Sandra Wood

Maidstone and Tunbridge Wells

NHS Trust

28 April 2015

Mr Roger Hatch ; Deputy Chief Executive
North West Kent Coroners Officers Office Maidstone and Tunbridge Wells NHS Trist
The Old Town Hall Maidstone Hospital
High Street Hermitage Lane
Gravesend Maidstone
DA11 0AZ Kent ME16 9QQ

Tel 01622 228925

By post and email: NWKCoroner@kent.gov.uk Email

Dear Mr Hatch

Regulation 28 Report to Prevent Future Deaths following the inquest of Sandra Rhoda
Marion Wood who died at Maidstone Hospital on 18 April 2015

| am writing to respond to the concerns you raised during your investigation into the death of Sandra
Wood, and to explain the actions that Maidstone and Tunbridge Wells NHS Trust has taken in order
to address those concerns.

1) The NHS Trust does not have facilities for routine CT scans to be carried out during
weekends.

| want to start by assuring you that we do have facilities to provide CT scans to our patients during
the weekend and that we carry out CT scans on all patients that require them, based on a clinical
decision.

Over the weekend of 18-19 April 2015 (when Mrs Wood died) we carried out 139 CT scans on
patients, based on a clinical decision for each patient.

The challenge to provide a like-for-like weekday and weekend service is not unique to this Trust,
and like all NHS Trusts we strive to operate in a climate of limited resources and budget constraints
set by central government.

Similar to other Trusts, we provide ‘routine’ CT scanning through the week and during the daytime
on Saturday and Sunday as those are the times when we can accommodate a greater throughput of
scans and can provide the service for both routine (non-urgent) and urgent cases. Out of hours we
provide an emergency service but it must be emphasised that there is no restriction on the number
of emergency scans that can be performed.

2) If an urgent CT scans (sic) are necessary a specific application procedure has to be
put in place.

Chairman: Tony Jones Chief Executive: Glenn Douglas
Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ
Telephone: 01622 729000 Fax:01622 226416

Maidstone and Tunbridge Wells NHS

NHS Trust

Respectfully | would refer you to my response at (1) above, and restate that the decision whether or
not to scan a patient is based on nothing other than clinical judgement based on the patient’s
condition.

The perceived barriers presented by our procedure for obtaining CT scans out of hours was a
concern raised by HM Coroner Patricia Harding in the Preventing Future Deaths report made on
conclusion of the inquest touching the death of Christine McNamara.

Without rehearsing my response, | am happy to assure you that there is sound reasoning behind
our procedure. Patients fall under the care of consultants, but spend more time being actively
treated by junior doctors. To ensure that patients are appropriately escalated for treatment of a
worsening condition (in the full knowledge of the treating consultant) it is necessary to ensure that a
consultant is aware when a patient is to be sent for a CT scan at all times. On weekdays when
consultants are more readily available on-site within the Trust these referrals are less noticeable
than out of hours or on weekends, but the procedure is always in place.

| attach for your information, a copy of our access policy for out of hours CT imaging. This policy is
in effect daily for the period 10pm — 7am. During the time period 8pm — 10pm the referrers contact
the on-call radiologists, and between 7am — 8pm there is access to the radiologist within the
department and scans can be discussed face to face.

| think it is helpful to highlight that CT scans are only one diagnostic too! of many at our disposal
and, in accordance with s.6 of The ‘lonising Radiation (Medical Exposure) Regulations 2000'
(IR(ME)R) we are required to justify that there is sufficient net benefit (when weighed against the
risks of radiation exposure) before scanning a patient. Given the level of skill required and
repercussions of unwarranted scans, the responsibility for that decision rests with our consultants.

3) In this case despite the requirements for an urgent scan to be undertaken in a
potentially emergency situation the scan was to be delayed until after the weekend,
which proved to be too late due to the fact that Mrs Woods died on Saturday 18" April
2015.

As a learning organisation the Trust is keen to ensure that we review and learn from clinical cases
to continually improve and acknowledge this is a distressing time for Mrs Wood's family. In the case
of urgent scans, there has been careful consideration of our systems and processes and we can
provide assurance that where urgent scans are deemed to be required based on the clinical
situation, that they are undertaken in a timely way.

In this particular case the evidence provided by Drs Nguyen, Ibrahim and Smith indicated that the
clinical presentation of Mrs Woods did not merit an urgent CT scan; Mrs Wood had no bowel
distension, her bowel was soft and non-tender on examination and her x-ray results (which would
highlight signs of obstruction) were unremarkable, as were her blood and urine test results.
However, the Trust has taken the opportunity to re-iterate the processes in place to clinical staff
regarding the availability of CT scanning 24/7 for urgent cases.

Chairman: Tony Jones Chief Executive: Glenn Douglas
Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ
Telephone: 01622 729000 Fax:01622 226416

Maidstone and Tunbridge Wells INHS

NHS Trust

The Trust strongly concurs that where there is a clinical indication CT scans should be undertaken
regardless of day or time.

| want to thank you for taking the time to bring your concerns to my attention, and | trust that this
response is to your satisfaction.

Yours sincerely

Gi

Jim Lusby
Deputy Chief Executive

Enc

1. Access policy for out of hours CT imaging

Chairman: Tony Jones Chief Executive: Glenn Douglas
: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ
Telephone: 01622 729000 Fax:01622 226416