Wilfred Pearson

Tameside Hospital INHS|

NHS Foundation Trust

Quality & Governance Unit
Tameside General Hospital
Fountain Street
Ashton-Under-Lyne
Tameside

OL6 SRW

\: Telephone: 0161 922 4466
v Fax: 0161 922 6190

Date: 18° March 2016
Your Ref; JSP/ER/01169-2014

Mr John Pollard

Senior Coroner for Manchester South
The Coroner's Court

1 Mount Tabor

Stockport SK1 3AG

RECEIVED
24 MAR 2016

Dear Mr Pollard,

Re: Regulation 28: Report to Prevent Future Deaths following Inquest into the death
of Wilfrid Pearson (Deceased)

| write further to your letter received on the 5° March 2016 enclosing a Regulation 28
Report issued at the conclusion of the inquest touching upon the death of Wilfrid Pearson,
which took place on 22" February 2016. | am, of course, very sorry that you had cause to
issue this report.

| hope to be able to address your concerns, as set out in section 5 of your report, to your
satisfaction, in this letter. | have addressed the areas of concern, adopting the same
numbering in section 5 of your report as follows:

You stated:
1. The protocol for the observation, diagnosis and treatment of Status Epilepticus was

written by the Consultant Neurologist who gave evidence to me. There was some
doubt as to whether the document had been properly updated and whether and
how it was promulgated fo all the relevant medical staff including locum doctors.

| am informed that since Mr Pearson's admission in April 2014 nearly two years ago, Dr
Douglass has revised the Trust's Status Epilepticus Policy on two occasions, Firstly in
direct response to the admission of Mr Pearson and additionally at the time of review in
2015. The policy has been revised to assist clinicians in being able to more easily review
and understand the appropriate steps to take when a patient presents with Status
Epilepticus. The revisions were made by direct reference to recent guidance on Status
Epilepticus published in the Lancelet Medical Journal. Please find enclosed a copy of our
current policy.

As well as making improvements to the Trust's local policy, steps have been taken to
ensure all clinicians at the Trust have awareness of the policy. It has been included as
part of the training of Junior Doctors, and has been discussed with the Trust's medical
teams. The policy is also easily available for clinicians on the Trust's intranet.

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Tameside Hospital INHS|

NHS Foundation Trust

The Trust's Education Department have confirmed that Status Epilepticus Policy will now
be included as part of the Junior Doctor Grand Round (this is the training programme that
all Junior Doctors must complete).

The Trust's intranet has a search facility for documents which directs staff seeking
guidance to documents including the Status Epilepticus Standards. The search also
directs staff to the NICE Guidance Quality Standards for Epilepsies.

2. The medical and nursing notes left much to be desired in terms of their clarity,
accuracy and completeness

| am disappointed that HM Coroner found the medical and nursing records left much to be
desired and | am sorry that you found this to be the case. HM Coroner will be aware that
individual nursing and medical clinicians are responsible for their own professional
standards. The Trust.has_a_ standard for medical record keeping and expects_records-to
be timed and reflect an actual chronology.

The Clinicians carrying out the assessment should document the time the assessment was
carried out as well as the time of the medical entry. This is our Trust standard and the
Trust encourage and promote this.

The Trust has, since Mr Pearson’s admission, revised some of the nursing documentation
and reinforced the role of Ward Managers and Matrons in monitoring the quality of
documentation completed by staff.

The Trust's Clinical Audit programme, the Trust's Clinical Lead for Clinical Audit has been
working with doctors in training and audits have been undertaken which include key
aspects of medical clinical documentation.

3. There was no understanding of the need for and method of escalation of the care
to the HDU or ITU and indeed according to the expert witness instructed by the
Trust the impression is that the ITU doctors did not consider that the brain
protection was a high priority in Mr Pearson's case

The decision to escalate a patient to critical care is ultimately a clinical decision made by
clinicians based on the patient's clinical picture at a point in time. The Trust has a standard
for the admission and discharge for Critical Care which provides guidance for clinical staff
on the process for admission/escalation and this was revised in May 2014 to include
further detail in relation to the National Early Warning Score and escalation and reviewed
again in May 2015. This is available to staff on the Trust's intranet.

The Critical Care Unit and the processes and pathway for Critical Care have been subject
to extensive change since April 2014 and have been subject to independent third party
review and inspection. They have been reviewed by the CQC as an independent third
party in April 2015.

4. There appears to have been a huge stress on the junior medical staff and | was
told that the ITU Registrar refused to attend the Ward but it is not normal for the
ITU registrar to refuse to attend and one of the junior doctors said that we were
short staffed and overstretched. This seems to have added to the omissions of
care which were apparent.

The Trust recognises observations made by HM Coroner that in many NHS Trusts
nationally medical staffing is challenging and that due to the national availability of staff
there has been a reliance on locum medical staffing at Tameside Hospital particularly in
emergency and acute medicine areas. The Trust also acknowledges that the quality of
care patients receive is dependent on the support and continuity of substantive staff who
know the hospital and the policies and procedures. This is why we have taken medical
staffing very seriously.

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. . a
Tameside Hospital [i"/ehy¥
NHS Foundation Trust

Since the time of mr Pearson’s admission the rotas for medical staffing have been
reviewed to maximise appropriate levels of senior cover and to monitor the levels of

medical staffing.

These take into account the mix in relation to substantive staff and locum staff. The Trust
maintains an ongoing recruitment programme and has been working with Health
Education North West and junior doctors to improve the experience of junior doctors in
training and to attract medical staff long term.

Additionally the engagement and support provided to Junior Doctors and cover provided
by Consultants has been actively reviewed by the Medical Director alongside other work
which forms part of the processes for the medical staff revalidation programme. The Trust
has also implemented more robust monitoring of study leave and staff sickness these
include ‘keep in touch’ days. and ways in which staff who are on sick leave can be
supported back to work even if they are not clinically active to provide advice and guidance

to colleagues.

5. The deceased “absconded”. He was brought back to the ward by security. | was
told that no DOLS order was made or even contemplated, and he was not subject
to compulsory detention under the Mental Health Act, therefore one has to ask
where they derived the Legal Authority to detain the patient?

Again | am disappointed and concerned that HM Coroner found that it was unclear where
the Trust derived that Legal Authority to detain the patient. | would like to take this
opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of
work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion
of when a DOLS is to be considered.

The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in
May 2014 and who also monitors that processes are followed. The Trust works closely
with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS
training sessions have been held in the Trust provided by an external expert in Mental
Capacity and DOLS this is open to all staff in the Trust. in addition Weightmans LLP have
provided four sessions of Mental Capacity Training in September and October of 2015 for
medical staff and Consultants. The Trust has another session scheduled for May 2016. To
further promoted the principles of DOLS and ensure staff are aware of these the trust has
promotes this through the Trusts communication including my Chief Executive Bulletins
‘Catch up with Karen’ and posters have been distributed and displayed across the Trust.
The Quality and Governance Team monitor DOLS and the timescales and a report is
produced weekly which provides an update to the Director of Quality and Governance on
the status of DOLS.

Since the admission of Mr Pearson the Trust has undergone two CQC visits during which
we have been challenged and scrutinised against the Trusts processes in place for
Safeguarding Adults and Mental Capacity. We have been deemed to have improved these

significantly.

| am very sorry you had cause to issue this Regulation 28.

| would like to take this opportunity to emphasise that | do take your concerns very
seriously. | hope that | have responded to your concerns and reassured you of all that the

Trust has already undertaken and is currently undertaking, in order to prevent the
recurrence of a similar set of circumstances in the future.

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Tameside Hospital INHS|

NHS Foundation Trust

Should you have any further questions arising from the contents of this letter, please do
not hesitate to contact me.

Yours sincerely

WD

Katen James
Chief Executive

cc. Monitor
cac
Tameside and Glossop CCG

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