Amanda Ellams

Si Lf ZINES
The Alexandra ;
Serious about health. Passionate about care.

fl Hospital

Your Ref: JSP/KN/00585-2015
Our Ref: SA/TJB-Ellams-7229761

17" September 2015

Mr J S Pollard

H M Coroner
Coroner’s Court

1 Mount Tabor Street
Stockport

SK1 3AG

Dear Mr Pollard
Re: Amanda Jane Ellams (Deceased)

| am writing in response to your Regulation 28 Report of 7" August 2015 2015, following
the Inquest of Amanda Jane Ellams.

You have asked The Alexandra Hospital for a response to the matters of concern raised
within the report and to detail the actions and proposed actions to be taken by the Hospital,
along with the timetable for these actions. Please see our responses below.

Concern 1

During the course of the inquest it was apparent that the standard of note keeping at
the Alexandra Hospital (both medical and nursing) was well below that which would
be generally regarded as satisfactory. There was even one attendance on the patient
by the consultant surgeon in February (according to the surgeon’s evidence to me)
for which there was no written record whatsoever. The surgeon conceded that he did
not have a full medical history available to him pre-operatively and he was not aware
of all the prescribed drugs which she was taking, (BMI Healthcare)

The patient record has been reviewed and this issue has been discussed directly with the
consultant surgeon and the nurse involved in the care of the patient. Whilst the majority of
the notes entered within the patient record are satisfactory, it is clear there were a number
of entries or omissions that were not of the standard expected.

The hospital expects and works to uphold, the highest standards of record keeping. At the
time of this response, hospital-wide completion of training on documentation and legal
aspects for patient records was 95%. Further documentation training has been scheduled
to be delivered by the Royal College of Nursing and we continue to work with all staff and
consultants to maintain and improve the standard of record keeping.

The consultant surgeon agrees that his hand written notes on occasion were very brief. As
he explained at the hearing, these were personal notes, which act as reminders when
writing dictated letters, which contained more detailed information. The consultant surgeon
will, in the future, ensure that he writes such information and clinical findings in more detail
in order to better comply with the guidelines of the Royal College of Surgeons.

Mill Lane, Cheadle, Cheshire SK8 2PX
T0161 428 3656 FOI6! 491 3867 Einfo@bmihealthcare.co.uk www.bmihealthcare.co.uk

BMI Healthcare Limited Registered in Eng'and Number 216427C. Registered office BMI Healthcare House. 3 Paris Garden, Southwerk, London SEI 8ND.

The consultant surgeon accepts that one post-operative visit to the patient was not
documented. He recalls that the patient was not on the ward when he visited but he met her
outside the building and walked her back to her room and consequently he omitted to write
this interaction in the notes. The consultant has reflected on events and has confirmed that
he will work to ensure that each visit to a patient is recorded in the patient record.

The consultant surgeon fully appreciates the importance of understanding details of past
medical history and medications. However, the consultant surgeon has advised that no
such information was provided by the patient's GP, (who would have provided details of the
patient's past medical history on referral) and neither Mrs Ellams nor her husband provided
such information when asked in the clinic. The consultant does however accept that more
could be done to elicit past medical history when discussing treatment with patients and he
will work to ensure that additional enquiry of the patient history is made.

We have taken the following actions:

1. From June 2015 a new documentation standards audit has been established. The
audit is completed by nursing staff and any variances, omissions or errors are
recorded and the results shared through a peer review to ensure learning is shared
and improvements made, where identified.

2. The company lead for care pathway development has been asked to attend the
hospital to deliver education sessions on the completion of patient care pathways to
all clinical staff. The delivery of this training is expected to be complete by the end of

October 2015.

3. The Royal College of Nursing have been invited to attend the hospital to deliver
presentations to nursing staff on the importance of documentation standards. This
training is expected to be complete by December 2015.

Concern 2

The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from
hospital even though it is now clear that her oxygen saturations were still too low for
such discharge to take place. There was what appeared to be a very lax attitude to
recording and monitoring the Blood/Oxygen levels and the patient was allowed to
disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI

Healthcare)

The consultant confirmed during the hearing that the patient's oxygen saturation readings of
90-92% would generally be adequate in view of her cigarette smoking and the recorded
oxygen saturation level was 89% on the morning of discharge when the nurse decided to
commence oxygen. It is unsatisfactory that information regarding the patient's oxygen
saturation level prior to discharge was not recorded. The consultant and the nurse accept
that all actions and decisions taken must be clearly documented in the patient record.

The nurse has reflected on her note keeping on that day, and admits that she should have
documented Mrs Ellams’ observations while off oxygen, before discharge. It should be
appreciated that there are difficulties in attempting to stop patients who wish to smoke
outside of the hospital premises, especially on the day they are due to be discharged. As
discussed at the hearing, the nurse made a clinical assessment of the patient's condition
due to the patient frequently removing the oxygen to leave the ward to smoke a cigarette,
and walking up and down the hospital corridor and stairs with no signs of shortness of
breath at the time. Having reflected on events, the nurse now always ensures that all

observations are recorded in the patient notes.

We have taken the following actions:

1. During September 2015 all relevant nursing staff will be notified that nursing notes
should always include a record of observations taken after patients have been taken
off oxygen.

2. Following the hearing, the nurse involved was reminded of her responsibility for

accurate record keeping and has reflected upon events and clearly recognises that
judgements in relation to the clinical presentation of a patient must be documented

in the patient record.

We have taken the matters of concern identified in your report extremely seriously and |
would like to assure you that the actions identified above are ongoing and will be continually

monitored.

| trust the responses given above have addressed your concerns and may | take this
opportunity to again express the Hospital’s sincere condolences to Mrs Ellams’ family.

Yours sincerely
Stee

Sarah Agnew
Acting Executive Director