Caroline Robey

Sent via Post and Email to: 

STRICTLY PRIVATE AND CONFIDENTIAL 
Addressee Only 
Mrs LC Brown 
Assistant Coroner 
Leicester City &  South  Leicestershire 
The Town Hall 
Town Hall Square 
Leicester 
LE1  9BG 

,,,1:kj

England

Midlands & East (Central Midlands) 
Medical Directorate 
Fosse House 
6 Smith Way 
Grove Park 
Enderby 
Leicestershire 
LE191SX 

16 March 2016 

Dear Mrs  Brown 

Re:  Regulation 28:  Report to Prevent Future Deaths 

I  write  in  response  to  the  Regulation  28  Report  to  Prevent  Future  Deaths  sent  to 
NHS  England,  Central  Midlands  and  confirm  that  this  case  was  discussed  at  the 
Performance Advisory Group (PAG),  held on Wednesday 24 February 2016. 

The remit of the  PAG  is  to  consider all concerns  raised  any relevant information  and 
recommend  options  for  the  management  of these  according  to  the  NHS  England 
Framework for Managing Performer concerns. 

The information reviewed included: 

•  The Coroners Regulation 28 Report 
•  Patient Medical Records 
•  Central Nottinghamshire Clinical Services (CNCS) Serious Incident (SI)  report 
  response  to  Assistant  Coroner,  background  information  and 
• 

Sepsis Screening Toolkit poster 

• 

 reflective report 

The  PAG  considered  the  case  and  concluded  that the  following  actions  should  be 
undertaken: 

• 

  has  been  requested  to  reflect  on  his  record  keeping  at  his 
next appraisal  and  on the diagnosis and treatment of patients with  suspected 
sepsis. 

The  PAG was assured that 
 had shown significant reflection  and  learning 
into  this  case  and ,  having  considered  the  options  put forward,  agreed  to  close  this 
case within the Practitioner Performance Team process. 

Continued/ ... 

High quality care for all, now and for future generations 

 
 
 
 
 
 2. 

16 March 2016 

NHS England  has,  through  the  local  medical  committee,  highlighted  the  importance 
of diagnosing sepsis and the use of the sepsis screening tool (attached). 

Yours sincerely 

 MB ChB MD FRCGP 
Medical Director and Responsible Officer 
NHS England, Midlands & East (Central Midlands) 

High quality care for all, now and for future generations 

 
 General Practice Sepsis Screening and Action Tool 

Sepsis  is a time critical condition.  Screening,  early intervention and  immediate treatment saves  lives. 

This tool should be applied to all  adult patients who are not pregnant who have a suspected 
infection or their clinical  observations are outside of normal limits 

Patient groups to consider screening: those in whom you are considering antibiotic 
prescription or stewardship discussion,  patients with "Flu", patients with gastroenteritis and 
the unwell patient without clear cause. 

I. Might this be more than a self-

N 

limiting infection? 
Symptoms of infection (e.g.  a recent h,storyoflever) 
Acute deterioration 

Unexplained illness,  especially 1n 
1mmunosuppressed or elderly people 

y 

2. Perform a full set of observations. 

Are any 2  of the following present? 

N 

>  38.3°c  or <  36°C 

Temperature 
Respiratory rate  >  20 per minute 
>  90 per minute 
Hea1t rate 

Acute confusion, disorientation,  reduced conscious level 
Consider blood glucose: >  7.7 relevant 1n  non-diabetics 

3.  Is any red flag present? 

Systolic B.P  <  90 mmHg 
Heart rate  >  130 per minute 
Respiratory rate >  25 per minute 
Oxygen saturations  <  91 % 
(may be approprrate lo accept Sp02 < 91 %  ,n patient, w,to loov.m COPD) 
Responds only to voice or pain/ unresponsive 
Purpuric rash 

N 

Y 

THEUK 
SEPSIS 
TRUST 

Sepsis  unlikely. 
Continue usual care. 

Sepsis may be present 
Evaluate whether acute 
referral / admission 
required,  especially if: 
-already on antibiotics 
-partially treated 

-no clear source of infection 
If treating in the community, 
consider: 
-planned second assessment 
-brief written handover 

documenting observations 
-specific safety net advice 

Red  Flag Sepsis 
This  is  a time critical condition, 

immediate action is  required. 

Dial 999 
An·ange blue light transfer 
Write a brief clear handover including 
observations and antibiotic allergies where 
present. 

Administer  oxygen  and  other  appropriate 
immediate care as available'

East Midlands Ambulance Service NHS)

NHS Trust

Emergency Care | Urgent Care | We Care

Trust Headquarters

1 Horizon Place

Mellors Way

Nottingham Business Park
Nottingham

NG8 6PY

Telephone: 0115 884 5000
Fax; 0115 884 5001
Website: www.emas.nhs.uk

Mrs L. Brown
Assistant Coroner
The Town Hall
Town Hall Square
Leicester

LE1 9BG

11" December 2015
Dear Mrs Brown
Re: Report to Prevent Future Deaths in the case of Caroline Elisabeth Robey

Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 16" October 2015, bringing to
my attention the Coroner's concerns arising from the inquest into the death of Mrs Caroline Elisabeth
Robey.

| would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to
patient safety are taken extremely seriously. The delivery of high quality, evidence based care is at the
heart of the Trust's clinical strategy. This work is continuous, however, | trust you will take assurance
from the measures outlined in this response which are pertinent for the time-frame from the date of Mrs
Caroline Elisabeth Robeys' death to the present day.

The concerns defined in the Prevention of Future Death notice pertaining to the inquest into the death of
Mrs Caroline Elisabeth Robey:

1. No Sepsis Screening tool was used by the community health providers, and so opportunities
were lost to consider the diagnosis of sepsis and refer as an emergency for hospital admission
and treatment.

2. A patient safety alert was issued on the 2 September 2014 by NHS England clearly sets out
the resources available in the provision of a UK Sepsis clinical tool kit, but this has not be
recognised or adopted by health care providers in this case.

3. Inadequate note was made of the number of different attendances Mrs Robey had initiated
despite previous good health, and there is no suggestion that she was a frequent attender or had
ever sort medical attention inappropriately.

|

17 DEC 2015

East Midlands Ambulance Service NHS}

NHS Trust

Emergency Care | Urgent Care | We Care

Background

East Midlands Ambulance Service (EMAS) serves a resident population of 4.8million across the East
Midlands region (Derbyshire, Leicestershire and Rutland, Lincolnshire (including North and North East),
Northamptonshire and Nottinghamshire), across 6,425 square miles. Each year we respond to over
616,000 emergency and urgent calls.

Sepsis screening tools

In March 2015 EMAS introduced an updated sepsis screening tool (both adult and paediatric) based
upon the Sepsis 6 red flags and NHS England Safety Alert (2014) (appendices 1a and 1b). Prior to this
EMAS had in place a generic sepsis screening tool based upon the same features as the updated tool
but did not have specific paediatric element included (appendix 2).

In addition to the Sepsis screening EMAS has in place the Paramedic Pathfinder Triage tool (PP). The
PP Triage tool is a pre hospital assessment guide based around the widely used and validated National
Early Warning Score. This is an objective screening tool which is based upon both physiological
parameters and clinical presentations to allow for safe See and Treat care and also to ensure the early
recognition of the sickest patients requiring Emergency Department admission. . Since its introduction in
April 2014 94% of staff have completed training. The application of this tool in this case would have
required Emergency Department conveyance based upon the presenting symptoms. A copy of the PP
tool can be found in appendix 3.

Communication and Education

As a part of our annual education programme for 2014/15 Sepsis assessment and management was
included for all clinical staff and continued into the 2015/16 plan to allow for all staff to undertake this
education. The educational material for this is found in appendix 4. In addition to educational material,
awareness of staff has been promoted via clinical bulletins issued over the period of the last four years.
Following this incident a further clinical bulletin has been issued to highlight the learning gained from this
incident and other cases where Sepsis management could have been improved (appendix 5).

In addition to our allocated annual education programme Paramedic Pathfinder has been delivered as an
additional face to face education session to all clinical staff from 2014. This tool was primarily launched
for Paramedics but has now been extended to include other qualified clinicians within EMAS.

As with any patient safety incident or incident investigation learning is taken both organisationally and at
an individual clinician level as required. In such cases, as a part of the investigation process, the EMAS
organisational learning team is utilised to develop support programmes for any member of staff noted to
have a linked educational need or support. It is essential that learning is taken across all levels; this
ensures that responsive changes to practice are achieved. In this case a supportive programme was
provided to the clinician both as a supportive and developmental measure. This process is supported by
a number of key policies within EMAS such as the Supporting Capability Policy.

East Midlands Ambulance Service NHS)

NHS Trust

Emergency Care | Urgent Care | We Care

| trust that the measure and safeguards cited above and evidenced in the appendices provide you with
the appropriate level of assurance in relation to the commitment and planning of EMAS in relation to
patient safety and the management of suspected sepsis.

Yours Sincerely

Ss

Sue Noyes
Chief Executive

INHS)

West Leicestershire
Clinical Commissioning Group

CCG Headquarters
55 Woodgate
From the office of: Loughborough
Telephone: Leicestershire
Your ref: CEM/GA/00705-2015 LE11 212
Tel: 01509 567 700
Fax: 01509 567 792
11 December 2015
H.M Coroner
For Leicester City and South Leicestershire
The Town Hall - - —
Town Hall Square | =
Leicester T
LE1 9BG

Dear Mrs Mason

Re: Caroline Elisabeth Robey — Regulation 28 Report Sa

| write further to your report made in accordance with paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

As outlined within your report, it is considered that action should be taken to prevent future
deaths and that NHS West Leicestershire CCG has the power to take such action. | am now
in a position to provide you with the following information.

| would firstly like to clarify that NHS West Leicestershire CCG is the commissioner of the
Loughborough Urgent Care, with Central Nottinghamshire Clinical Services (CNCS)
providing the clinical services from the Loughborough Urgent Care Centre. This response
has been jointly prepared by both the CCG and CNCS.

| can confirm that the matters raised Mrs Robey's care has been formally reported as a
Serious Incident (SI) and is being managed through the CCG's SI process.

| will now respond to each of your specific requests for information in turn.

No sepsis screening tool was being used by the community health care providers, and so
opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for
hospital admission and treatment

Please see the enclosed action plan developed by the Loughborough Urgent Care Centre.
As you will note, an organisational sepsis policy has been developed and during April and
May 2015 all staff at the Loughborough Urgent Care Centre completed a training course in
sepsis recognition. In addition, work is currently ongoing at the Loughborough Urgent Care
Centre to implement the sepsis6 pathway.

a Patients, Practices, Partners

A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources
available in the provision of a UK sepsis tool kit, but this had not been recognised or adopted
by the health care providers involved in this case

| would again refer you to the enclosed action plan developed by the Loughborough Urgent
Care Centre. As you will note, an approved system to review and implement patient safety
alerts at the Loughborough Urgent Care Centre will be developed by January 2016, with
regular assurance reports subsequently provided to the Clinical Governance Committee at
CNCS on the implementation of all relevant Patient Safety Alerts.

In addition, the CCG's Head of Infection Control has arranged for an email to be circulated to
all GPs within Leicester, Leicestershire and Rutland (LLR) entitled ‘Managing Sepsis’ as
follows:

In September 2014 NHS England issued a Stage Two Patient Safety Alert relating to
the prompt recognition of sepsis and the rapid initiation of treatment. This alert was
sent out to all GP’s by NHS England via the CAS system on 3 September 2014. The
aim of the alert was to raise awareness of sepsis and signpost GP's to a set of
resources developed by the UK Sepsis Trust, and others, to support the prompt
recognition and initiation of treatments for all patients suspected of having sepsis.
Following a Coroner's case the CCG has re-issued the alert reminding GPs of the
need to ensure staff have access to both adult, paediatric and infant sepsis screening
and action tools that can be used for patients presenting on first attendance or
developing suspected infection. Staff are reminded that the resources should now
have been introduced into clinical practice, in particular the administration of
antibiotics within one hours of suspicion of sepsis. The UK Sepsis Trust Toolkit:
General Practice management of Sepsis guidance is available at:
http:/sepsistrust.org/wpcontent/uploads/20 15/08/1409322498GPtoolkit2014.00f

| can further confirm that a WLCCG Board GP, Dr Chris Barlow, has a meeting arranged
with Dr John Parker, a Critical Care Consultant at the University Hospitals of Leicester
(UHL), on 15 December 2015; as UHL have successfully implemented a number of quality
improvement projects for sepsis in UHL, they have offered to meet with the CCG with the
aim of sharing their experience/materials and to provide support in ensuring that staff have a
developed understanding of the management of sepsis.

Following the above meeting, a Protected Learning Time (PLT) event will subsequently be
arranged to further raise awareness of sepsis within primary medical care.

Inadequate note was taken of the number of different attendances Mrs Robey had initiated
despite previous good health, and there was no suggestion she was a frequent attender or
had ever sought medical assistance inappropriately

| would again refer you to the enclosed action plan developed by the Loughborough Urgent
Care Centre. As you will note, a clinical newsletter was circulated in July 2015 to alert
clinicians at the Loughborough Urgent Care Centre to key learning points from the case of
Mrs Robey. In addition, the Loughborough Urgent Care Centre are in the process of
developing a Local Operating Procedure for multiple attendances, which is to be approved
and implemented by February 2016,

It is my understanding that the CCG’s Chief Nurse has liaised with the Head of Quality at
NHS England regarding the actions of the specific GPs involved in Mrs Robey's care and
has received assurances that Dr Khokar has been referred to their Professional & Practice
Information Gathering Group (PIGG) to review their individual performance as a practitioner.