Robert Entenman

Care Quality Care Quality Commission
Commission Citygate

Gallowgate
Newcastle upon Tyne
NE1 4PA

BY EMAIL and POST
Telephone: 03000 616161

Ms. Henrietta Hill QC Fax: 03000 616171

London Inner South
Southwark Coroners Court
1 Tennis Street

London

SE1 1YD

www.cqc.org.uk

31 March 2017
Ref:

Care Quality Commission
Health and Social Care Act 2008

Dear Ms. Hill,

Re: Section 28 request for information from CQC regarding the Coroner’s
report into the death of Robert Entenman

Thank you for your Regulation 28 Report dated 3 February 2017 which identified the
CQC as a named responder in respect of the third area of concern identified during
the Inquest into the death of Mr Entenman. The concern being there were delays in
identifying that the endotracheal tube had become blocked between 5.32 and 6.00
am on 23 May 2015 which affected its earlier replacement, subsequent similar delays
and possible delays in providing information the suction catheter difficulties to doctors
who arrived after the cardiac arrest call was put out. This letter is the CQC’s
response to the issues raised by the Regulation 28 Report which is required by 31
March 2017.

Prior to the death of Mr Entenman, the CQC carried out a comprehensive inspection
of the Hospital on 13 December 2013, with the report published in January 2014. At
that inspection, the Hospital met all of the standards under the CQC’s model
inspection model of that time.

Inspectors found that:

Hospital staff were trained in the use of equipment. We reviewed the training records
for equipment in the operating theatre suite and saw evidence of training provided by
manufacturers. Staff also received training on induction to ensure that they had the
relevant knowledge, skills and competencies for relevant equipment.

The chief nursing officer and the medical director told us incident reporting was
encouraged. We were given examples during our visit of learning that had been
implemented as a result of reports. If human error was found to have contributed to
an incident there was an emphasis on retraining and subsequent reassessment of

competence.

The CQC was formally notified of the death of Robert Entenman on 1 June 2015.
The notification initially stated that this was an expected death. However, on 20
August 2015, the Hospital sent a further notification clarifying that this had, in fact,
been an unexpected death. On that notification, the Hospital stated that they were
carrying out a full Route Cause Analysis of the incident.

CQC inspectors monitor all enquiries and notifications relating to individual providers,
including statutory notifications, complaints or concerns from members of the public
and whistleblowing concerns. The decision to undertake unannounced, focused
inspections is informed by, but not dictated by such information. A single unexpected
death, where the provider followed its duty in informing the CQC, was undertaking an
RCA and there was a Coroner's investigation ongoing would not necessarily trigger
an unannounced inspection, unless in association with other related concerns. Such
incidents are, however, likely to be discussed at engagement meetings between
CQC inspectors and the provider.

The CQC requested a final copy of the RCA document as part of the inspection
process in 2016, and received this on 28 October 2016. The document had been
completed on 30 October 2015. It set out the background to the incident, the possible
causes and a proposed action plan to prevent the re-occurrence of similar incidents.
The CQC was satisfied that the actions set out in the RCA would be sufficient to
mitigate the risk of re-occurrence and, further, that those actions had been carried
out.

Actions included re-training for all nursing staff on humidification purpose, function
and monitoring, with one-to-one training for ‘key staff. The majority of the actions
were identified for immediate action, or to have been enacted by December 2015.
Other actions were audits and were therefore of an ongoing nature. The Hospital
have confirmed that all nursing staff have been re-trained on the humidification
purpose, function and monitoring. There is also a rolling programme for new starters
on the unit. Further, a weekly spot check was introduced for medical documentation,
following the Hospital’s auditing criteria. The Hospital has confirmed that the
InteliSpace Critical Care and Anaesthesia lead nurse carries out this check, the
audits are followed up and any learning from the audit is discussed with the
individual. The audits are also shared at the appropriate Critical Care forum.

Prior to the scheduled inspection of September 2016, enquiries relating to the
Hospital were re-examined to inform inspectors of areas to examine during the
inspection. During the inspection, inspectors were satisfied that critical care staff
were practicing safely and that clinical governance structures and training
programmes were sufficiently robust to ensure the delivery of safe care; mitigating
against the issues identified that led to Mr Entenman’s death. In particular, the
Critical Care inspector identified:

Leadership at a local level was excellent and staff told us about being supported and
empowered and enjoyed being part of a team. The service had reviewed its
governance arrangement in order to ensure it continually met best practice and
ensured its systems were robust and fit for purpose. There was an open, transparent
no blame culture.

Further;

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The CCU was part of the weekly records audit which ensured that quality checks
were undertaken before scanning documents. This resulted in action plans being
developed where non-compliance was found. CCU was found to be compliant with
these standards.

In November 2015 TLBH introduced a critical care daily safety briefing sheet. This
included any staff sickness or training issues, any specific problems with individual
patients, admissions, discharges and specific safety issues such as sepsis, breathing
problems, risk of pressure injuries or any new equipment being used. This was
attended by the RMOs, the duty hospital manager, senior nursing staff, outreach staff
and some Clinical Nurse Specialists. Roles were the allocated for the day such as
the lead for outreach, resuscitation lead and the runners’ roles.

This was followed up by a ward round at 9.30 am led by the consultant in charge
which was multi-disciplinary and included senior nursing staff, occupational health
staff, physiotherapists, dieticians, the diabetes nurse specialist and RMOs. The
purpose for this was to update staff on the condition of individual patients over the
night time period.

For further detail of the findings, please follow the link below to our full report:
http:/Awww,cgce.org.uk/location/1-126955902

Following its inspection of the Hospital, the CQC continues to monitor the care
provided through regular engagement meetings, notifications from the Hospital,
information from patients and whistleblowers. The next engagement meeting is due
to take place in April 2017. At that meeting, inspectors will discuss the Hospital’s
response to the Coroner and any additional actions it has assured the Coroner that it
will take.

Yours sincerely,

Head of Inspection — Hospitals, London South
Care Quality Commission

: : 27-29 Tooley Street
London Bridge Hospital London SE 2PR

T +44 (0) 20 7407 3100

F +44 (Q) 20 7407 3162
info.lbh@hcahealthcare.co.uk
www.londonbridgehospital.london

partot HCANealthcare UK

31* March 2017

Ms Henrietta Hill QC
Sent by email only

Dear Ms Hill QC

Regulation 28 Response following the Inquest touching the death of Mr Robert
Entenman

I attach the Regulation 28 Response made in relation to your PFD Report dated 3 February
2017. We have adopted a layout to enable you to cross-refer those areas of concern directed
towards London Bridge Hospital (“the Hospital”), with the actions which have since been
taken by the Hospital.

You will observe that the signatory to this document is P| President of
Operations at HCA.

Although your PFD Report was addressed to me as the Chief Executive Officer of the
Hospital, I was not in post at the material time that care was given to Mr Entenman, nor when
the majority of the steps were implemented at the Hospital to address the concerns. (I was
appointed Chief Executive Officer of the Hospital on 1 January 2017.)

The Chief Executive Officer of the Hospital at the material time was PY and who
has since been promoted to the position of President of Operations, HCA. It was considered
by HCA that it is more appropriate for to be the signatory to the Regulation 28
Response.

Tam advised I am entitled to make representations to you and to the Chief Coroner in relation
to whether or not some or the entirety of the Regulation 28 Response should be published.

As your PFD Report appeared on the Chief Coroner’s website on 19 February 2017, I would
invite the Chief Coroner and you to also publish this Regulation 28 Response. I request this
on the basis that your PFD Report identifies concerns, and which concerns are addressed in
the Regulation 28 Response. It would appear reasonable that any reader of your PFD Report
should be entitled to read of the steps taken by the Hospital in response to those concerns.

If I can provide any further assistance, please do not hesitate to contact me.

Yours sincerely

mma,

Janene Madden
Chief Executive Officer

HCA Realtheare UK is a trading quipe for HCA [nternational Limited. HCA Intemational Limited is a private timited company reglstered
in England ond Wales. Registeced No.03G20522. The registered office addtess fs situated ot 242 Marylebone Road, Loton NWI BIL

Blostoms Healthcare HCA Hoaltheare UK Joint Ventures London Bridge Haspital Roodlane Medical The Horley Street Clinle TheUstor Hospitet Tho Portlond Haspltat The Princess Grace Hospital The Wellington Hospital

REGULATION 28 RESPONSE;
RESPONSE OF HCA HEALTHCARE UK (“HCA”) AND LONDON BRIDGE HOSPITAL (“LBH”) TO
THE REPORT TO PREVENT FUTURE DEATHS DATED 3 FEBRUARY 2017 (“the PFD Report”)
MADE PURSUANT TO THE INQUEST TOUCHING THE DEATH OF MR ROBERT ENTENMAN

SECTION 5: CORONER’S CONCERNS

The PFD Report identifies the Coroner’s Concerns arising from the inquest which concluded
on 21 October 2016. The Coroner identified three areas of concern which, unless action is
taken, risk the occurrence of future deaths. Of those three concerns, the Coroner has
identified only one which requires action to be taken by the Chief Executive of LBH and
HCA:

Concern numbered (1) indicates that the Nursing and Midwifery Council (“NMC”) has the
power to take action. LBH is not_required to take action having already satisfied the
Coroner that it is not responsible for addressing this concern.

Concern numbered (2) indicates that Fisher and Paykel (manufacturers of the humidifier)
have the power to take action. LBH is not required to take action having already satisfied
the Coroner that it is not responsible for addressing this concern.

Concern numbered (3) indicates that HCA, LBH, the NMC and the Care Quality Commission
(“CQC”), all have the power to take action in relation to the following matters:

3.1 “There were delays in identifying that the endotracheal tube had become
blocked between 5.32am and 6.00am on 23 May 2015, and thus replacing it
earlier, There may have been further such delays after 6.00am.

3.2 There may have been a delay by nursing staff in providing information about
difficulties with the suction catheter to doctors who arrived after the cardiac
arrest call was put out.”

This Response sets out the actions taken by LBH and HCA to address the two concems -
numbered 3.7 and 3.2 - above.

SECTION 6; ACTION SHOULD BE TAKEN
A, LBH has reviewed Concern numbered 3.1, (above)

This concern is addressed in two parts:

e Action which LBH has taken with the team who cared for Mr Entenman at
various material times indicated by the Coroner; and

¢ Action which LBH has taken to improve systems and processes to ensure that
the risk of such events has been minimised in the future.

A.1. Team who cared for Mr Entenman

Alt individuals (whether they be medical or nursing, Permanent, Bank or Agency staff) who
are still employed/engaged by LBH, have reflected upon the concerns raised by the Coroner
in the context of their own clinical practice. Further, they have been motivated
participants in the improved systems and processes which are described in more detail
below (see A.2) and these include Human Factors Training, which is particularly pertinent
to the Coroner’s concerns.

ESSER

A.2, Improved Systems and Processes

The following steps have been implemented in relation to equipment, training and human
factors relevant to the Coroner’s concerns:

1.

a.

b

e.

Capnography:

Continuous capnography is used to monitor all critically ill patients who are
intubated (either with an ETT or tracheostomy) and ventilator-dependent.

Clinical staff working in ICU receive training in the interpretation of
capnography {prior to commencing work in ICU) via courses (critical care, in-
prep, and foundation) and via competency booklets. It is thereafter reinforced
through a regular programme of training, implemented through the HCA
Learning Academy (see A.2.2.b below).

LBH has purchased two portable End-Tidal CO2 monitors to augment the
availability of capnography during an emergency or Outreach situation, The
function of the Outreach service is to provide clinical support and critical skills
for the ward areas when a patient becomes unwell. Whereas prior to the
purchase of these mobile monitors measuring ETCO2 during a cardiac arrest
outside a critical care area would be unusual, these mobile monitors now
extend the areas where capnography may be performed.

Capnography is monitored in all cardiac arrest situations and is part of the mock
arrest scenario training. It has been added to the Cardiac Arrest Record
Checklist (see B.3 below) as a prompt for the cardiac arrest team’s scribe.

LBH has also implemented DOPES (see B.4 below), a system of assessment and
diagnosis to be followed by staff in a situation where a suspected “difficult
airway” problem arises. DOPES has also been added to the Cardiac Arrest
Record Checklist as a prompt for the cardiac arrest team’s scribe.

Training:

Immediately following the event, LBH engaged an external training company to
deliver advanced airway training to medical and nursing staff working on LBH’s
ICUs. This was prior to the introduction of the more comprehensive advanced
airway management training course described in A.2,2.f below.

The HCA Learning Academy, which is responsible for delivering education
relevant to clinical processes, knowledge and skills to all HCA facilities,
oversees the Learning Management System (“LMS”). LMS is a software system
facilitating on-line access from home or work to undertake, complete and store
training courses, as well as accommodating book- and classroom-based training
for all staff. Atl data can be updated and stored and LMS provides a robust
system for monitoring training records.

Intensive Care nurses, dependent on their grade, have undertaken and continue
to undertake training on either the {Intermediate Life Support (“ILS”)
qualification or the Advanced Life Support (“ALS”) course, Ail Outreach nurses
must hold the ILS qualification.

Shift leaders and Critical Care Resident Medical Officers (“CCRMOs”) have
completed the ALS course and which qualification is reviewed annually and
renewed every 4 years. Many Outreach nurses also hold the ALS qualification.

7

. To prevent ILS or ALS qualifications from becoming out of date, the new LMS

flags to both the nurse/CCRMO and his/her line manager when the qualification
requires revalidation. Staff wilt not be permitted to perform in key roles if
these qualifications are out of date.

HCA and the Simulation and Interactive Learning (“SalL”) Centre at Guy’s and
St Thomas’ Foundation Trust have collaborated to deliver additional intensive
Care Airway training for intensive care staff (medical and nursing) working
within LBH intensive care environments. ‘This is an ongoing programme of
training.

Simulation training aims to develop and enhance key skills in a training
environment away from the clinical setting at HCA, whilst remaining in mock
clinical areas. The areas addressed include (i) technical skills; (ii) challenging
key clinical situations critical to patient safety; (iti) human factors/non-
technical skills such as communication, decision making, prioritisation, task
allocation, teamwork, patient care and compassion.

Reflective practice for medical and nursing staff continues to be facilitated.

An external training company speciatising in healthcare and emergency training
delivers an ongoing programme of training including mock arrests and involving
the LBH intensive care staff. There is a particular focus on blocked tube
scenarios in this training programme.

Consultant Anaesthetists will be undertaking a periodic review of clinical skills
of, and Consultant Intensivists will meet on a similar basis with, the CCRMOs for
clinical supervision.

All the critical care courses offered by HCA {usually via a leading London
university) have been reviewed and the roles of capnography, SBAR and POPES
introduced where they did not exist previously (see B.4 below).

LBH will offer its RMOs rotational work in the operating theatres. This is for
RMOs to receive regular updates and input from Consultant Anaesthetists on
airway skills.

Patient Safety Checklists:

a. A picture intubation checkiist has been developed and is used in all
intubations of critically ill patients.

b. An emergency induction checklist is being introduced. This has been
agreed by HCA’s Critical Care Delivery Group for implementation across
all of HCA’s operations.

c. The Cardiac Arrest Record Checklist has been revised to include
prompts for capnography and DOPES (see B. 3 below).

:
i

B.

LBH has reviewed Concern numbered 3.2, (above)

This concern has been addressed by communication during an arrest being reviewed and
improved by LBH having implemented the steps described below.

B.2,

B.1,. ANew Airway Management Process has been introduced:

This consists of a 5 step process for patients with an artificial airway in situ. It
introduces a “Red, Amber, Green” (or RAG) scoring system (see below).

a.

-

2

On admission to ICU, either the Consultant Anaesthetist hands over to the
CCRMO (if the patient has arrived from Theatre) or the CCRMO establishes
airway facts.

The admitting primary nurse/Nurse in Charge then facilitates an airway
discussion with the CCRMO and Consultant intensivist.

The patient's airway status is established as “Green”, “Amber” or “Red”.

Green (equates to intubation grade 1-2}, Amber (equates to intubation grade of
2 if a bougie is used) and Red (equates to an intubation grade of 3 or more}, In
patients colour-scored Amber or Red, a bespoke Airway Plan is chen completed.

The Admitting Nurse/Nurse in Charge then places the appropriate “Airway” sign
at the patient’s bedside which clearly indicates the patient’s airway status,

The Airway Plan is easily accessible at the patient’s bedside. The Airway Plan
also forms part of the shift handover (see B.2 below) and remains in the
patient’s electronic medical records,

LBH Resuscitation Team: Safety Briefing Handover

a. Patients with potentially high risk airways are identified and
discussed at the Safety Briefing Handover to ensure that they
are clearly identifiable to those caring for them.

b. The Safety Briefing Handover is undertaken by the cardiac
arrest teams at 9am and 9pm every day.

c. Roles are allocated to the team members during the Safety
Briefing Handover to ensure that in the event of a cardiac
arrest, everyone can assume their roles immediately.

a

Specific questions are considered including (i) whether any
patients have potentially difficult airways/intubation grades, if
so who/why/what grade, (ii) have there been any reintubations
or readmissions, if so who/where? (iii) whether there have been
any extubations or de-cannulations planned, if so who?

e. Two documents are produced during the Safety Briefing
Handover as follows:

i. The Safety Briefing Form (which remains with the Critical
Care Shift Leader); and

ti. The Cardiac Arrest Allocation Sheet identifying the specific
roles of individuals in the event of an arrest. This remains

with the Duty Manager and is part of the Duty Manager’s
log,

B.3, Cardiac Arrest Management
In the event of a cardiac arrest:

a. The Cardiac Arrest Record Checklist is completed by the scribe (this
js generally the Duty Manager) who will prompt the cardiac arrest
team on capnography, SBAR and DOPES if necessary during the
arrest.

b. During the Cardiac Arrest Debrief, which takes place after any
arrest, a further document is completed - the Cardiac Arrest
Debrief Record. The Cardiac Arrest Debrief Record is audited and
reviewed by the Resuscitation and Training Teams. This is stored on
the cardiac arrest trolley.

B.4. Handover Techniques in emergency situations

LBH has adopted the follow strategies.

e SBAR (Situation, Background, Assessment, Recommendation)

a. {BH has highlighted the importance of early verbal communication and
escalation using the SBAR system of communication in real time.

b, The SBAR technique is known to be the best practice approach for
standardising and structuring critical information-sharing between care
givers,

c. SBAR forms part of the National Resuscitation Training and is included in ILS
training annually and ALS training every 4 years.

» DOPES

a, DOPES is a pneumonic used to identify the potential cause of a suspected
airway difficulty in an arrest situation:

i. Displacement of tube,
ii. Obstruction of tube,

iii. Pneumothorax,
iv, Equipment failure,
v. Stacked breaths.

b. It is the first step which is considered following the SBAR handover of a
potential airway issue.

TSOP RIA

;
;
:
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c. It has been adopted by LBH as part of its improvement in assessments and
communications and has been added to the ILS and ALS courses, and to the
Cardiac Arrest Record Checktist.

B.5. Human Factors Training

a. Human factors training is the scientific discipline concerned with the
understanding of interactians between humans and with elements of a
system of work. Unfortunately even the most highly trained and motivated
professionals will still make mistakes. However, with a suitable level of
understanding of human factors and appropriate training, such errors can
be extinguished or mitigated against by restricting the effects of such an
error.

b. Accordingly, in July 2015, LBH introduced Human Factors Training as part of
the curriculum to improve and develop situational awareness and which is
open to all levels of staff to attend, Records of attendance are maintained
in LMS (see A.2.2.b. above}, |

President of Operations,
HCA
31 March 2017

Nursing &
Midwifery
Council

Henrietta Hill, Assistant Coroner
Inner London South Coroner's Court
1 Tennis Street

Southwark

SE1 1YD

29 March 2017

Dear Madam
Robert John Entenman (JNR)

Further to your Report to Prevent Future Deaths made under Paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners (investigations)
Regulations 2013, | am writing on behalf of Director of Fitness to Practise, to
provide you with our response. | am the case manager with oversight of this matter.

We thank you for bringing your concerns to our attention in respect of the nursing care provided
to a patient who passed away, in which you found that certain aspects of care provided by the
nurse were not properly completed.

We are aware of the particular issues raised about the registered nurse who reviewed Mr
Entenman in the time leading up to his death. We are currently investigating this matter and are
considering the concerns in accordance with our statutory functions.

| understand the case officer dealing with this matter has been corresponding with you and will
be in a position to provide you with a further update in due course.

if we can provide any further input on this matter, please do not hesitate to contact me on ||

Yours sincerel

Investigations Manager

First Floor, 1 Kemble Street, London WC2B 4AN
T +44 20 7462 5800/5801 F +44 20 7580 3410
DX 37970 Kingsway

www.nmc.org.uk,

The nursing and midwifery regulator for England,
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Registered charity in England and Wales (1091434) and in Scotland {SC038362)