Agnes Hannan

a

Tameside Hospital INAS]

NHS Foundation Trust

Chief Executive Office
Silver Springs

Tameside General Hospital
Ashton-Under-Lyne

OL6 SRW

Our Ref: a

Date: 19 December 2014
Mr Pollard

Senior Coroner
Coroner's Court

1 Mount Tabor Street
Stockport

SK1 3AG

Dear Mr Pollard

Thank you for your letter dated 27° October 2014 enclosing a Regulation 28 report following
your investigation into the death of Agnes Mary Hannan.

| am sorry to note that the evidence raised a number of concerns. | hope that the responses
below will provide you with reassurance of the steps that have been taken by the Trust to
improve patient safety and minimise the risk of future deaths. Addressing your concerns

individually (adopting your numbering):

1 That there was an actual, or perceived, lack of availability of the hospital notes
and records of previous diagnoses and treatments by hospital doctors, for the

staff working in the Emergency Department.

Response
‘ords which was in place at the time of Mrs Hannan’s

The computer system for medical rec
attendances at the Accident & Emergency Department has since been replaced by a new

system. Staff working in Accident & Emergency are able to access extensive details of
patients’ medical records including correspondence, previous in and out-patient attendances
including attendances in Accident & Emergency.

The physical records of all patients seen in the Accident & Emergency Department are held
Ive weeks following a patient’s

within the department for ease of access for a period of fi
attendance so that they are easily accessible for staff attending on patients who might return

to the department within that period. After five weeks the notes are scanned on to the
computer system. In order to minimise delay in those notes being accessible on the system
the Trust is purchasing a scanner specifically for the Accident & Emergency Department and

- Everyon
! Matters # Pa

once in place staff training will be arranged to ensure that the scanning and uploading
process is carried out efficiently.

2 On one occasion whilst she was an in-patient, Mrs Hannan who was
desperately ill and needing intravenous hydration, was found to be lying ina
soaking wet bed because the tube leading to her cannula had become
dislodged and disconnected. The nursing staff had failed to notice this
problem. The doctors in evidence, acknowledged that her lack of hydration
would inevitably have worsened her already thrombosed veins.

Response

The Trust's nursing staff are trained to carefully insert and tape cannulas to the skin to
minimise the risk of them becoming loose, disconnected or falling out. Unfortunately, despite
taping them down cannulas do, on occasions, become loose, for example, if patients
inadvertently dislodge them. If a cannula becomes dislodged patients May alert nursing staff
so that it can be re-secured to prevent the loss of fluid. We appreciate that on occasions
patients are not aware or are not well enough to alert nursing staff themselves. If that occurs
our staff should become aware that there is a detached cannula and/or loss of fluid on next

attending at the patient's bedside.

Whilst the risk of cannulas detaching cannot unfortunately be completely avoided we have
taken steps to minimise that risk by training our nursing staff to carefully insert and tape
cannulas and to be observant and check for problems when attending on patients.

3 There was extremely poor communication between hospital staff and the
patient (and her family), and between and amongst themselves. There was
evidence of a lack of handover between staff, and this was exacerbated by the
fact that the medical and nursing notes were frequently inadequate.

Response
The Trust promotes safe handover of patient care by providing protected time, to enable

handover of all relevant patient information, both at the beginning and end of shifts. The
Trust is currently undertaking a review of its current training on record keeping standards
which will include an emphasis on the importance of good communication between staff and

the importance of careful handover.

4 Whilst it was. or should have been apparent that she was under the long-term
care ia no-one made any attempt to speak with him or his
department for advice.

Response
The Trust's medical staff treating Mrs Hannan had access to details of her previous medical

history including her care under and therefore should have been aware o'
EE err0.: involvement in her treatment. The records available to the clinical staff

did provide the means by which they could obtain information about it and contact |
or other members of his department whenever they needed to. Professional staff have been
reminded of the importance of both reviewing the patient’s notes (either the physical notes or
electronically on the Lorenzo system) and communicating with the previous relevant

+8

consultant and / or their department if advice is required in order to ensure the patient
receives appropriate treatment.

5 Throughout the hospital notes for this patient, there is widespread use of
initials and abbreviations. On at least one occasion in court, none of the
medical / nursing staff present could explain to me what the abbreviation in the

notes meant.

Response
As mentioned above the Trust is undertaking a review of its current training on record keeping

standards. The training will reinforce the need for clarity and the importance of avoiding the
use of unclear abbreviations.

6 This patient needed very careful monitoring at all times and yet there was a
period of 24 hours when no nursing observations were carried out or recorded.

Response
At the time of Mrs Hannan’s treatment the Trust used a PARS scoring system for recording

nursing observations. That system is designed to track observations, determine the regularity
of them and trigger escalation of care whenever required. Instructions for use of the PARS
Score system was provided to nurses through training and also by clear explanatory notes
within each individual nursing observation chart. The insufficient observations in this case
arise from failure to adhere to the Trust’s PARS system.

Since Mrs Hannan’s treatment the PARS scoring system has been replaced by a different
system called the NEWS system and all of the Trust’s staff have been trained in the use of it.
A quick reference NEWS escalation and response guide has also been made available to all
staff. The NEWS system is more sensitive than most other existing systems and it provides
an enhanced level of surveillance and clinical review of patients with greater specificity in

identifying those at risk of clinical deterioration.

7 The communication of medical / nursing diagnoses and decisions to the family,
was extremely poor and frequently did not happen. An example of this was the
failure by the staff to explain the critical nature of Mrs Hannan’s condition, so
that the grandson of the deceased failed to be able to come and see his
grandmother in hospital before she died.

Response

The Trust is striving to improve communication between staff and family members. The Trust
has created a bedside booklet available for patients and relatives — “Patient Safety —- Keeping
you safe during your stay in hospital”. This includes a section on recognising acute illness
and how this is monitored and empowers patients and their families to ask questions.
Professional staff have been reminded of their duties to communicate proactively and

effectively.

8 | was told that there is no CT scanner facility available for the use of the ED out
of normal hours. This meant that a scan was delayed / missed and ledtoa
delay in diagnosis of her underlying condition.

Response
, a CT scanner available for the

9 ! was told in evidence that it takes up to three months for the Paper records of
the ED to be scanned electronically. This means that recent notes may not be
available on the computer screens for the staff in the ED.

Response
A new scanner has been purchased specifically for the Accident and Emergency department

to minimise any delay in records being accessible on the computer system. That will avoid
any delay in records being uploaded on to the system. Staff training has already been
scheduled to ensure that the scanning and uploading process is carried out efficiently.

10 When a patient is admitted there is little or no logic as to determining which
all be in charge. In this case she was allocated under the Care of
who was not even in the hospital for the first two days of her
admission and in fact who never actually saw the patient.

Response

! apologise for any confusion at inquest and if the patient's family were not info
arrangements in place for the medical care of Mrs Hannan. | understand that

i rs Hannan was transferred from MAU to Ward 31, Adult Medicine.

was in the

At the time] was on-call for emergencies and was with other Patients in another
department. who is MD 2c istcr was ake a clinical
examination of Mrs Hannan and as supervising consultant, Provided advice

over the telephone. Please be assured that whilst on the ward, Mrs Hannan was seen ona
daily basis by other well qualified doctors. The concerns regarding the direct Contact of
consultants will be fed back to all division.

11 The End-of-Life Care Pathway must be initiated only after full and meaningful
discussion with the patient and / or her family. In the present case there was
no evidence to show that any such discussion had taken place.

Response

The Trust's DNACPR policy has been reviewed since nnan was treated at the Trust
and in accordance with R (on the application of v Cambridge University
'y emphasizes the importance of discussion

Hospitals NHS Foundation Trust. The new polic
with patients / their family. Also, a DVD has been created and is available on the Trust's

intranet. This was also Promoted through screensavers to inform staff of the new policy and
emphasize its importance.

The current Trust policy dealing with decisions relating to DNACPR, which was updated in
November 2014, stresses the importance of clear, accurate and honest communication with
the patient and those close to the patient (unless the patient has requested confidentiality)
including provision of information and checking their understanding of what has been

explained.

your concerns and that | have reassured you that the steps

| do hope that | have addressed
€ recurrence of a similar set of circumstances as those in the

taken by the Trust will prevent th
case of Mrs Hannan.

Should you have any further questions arising from the contents of this letter please do not
hesitate to contact me. | am again sorry that your investigation into this death caused you
such significant concern to issue a Regulation 28 Report but | hope that you are now

reassured.

Yours sincerely

Karen James
Chief Executive