Alwyn Head

Medway

NHS Foundation Trust
CHIEF EXECUTIVE’S OFFICE

Direct Line 01634 833944 i la st ss

Email: Windmill Road
mail: Gillingham
Kent

Our Ref: LD/mijc ME7 BNY
18 April 2016 01634 830000

Strictly Private & Confidential

Ms Patricia Harding

Senior HM Coroner Mid Kent & Medway
Kent Register Office

The Archbishop’s Palace

Mill Street

MAIDSTONE

Kent ME15 6YE

Dear Ms Harding
Regulation 28: Report to Prevent Future Deaths: Alwyn Ann Head (“the Report”)

| refer to your Report issued following the inquest pertaining to Alwyn Head and reporting the
circumstances of the death to me, pursuant to Regulation 28 of the Coroners (Investigations)
Regulations 2013.

The Trust has sent a letter of apology to Mrs Head’s family and has offered to meet with them to
discuss the circumstances of her death, and the actions taken by the Trust as part of our coronial
investigation process.

A full investigation was carried out following Mrs Head’s death and a copy of the actions from that
investigation are provided to you within this response (Appendix 1).

" [can confirm that lessons have been learnt and the Trust has changed its practice to minimise the
chance of any other family having the same experience.

| will address the specific issues that you identified in your Report of 23 March 2016, as follows:

1 That Mrs Head had a history of MRSA that was not established prior to surgery despite
opportunities in 3 different hospital departments to obtain this information from Mrs Head or
her family.

We acknowledge that although Mrs Head had a history of MRSA this was not established prior to the
surgical procedure. We have therefore introduced a series of measures to reduce the risk of this
situation re-occurring, which are:

e New admission/transfer assessment documentation of patient infection status was introduced
in April 2016.

e Staff are made aware of the new documentation on the twice monthly level 3 infection control
update sessions.

e As part of their daily routine patient reviews the infection control team are checking the new
documentation has been completed and provide the nursing staff with feedback at the time.

Delivering high quality healthcare’
An Associate Teaching Hospital; of the University of London
www.medwaymaritimehospital.nhs.uk

+2
LD/mjc
18 April 2016

e The outcome of the patient reviews are reported monthly and areas of poor compliance will
receive additional support from the infection control team.

e The new documentation will be incorporated into a new nursing patient assessment / care
planning document which is due to be implemented in July 2016.

2 Prophylactic Teicoplanin was not provided pre or post operatively even though the results
of the MRSA Screen would not have been available at the time of the surgery (MRSA -ve
written on pre-op form erroneously)

We have recognised the importance of ensuring that MRSA status is checked and appropriate
antibiotic regime applied. The orthopaedic antimicrobial guidelines have been updated to provide
more clarity over the prophylaxis for patients with unknown MRSA status.

The surgical safety checklist is being amended to ensure MRSA status and MRSA History is verified
by two staff and with the patient pre operatively in the Anaesthetic Room before induction and again
with the whole theatre team at ‘sign in’.

3. A post-operative wound care plan was not instituted contrary to NICE guidelines and

4. There was no evidence of the surgical wound having been inspected by nursing staff or
doctors between 13th August and 25th August 2015 and

5. Entries in the nursing notes relating to dressing and wound were meaningless and would
not assist a determination of whether there was deterioration in the wound.

We are updating our tissue viability policy and associated standard operating procedures (SOPs) to
include NICE guidance and standards for post-operative surgical wound management.

Wound care documentation, care plans and wound assessment standards have all been reviewed.
The wound care documentation will be incorporated into the new nursing assessment / care planning
document in July 2016.

The documentation and standards will be presented to the Trust Patient Safety Group and the
Nursing & Midwifery Quality Forum. Directorate representatives will be responsible for cascading the
information through their Directorate.

Compliance with the policies and SOPs will be monitored as part of our established assurance audits.
Results of audits are presented at Patient Safety Group which has responsibility for monitoring
compliance in this area and the Nursing & Midwifery Quality Forum. .

In addition, the recognition and management of Sepsis and the Deteriorating Patient are key priorities
for the Trust. A programme of work has commenced which aims to improve patient safety, outcomes
and reduce the incidence of deterioration and sepsis, through early recognition and timely response.

Summary of actions:

e Ward to Board rounds to assess and monitor patients’ conditions more regularly

e Deteriorating Patient Programme commenced in January 2016 which includes three key work
streams - 1. Recognise 2. Respond, 3. Data Quality

e A multi-disciplinary Sepsis Action group is in place which monitors performance against the
Sepsis six bundle, the National CQUIN performance and sepsis mortality.

e The Trust has provided feedback to the NICE consultation on the proposed new Sepsis
Guidance (due to be published in July 2016).

Delivering high quality healthcare’
An Associate Teaching Hospital; of the University of London
www.medwaymaritinehospital.nhs.uk

aii
LD/mjc
18 April 2016

Trust representation at the Sepsis Nurse Forum.
Monthly auditing against the Sepsis bundle

A robust Education and Training programme in place
Learning events have commenced across the Trust

The Standardised Mortality Ratio for patients with a primary diagnosis of Septicaemia is currently the
lowest it has been in the last two year period. This reflects the work undertaken currently.

The learning from our investigation into Mrs Head’s death has been shared with the specific ward and
also Trust wide.

| hope you will agree that the learning points have been acted upon, and the actions developed
following Mrs Head’s death continue to be actively and robustly implemented and reviewed. Although
we know that we will never eliminate risk completely, the action plan will continue to be addressed
and monitored via the Trust’s Governance processes to ensure that we reduce our risks to the lowest
level possible.

We apologise unreservedly to Mrs Head's family for any distress and anxiety caused by us.

Yours sincerely

Lesley Dwyer
Chief Executive

}

Encl: Appendix 1: Action Plan

Delivering high quality healthcare’
An Associate Teaching Hospital; of the University of London
www.medwaymaritimehospital.nhs.uk