Susanna Geraty

Surrey and Sussex NHS)

Healthcare NHS Trust
Please reply to:

Michael Wilson wags |
Chief Executive = —_— an |
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Fa: Canada Avenue I

“. Redhill
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Tel: 01737 768511
Dr Karen Henderson www.sash.nhs.uk
H M Assistant Coroner for Surrey
H M Coroner’s Court
Station Approach
Woking
Surrey
GU22 7AP

By recorded delivery
23 March 2015

Dear Dr Henderson,

Re: Prevention of future death report, following an inquest into the death of Mrs
Susan Geraty

| write in response to your prevention of future death report dated 27 January 2015 and
received at our Trust on 3 February 2015. As this inquest was heard almost four and half
months ago (on 19 September 2014), it has been a little more difficult to understand what is
meant by some of the ‘areas of concern’. | apologise in advance if you feel | have missed
your point on any particular issue.

Your report was addressed to three individuals at the Trust: myself, the Medical Director
and the Chief Nurse. The Act requires that “a person to whom a senior coroner makes a
report, must give the senior coroner a response to it”. | hope that you will accept this letter
as the Trust's joint response to your concerns. In future, | would be grateful if any prevention
of future death report could be addressed to me only, so that a single co-ordinated
response will result.

Thank you for raising your concerns with me. | was of course aware of the death, our
investigation report, your expert report and the conclusions of your inquest.

Trust response to the matters of concern
| will now address each of the areas of concern that you raise: |

‘ Coroners and Justice Act 2009, schedule 5 7(2).

Putting people first Se, An Associated University Hospital of 1
Delivering excellent, accessible healthcare @ Brighton and Sussex Medical School

1. Failure to assess, monitor and record post-operative fluid balance.
2. Inadequate nursing records.

3. Inadequate fluid balance charts.

5. Failure to recognise an acutely unwell patient

Since this incident in 2012, SASH have implemented a number of improvements in the
way that it records a patient’s fluid balance and in the way that it trains nursing staff with
regards to recognising and acting on the identification of an acutely unwell patient and on
monitoring post-operative fluid balance.

The new Early Warning Score (EWS) paperwork which complies with the national
standard (appendix 1) was launched in January 2014 and training on this has a regular
session on the Mandatory and Statutory Training day (MAST). The Critical Care
Outreach Team (CCOT) has made a EWS training film, stressing the importance of
detecting and-managing the deteriorating patient This is-shown to all-nursing_ staff
attending MAST training and will be accessible through the Intranet later in the year.

The Organisation-Wide Policy for Patient Observations (Vital Signs) in Adults is updated
regularly to reflect the changes in the Trust regarding the paperwork and escalation
process and this is available on the Trust's intranet.

An audit of the completion of the EWS chart has been completed but the results are
being collated, and will be finalised in April 2015. However, our EWS training has already
been changed as a result of the findings to emphasise the importance of completing the
frequency of observations and monitoring plan sections correctly. Training is reviewed
regularly based on feedback from staff.

The EWS chart now has an SBAR (Situation, Background, Assessment,
Recommendation) communication guide section, which outlines a succinct way of
relaying information between members of staff. SBAR pads were introduced to the
wards in January 2015 (appendix 2). Once completed, the note can be stuck into the
patient's medical record. An audit will be conducted later in 2015 to review compliance.

The CCOT have also started to provide a Sepsis/Acute Kidney Injury (AKI) and Fluid
Balance Monitoring study day for ward nurses. The morning session consists of teaching
sepsis theory followed by relevant case studies. The afternoon session, concentrates on
AKI theory and further case studies; the importance of fluid balance monitoring is also
included in this session (appendix 3).

Ward based teaching sessions have been held on Newdigate and Leigh wards in
January 2015 by CCOT to educate the staff on patient assessment, AKI and fluid
balance. These sessions were well received and more sessions are planned for staff
during the year.

There is now a named CCOT nurse for the orthopaedic wards, who has worked with the
staff on those wards to understand the staff's issues, and has then delivered AKI training
to both trained and untrained ward nurses.

Following the publication of ‘Improving Outcomes for Patients with Proximal Femoral
Fractures’ —_—_ and colleagues at the Queen's Medical Centre in Nottingham, a
site visit is currently being arranged. The paper includes measures to significantly
decrease incidences of AKI for this type of patient. 7

asbee efurbished to include bays with increased monitoring and

staffing.
ALERT™ courses (a multi-professional course to train staff in recognising patient
deterioration and act appropriately in treating the acutely unwell) started again within the
Trust last year, which includes a section on AKI and fluid balance charts. BEACH

(Bedside emergency assessment course for health care staff) courses will start in April
2015, which will also stress the importance of fluid balance monitoring.

There is a Trust wide audit planned for 2015, to assess the completion of the fluid
balance chart to monitor compliance.

Members of SASH staff have attended the Kent, Surrey and Sussex Academic Health
Science Network Patient Safety Collaborative AKI day on Wednesday 18'" March 2015.

In response to the Patient Safety Alert from NHS England in June 2014 ‘Standardising
the early identification of Acute Kidney Injury,’ a medical lead for AKI was appointed for
the Trust. From 2™ March 2015, patients identified with an acute reduction in renal
function will be identified by the AKI algorithm in Apex, the Trust’s pathology reporting
tool. All level 2 and 3 results will be phoned through by the pathology team to the
requesting doctor 24 hours a day. New messages will show in Apex and Cerner alerting
the user to any patient identified with AKI (appendix 4).

Monthly mortality and morbidity meetings are held for all the specialties, to review the
management of patients who have died and why. This presents an opportunity to
discuss the care received and ensure that lessons are learnt for the future.

4, Failure to respond to legitimate concerns raised by the family

| understand this to be a reference to the lack of action following the abnormal ECG
result. This problem was identified in the Trust’s investigation report and included as a
‘lesson learned’. Our report recommended that in future any investigation should be
reviewed by the clinician ordering it, or handed to another clinician if the results are not
available immediately. The report also identified that this learning would be shared via
the junior doctors induction programme, and ward rounds, to highlight the new
procedure.

SASH acknowledges that in this case, the nurse did not follow the normal and expected
process of acting upon concerns raised by family. Learning from this incident has been
central in the delivery of improvements and cascaded across our multi professional
teams. This has been supported by the launch and roll out of our SBAR framework, and
the use of patient stories for improvement.

There is now a whiteboard on every ward which details the names of the staff on duty

and the name of the consultant in charge of the patient is now above every bed. The

wards operate a ‘Meet the Matron’ scheme, which is advertised on entry to the ward

which gives patients and their families the times they are available to discuss any issues |
they may have. |

i

A notice by every bedside has the contact details for patients or their relatives to raise |
any concerns (appendix 5)

Contact with patients and their family has been further strengthened by the new Duty of
Candour policy. Being Open arrangements have now been designed into the Datix
system to ensure the process has been followed when patients have been involved in an
incident that has caused a level of harm to the patient (appendix 6).

6. Failure of the SI report to consider or acknowledge dehydration as a possible
cause of acute renal failure.

As described above, the SI report was produced many months before the expert
suggested dehydration. The SI report had been unable to identify the cause of the
hyperkalaemia, in a case which was complicated by a lack of any clinical signs and
symptoms of dehydration either in life or at post mortem, and in a patient who had been |
conscious and documented to be eating and drinking well. The Trust does not agree that |
the investigation failed to recognise dehydration as the cause of AKI. The consultant

who led the investigation felt that there were multiple causes in the deterioration in renal
function which he considered at the time, including inadequate fluids, but accepts that

this was not explicitly detailed in the report.

In addition, the pathologist, having considered the medical records and the blood results,

had stated in his post mortem report: “Potassium is present within muscle cells and if |
these are damaged by a rise in local pressure due to haemorrhage; there is a significant
risk of muscular damage leading to raised potassium levels (hyperkalaemia). There is
clear histological evidence of recent haemorrhage into the soft tissues of the right lower
left, and this is associated with histological degenerative changes within the voluntary
muscle. It is therefore my opinion that the death was due to a recognised complication of
limb trauma and the cause of death is:

. la hyperkalaemic cardiac arrest
lb compartment syndrome
Ic fracture of the right tibia and fibular (surgical repair). “

At the inquest, based on the expert report (which said that compartment syndrome was very
unlikely, and that dehydration was likely), the pathologist amended his opinion to 1b to
acute kidney injury instead. Our clinicians found the facts to be extremely unusual and not
at all easy to explain. Had the pathologist identified an acute kidney injury as a cause of
death before the inquest, this may have assisted with this issue having been explored in
more detail within the SI report.

All SI reports are reviewed by the Clinical Commissioning Group (CCG) at their Serious
Incident Scrutiny meeting. This took place on 18" July 2013 and their response was that
they felt the root cause was too long and asked for an assurance that the staff are fully
aware of the fractured neck of femur pathway and routine monitoring of post-operative
bloods.

The Trust now has a Serious Incident Review Group (appendix 7) made up of multi-
disciplinary members which meets fortnightly to review SI investigations and their reports.
This presents an opportunity for the investigation team to give a thorough explanation of the
investigations findings and a chance to review the report before closure.

Yours sincerely

Michael Wilson
Chief Executive

Encs.