Thelma Jones

Brighton and Sussex NHS |

Your ref: VHD/LP/INQ University Hospitals
Our Ref: MK/CD/C9/15/35 NHS Trust

5 November 2015
Headquarters
The Royal Sussex County Hospital
Eastern Road

Miss Veronica Hamilton-Deeéley | Brighton
Coroner's Office BN2 5BE
Woodvale

Lewes Road Tel: 01273 696955
BRIGHTON

BN2 3QB

Dear Miss Hamilton-Deeley,
The Late Mrs Thelma Patricia Jones

Thank you for your letter of 13 August 2015 enclosing the Regulation 28
Report outlining the two matters that cause you the most concern, namely
AMU and the NEWS scores and thank you also for agreeing to extend the
deadline date for a response to 7 November 2015

Would you please pass on our condolences to the family and friends of
Mrs Thelma Jones on their sad loss.

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. We
have carried out a careful review of the medical records with the
appropriate personnel.

AMU - Care and Discharge planning

The Acute Medical Unit has a daily bed/MDT meeting at which each patient
is discussed individually.

Mrs Jones was admitted to AMU on 16 February 2015 with diarrhoea and
fast atrial fibrillation/flutter. A chest X-Ray showed no acute findings,
inclucing no evidence of cardiac failure or infection. She was reviewed by a
Consultant at 18:24 and an initial diagnosis of Atrial Flutter/Fibrillation was
made with a query as to whether it was a new onset or secondary to
diarrhoea.

Mrs Jones was reviewed by a Consultant on four separate occasions
throughout the 17 February. She was given IV fluids, digoxin and Bisoprolol.

On 18 February 2015 Mrs Jones was again assessed by the Consultant and the
plan was to involve the Hospital Rapid Discharge Team (HRDT) as it was felt

the patient could be discharged if her eating and drinking were adequate
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and if her observations had returned to baseline. The records document her
blood pressure at 150/90, heart rate at 95, afebrile and oxygen saturations
on air at 98%.

On 19 February it was noted that Mrs Jones’ diarrhoea had settled and the
catheter was to be removed. The Hospital Rapid Discharge Team reviewed
Mrs Jones. They noted that she needed help at home, her mobility being
much decreased from baseline and they concluded that she was not ready
for discharge on that day. They noted that she may need in-patient
rehabilitation.

On 20 February 2015 Mrs Jones had loose stools and had vomited. A
stool sample was sent for testing. The HRDT reviewed her and noted that
the patient was still able to mobilise but that due to her diarrhoea and
decreased mobility she would benefit from extra support at home, i.e., a
tunch time call and occupational therapy and physiotherapy input. Mrs
Jones was referred to Community Short Term Services (CSTS) by way of a
faxed single assessment process (SAP) form.

On 21 February at 06:30 the patient became short of breath and
respirations increased to 28. She was placed on 02 therapy at 2 litres per
minute. She was reviewed by a Consultant and given 40 mg of oral
furosemide and IV fluids were stopped.

On 22 February Mrs Jones was again seen by a Consultant. She was still
receiving oxygen therapy but had had no vomiting and was no longer
overloaded. The plan was to wean her off oxygen and discharge her
home when the HRDT was happy, but it was noted that she would now
need to be transferred to a ward for physiotherapy and occupational
therapy.

On 23 February 2015 Mrs Jones’ condition deteriorated and she was
attended by the Medical Emergency Team and transferred to ITU.

Having reviewed the medical records we consider that there is evidence
that suitable care and treatment were provided and that discharge
arrangements were planned and coordinated.

NEWS scores after 9:45 23 February 2015

The medical records note that on the day of 23 February 2015 the NEWS
scoring is complete up to and including at 09:45 when it was scored at 8
whilst Mrs Jones was sitting in a chair.

Mrs Jones was then transferred to the bed where her observations were
repeated at 10:30. A change in her level of consciousness was noted at V
(responding to verbal stimulus) whereas previously it was noted as A (alert)
at 09:45. This triggered the medical emergency call (MET). There is no
score from this point, however the nursing notes, written retrospectively at
12:30 on 23 February also document this period of time,i.e, 10:30 and it is

recorded that the nurse was unable to determine Mrs Jones’ heart rate and
an ECG was recorded. The oxygen saturations remained reduced and a MET
call was initiated.

The general medical notes at 11:00 document the MET attendance on 23
February and there are 10 pages of completed general medical notes that
record the treatment given on this day, plus an ICU chart and separate
nursing notes.

A Critical Care Outreach Nurse was with Mrs Jones continually from the MET
call until 17:00. This involved stabilisation and transfer from AMU to the CT
scan and then to the theatre recovery until a bed was available on the
intensive care unit. Throughout this time Mrs Jones was on a cardiac
monitor which continuously recorded her ECG (rhythm and heart rate) and
blood pressure. There is clear documentation in the medical notes and her
observations continue to be recorded on an ICU chart from 14:00 on
23.02.15.

In summary it would not be expected that NEWS scores would be calculated
from the observations during a medical emergency response as the focus is
on rapidly treating and managing the patient. The NEWS is an early warning
system and it had fulfilled its function at the point a MET call was made.

As with all cases we have carefully reflected on the issues in this situation
and are open and committed to learning from such events. In this particular
case, the Trust believes that the medical notes contain appropriate detailed
information on the care and treatment given within AMU and in relation to
the NEWS scores. To that end we do not believe that remedial action is
necessary on the part of the Trust in this respect.

Thank you once again for raising your concerns with us.

Yours sincerely

Matthew Kershaw  aarraerrcom Fe
Chief Executive jief Nurse AMU Ward Manager