Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0026, written 18 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jan 2017 |
|---|---|
| Reference | 2017-0026 |
| Deceased | Teresa Dennett |
| Coroner | Heidi Connor |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Peter Homa, Chief Executive, Nottingham University Hospitals NHS Trust 2. Sir Andrew Cash, OBE, Chief Executive, Sheffield Teaching Hospitals NHS Foundation Trust 3. Mr Simon Stevens, CEO, NHS England 1 | CORONER | am Heidi Connor, assistant coroner for the coroner area of Nottinghamshire. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 3 October 2016 | commenced an investigation into the death of Teresa Dennett, aged 58. The investigation concluded at the end of the inquest on 6 January 2017. The medical cause of death was : 1a Malignant middle cerebral artery territory infarct 1b Hypertension. ~ | recorded a narrative conclusion as follows : Teresa Dennett's death was the result of a rare type of stroke. Attempts were made to arrange for her to be transferred for urgent neurosurgery, but this did not happen. If an operation had taken place before her final deterioration at around 0330 on 7 February 2016, then it is likely that she would have survived, albeit with ongoing neurological disabilities. ‘4 | CIRCUMSTANCES OF THE DEATH | have summarised the key evidence below. | am mindful of the fact that not all recipients of this letter will be familiar with local hospitals and policies and take that into account in my summary. A full note of my summing up and conclusions has been supplied to all Interested Persons. The coroner will consider any further request for a copy of this from the recipients of this report. The family requested that we refer to their mother as Teresa at the inquest, and | reflect that request in this report. Teresa Dennett was born 17.2.57. She was admitted to the ED at Kings Mill Hospital (‘KMH’) at 09.20 on 6 February 2016 via ambulance, and diagnosed as having suffered a stroke. Subsequent review of the CT scans indicated that she may be suffering from a rare type of stroke that carried a risk of sudden deterioration, requiring neurosurgery to relieve any subsequent raised intracranial pressure. KMH in Mansfield does not have neurosurgery services. It usually refers neurosurgery patients to the Queen’s Medical Centre in Nottingham. Initial advice from Nottingham neurosurgeons consulted at around 1600 was that Teresa should be observed. At that time her GCS was 12, and she was able to obey commands. There was no midline shift. The advice was that neurosurgeons should be contacted again if her GCS dropped, especially if she became confused or drowsy. Concerns were later raised about Teresa’s condition, and a further CT scan (carried out at 2107, reported at 2153, and actioned by ward staff between 2300 and 2330) showed increased mass effect and an 8mm midline shift. Further contact with Nottingham was made, and the Nottingham-neurosurgery registrar sked for the scans to be sent to him, indicating that it would be a further alf an hour before he could access them. We were told that radiologists used the IEP (Image Exchange Portal) to send the scans. After reviewing the scans, the neurosurgery registrar indicated that Teresa should be transferred to Nottingham for urgent decompressive hemicraniectomy. KMH records state that this call was at or shortly before 0020 hrs on 7 February. He did not consider whether an ICU bed was available before giving this advice. When he checked this after speaking to his consultant, it became clear that a post-operative ICU bed was not available and there was no prospect of one becoming available in the near future. (ICU consultant) told us that not only were all the ICU beds full, but he had already transferred out his least sick patient to make way for another, and a further patient was being looked after in theatre recovery, already a far from ideal situation. dvised the medical registrar” to ask Sheffield to take this patient. Mansfield is almost equi-distant between Nottingham and Sheffield (Sheffield being perhaps 5 or 10 minutes further away). Sheffield is in a different catchment area. | accepted in evidence that Nottingham and Sheffield neurosurgery units have in the past assisted each other where one unit has not been able to provide urgent surgery to a patient. This is not an everyday occurrence, but this has occurred not infrequently in the past. Sheffield neurosurgery registrars were happy to accept the patient, but their consultant, advised that Nottingham should treat the patient. KMH records state that contact was first made with Sheffield at 0115 hrs. Sheffield records give a time of 0159 hrs. The Sheffield trust's response to a Freedom of Information Act request by Teresa’s family indicates that surgeons were available, and there were 8 ICU beds free that night. Although the Sheffield consultant indicated that he may reconsider via a ‘consultant to consultant referral’, this possibility was not mentioned to either i = KMH or in Nottingham. declined to contact his consultant despite requests b' . He advised to approach Birmingham or Oxford. a «... that Teresa wouid not survive the journey to Birmingniarn or Oxford, and time was against her. He contacted an on-call stroke physician in Nottingham, | | made further contact with [EB and all agreed that she should come to Nottingham for surgery — as that was the clear clinical priority — and the ICU bed situation would be resolved thereafter — even if that required ICU management at a different centre post-operatively. Sadly, by this time, Teresa had deteriorated too much for surgery to be carried out. Her GCS at 0326 hrs was noted to be 6. She died later that morning. The evidence of 3 consultant neurosurgeons at the inquest was that if the operation had been carried out, then on the balance of probabilities, Teresa would have survived, albeit with ongoing neurological disabilities. This of course depends on whether transfer to a neurosurgery unit would have been possible before her final deterioration. Even if Sheffield had agreed to take the patient when first contacted, | found it unlikely she would have had the operation in time. Key concern With the exception of BB inser, all neurosurgery witnesses stated that, on the facts of this case, and taking account of the steps already taken to try to arrange transfer, hould have accepted the patient. These witnesses include Ii a senior neurosurgery consultant colleague in Sheffield. | made no enquiries as to why Nottingham had not felt able to take Teresa — either directly or via the registrars involved. He gave evidence that he did not know where KMH was — although he accepted that he knew it was in the Nottinghamshire area, given that he had advised that Nottingham should take the patient. We heard evidence about a 2015 Care Quality Statement made by the Society of British Neurological Surgeons. This in effect says that a patient requiring “life-saving, emergency surgery” should always be accepted by the regional neurosurgical unit — and that critical care bed availability should never be used as a reason to refuse admission. i: that he relied on this in support of his decision. We heard in evidence that this Society is a voluntary one. Many of the neurosurgeons involved in this case had not heard of the statement before this case, and some described it as ‘aspirational’. We also heard that the Mid Trent Critical Care Network policy (November 2014) allows admission for emergency neurosurgery regardless of critical care bed availability only in .3 specified clinical scenarios (which would not include Teresa). The Mid Trent area does not include Sheffield. ; / Crucially, it was clear that there was no written protocol in place to set out a clear pathway for referral for emergency neurosurgery. The medical registrar at KMH was left to try to ‘broker a deal’ with multiple neurosurgery units, and valuable time was lost in this process. | made it clear at the inquest that the efforts of the medical registrar, P are to be praised for all he tried to do to facilitate this. There are clear advantages to surgery and post-operative management happening at the same centre. In Teresa’s case, that would have meant 1 transfer rather than 2, but the most time critical step which Teresa required was neurosurgery. By the time a decision was made to transfer her regardless of critical care bed availability, it was too late for her to have the operation. Other concerns 1. Radiology access | reviewed the neurosurgery contract with NHS England. This states clearly that all neurosurgical units must have immediate and direct web-based access to critical diagnostic imaging in all referring units. Whilst we heard that Nottingham now has this arrangement with most of its referring hospitals, the exceptions to this are Derby and ° Burton hospitals. Sheffield does not have immediate access with any of its referring hospitals. These hospitals are now invited to review this arrangement as a matter of urgency. 2. Input from stroke physicians | found it likely that Teresa did fit the criteria for NICE CG 68 (‘Stroke and TIA in over 16s : diagnosis and initial management’) from the time of her first CT scan. Although she was subsequently considered for hemicraniectomy, in line with that guidance, the evidence of , a senior stroke physician at KMH, was that input from a stroke hysician would have been useful. The type of stroke Teresa suffered is a rare type and aid that patients with this condition can deteriorate suddenly. The neurosurgery witnesses agreed that this would have been useful. Interested Persons are invited to review stroke care pathways to take this into account, and NICE is invited to reconsider NICE 68 in this respect. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery) and two further concerns (regarding diagnostic imaging, and input from stroke physicians into appropriate cases). The Way Forward On the final day of the inquest, we heard evidence from , ICU consultant consultant neurosurgeon in Sheffield, and consultant neurosurgeon in Nottingham. old us about a proposed new way of working, to reduce the risk of a similar occurrence. He advised us that his proposal is the start of the process, but that he had discussed this with his clinical director. : In essence, the proposed system would mean that, if a decision is made that a patient needs life-saving surgery, they should be transported immediately to their local unit. This may mean that a critical care bed would have to be found for that patient thereafter — even if that requires extensive ‘bed-juggling’ (as | termed it) by critical care doctors — or in extreme cases, treatment post-operatively being offered elsewhere. The proposal is that this shouid cover ali types of iife-saving surgery — not just neurosurgery. The advantage of this system is that it avoids all uncertainty for a hospital referring a | patient. Teresa could have been prepared for immediate transfer for surgery to a clearly defined destination, without delay, if this protocol had been in place. This is clearly vital for patients whose priority is life-saving surgery. It was proposed ~ and agreed by the 3 witnesses referred to above — that the decision as to whether proposed surgery is ‘life-saving’ or not should be a matter for the consultant surgeon — who would routinely be contacted for a new admission in any event. | believe that is right for the reasons suggested, but also because no protocol can ever cater for every situation — sometimes a senior decision needs to be made to deviate from a protocol, for common sense reasons and in the best interests of a patient. This is of course just the start of the discussion. There will need to be input into the new policy/ies by surgeons and critical care doctors. | am aware that the Mid Trent Critical Care Network policy is also undergoing review. This will need to be consistent with any new approach adopted. It was agreed that close working between Nottingham and Sheffield is to be encouraged, to adopt policies that are consistent. | also appreciate that, as with any big change, there will need to be careful auditing to make sure that this does not disadvantage other patients or not work well for some other reason. © It is clearly vital that any new system of working — for surgeons and critical care at both trusts --be put in writing. It has been agreed that both Nottingham and Sheffield will work together on this, with I eacing the process, and providing a response to my report from NUH by the end of March this year. Sheffield’s response will be required by the same date. In those responses, | will also want to hear about the proposal for communicating this new approach to all referring hospitals. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE For the avoidance of doubt, and given the multiple recipients of this report, | require formal responses as follows : e Nottingham University Hospitals NHS Trust and Sheffield Teaching Hospitals NHS Foundation Trust — response regarding the ‘key concern’ and 2 ‘other concerns’ referred to in paragraph 4 above. They should also address how any new policy/ies are to be communicated. Response by 31 March 2017. e NHS England — to consider the ‘key concern’ referred to in paragraph 4 only. By 30 June — ie 3 months after Nottingham and Sheffield’s response — predominantly to consider whether this should be a country-wide policy. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. Derby and Burton Hospitals are invited to review radiology access — see paragraph 4 above. No formal Regulation 28 response is required, although a written response would be welcomed. NICE is invited to review NICE guidance 68 — see paragraph 4 above. No formal Regulation 28 response is required, although a written response would be welcomed. COPIES and PUBLICATION | have sent a copy of this report to the following : Teresa’s family Nottingham North and East CCG NHS Sheffield CCG Chief Executive, Derby Teaching Hospitals NHS Foundation Trust Chief Executive, Burton Hospitals NHS Foundation Trust National Institute for Clinical Excellence Mr Chris Dorries, Senior Coroner for South Yorkshire West Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust Chief Coroner for England and Wales | am also under a duty to send the Chief Coroner a copy of your responses. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. [DATE] iQh& tT mee ee
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mrs Heidi Connor NHS) England Professor Sir Bruce Keogh National Medical Director Skipton House 80 London Road SE1 6LH Assistant Coroner Nottingham Coroner's Court The Council House 26 June 2017 Old Market Square Nottingham HG1 2DT Dear Mrs Connor Re: Regulation 28 Report DENNETT Thank you for your Regulation 28 Report following the inquest into the sad death of Teresa Dennett. | would like to express my deep sympathy to Ms. Dennett's family. In your Regulation 28 Report you asked NHS England to consider whether it should change its countrywide policy in relation to neurosurgical emergencies. Following receipt of the report NHS England has sought assurance from both Specialised Neurosurgical Centres and their referring non-specialised hospitals that the appropriate protocols are in place to ensure patients requiring a life-saving surgical intervention will be referred to the appropriate surgical centre regardless of the availability of a Critical Care Bed. This process has been led by the Midlands and East and North Regional Clinical Directors for Specialised Services as the incident to which this report relates involved hospital trusts from within both regions, although we acknowledge that the Coroner suggested that country-wide changes were to be considered. Process Undertaken The Medical Directors of all acute hospital trusts within Midlands & East and North regions were asked to assure NHS England that the appropriate pathways are in place and, if protocols had been agreed between themselves and referring hospitals, to ensure that no critical surgical transfer would be refused on the grounds of availability of a critical care bed. Responses have been received from all Midland & East and North Neuroscience Centres confirming that these protocols are in place and are being adhered to. Where there are currently only informal agreements, we have asked that the appropriate written protocols are agreed and signed off by both the neuroscience centres and referring trusts. This process will be rolled out to London & South regions between September and December 2017. Individual responses have been sent to yourself from both Nottingham University Hospitals and Sheffield Teaching Hospitals NHS Foundation Trust regarding this individual incident with full reviews having been undertaken within both trusts. Both Trusts have revised their current protocols to reflect the Society of British Neurosurgical High quality care for all, now and for future generations Surgeons guidelines and have been signed off by the Trust Boards. NHS England has had sight of these protocols and note that they are in line with the recommendations from your Regulation 28 report. NHS England Position Going Forward NHS England has been working closely with the Neurosciences Clinical Reference Group (CRG), the Adult Critical Care CRG and the Society of British Neurological Surgeons (SBNS). The following actions have been agreed: e The Neurosciences CRG are in the process of reviewing the Neurosurgery Service Specification and will require all services to meet the guidelines issued by the SBNS. This review will be complete by 31 March 2018. e A National Coroners Regulation 28 Working Group has been established within NHS England to review Regulation 28 reports and to disseminate actions raised where considered appropriate. e The Society of British Neurological Surgeons has re- circulated their guidelines on the transfer of patients requiring emergency treatment, the link to which is below; http:/Avww.sbns.org.uk/index.php/download file/view/975/87/ NHS England will continue to monitor the relevant healthcare sector to endeavour to ensure that pathways and protocols are being met. | do hope the above sets out the actions that were required of NHS England and provide assurance this concern has been addressed with the importance required. Please do not hesitate to contact us if you require further evidence. Yours sincerely, Professor Sir Brice Keogh KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England High quality care for all, now and for future generations
Response to HM Coroner following Regulation 28 Report (PFD) dated 18 January 2017 Deputy Medical Director 29 March 2017 The key concern of the Coroner was that “There should be a clear written protocol for patients requiring lifesaving surgery that allows immediate transfer of a patient to a place where an appropriate intervention can be undertaken.” The following actions have been taken. A new protocol has been written after consultation with the following groups: NUH Critical Care Consultants NUH Theatres and Anaesthetic teams NUH Surgical Divisional and specialty teams (including Neurosurgery and Gastroenterology) NUH Interventional Radiology NUH Medical Division and specialty teams (including Stroke team) Mid Trent Critical Care Network and Clinical Leads. Medical Directors and Critical care service leads at NUH, Lincoln, Derby and Kings Mill Hospitals. Sheffield Teaching Hospitals neurosurgery team and Medical Director The new protocol is attached as a flow-chart in Appendix 1. Although primarily directed at requests for transfer of patients to NUH or Sheffield Teaching Hospitals for emergency neurosurgical intervention, this arrangement will apply at NUH to requests to consider other life-saving specialist procedures. The protocol will not override extant policies for transfers to NUH for Major Trauma or Coronary Interventions. The protocol can be summarised as: 1. If the local hospital consultant considers that a life-saving emergency intervention (that cannot be provided in the local hospital) should be considered for a patient they will contact the relevant on-call specialty consultant at NUH. 2. The NUH specialty consultant will discuss the patient’s management with the referring consultant. If the NUH consultant agrees with the clinical judgement (taking account of relevant national guidance where applicable) that life-saving intervention in less than 6 hours is indicated, the patient will be accepted for transfer to NUH irrespective of the critical care (or other) bed state. It is expected that wherever possible this will be a consultant to consultant conversation. 3. The accepting NUH consultant will confirm details of the case with the NUH theatre manager who will ensure that all relevant teams are informed. 4. The only exceptions to the patient being accepted for immediate transfer as in 2 will be if there is major infrastructure failure in NUH theatres or a major incident that is overwhelming theatre capacity. In these exceptional circumstances the NUH consultant will discuss the patient with a consultant in an alternate specialist centre. 5. The referring hospital will arrange safe transfer of the patient to the NUH theatre recovery area, where the patient and transfer team will be met by the on-call anaesthetic, theatre, surgical and critical care team. The transfer team will maintain responsibility for the patient until the patient has been handed over and accepted by the NUH team. 6. The NUH multidisciplinary team will agree the next course of action and the likely post-operative care requirements. 7. In circumstances where it is likely that the patient will require post-operative critical care and there is no capacity (or prospect of imminent capacity) in critical care at NUH (ensuring appropriate utilisation of both QMC and City campus intensive care units), the consultant responsible for critical care will consider the following options: o Patients who are considered suitable for repatriation to the referring hospital ICU will be identified and discussed with the referring hospital critical care team for urgent transfer. [a ‘non-clinical’ transfer] o o Patients who are considered suitable for transfer to the referring hospital ICU will be identified and discussed with the referring hospital critical care team for transfer. [a ‘non-clinical’ transfer] If the referring hospital has no ICU capacity the critical care consultant will identify the next nearest ICU for repatriation or non-clinical transfer If it is not possible to identify suitable patients for repatriation or non-clinical transfer, the NUH ICU consultant will consider with NUH surgical colleagues referral of the index patient to another specialist centre (e.g. Sheffield neurosurgical unit) as is consistent with national guidance (e.g. SBNS Quality Statement for neurosurgical provision). o o If ICU capacity cannot be generated at NUH or a suitable alternate specialist centre to accommodate the index patient using one of the above manoeuvres the consultant will consider the use of surge capacity at NUH or will discuss with the referring hospital critical care about extending to surge in that institution. 8. The Transfer team from the referring hospital will remain at NUH until discussion has taken place with the NUH critical care consultant regarding critical care capacity. Whenever possible, the same transfer team will conduct any transfer from NUH necessary to make capacity available for the index patient. Patients whose transfer to NUH is agreed for urgent, but not lifesaving treatment, will continue to be accommodated at NUH after discussion between relevant clinical teams (including ICU if necessary) to ensure timely transfer and specialist intervention. Additional notes A non-clinical transfer may carry risk to the patient transferred and the critical care consultant will use their clinical judgement to determine the optimal course of action. The decision-making and communication processes described offer partial mitigation. There has been extensive discussion with clinical teams and referring hospitals about their responsibilities in accepting patients for repatriation or transfer. An electronic log of all patients referred under this protocol will be maintained using ‘Medway’ patient administration system and ‘Nervecentre’ software. This additional software programming has been approved but is not yet fully developed or functional. Medway recording will be available within 2 months. It is expected initial ‘Nervecentre’ updates will be complete in 3 months, however this will only log internal referrals and the external referrals will be included in a more extensive upgrade as part of a bed management project. In addition to recording the use of this protocol, these electronic logs will allow regular review of the care and outcomes of any patients transferred to accommodate the incoming patient. The significant national interest generated by this PFD have resulted in NUH adopting this policy of accepting patients for lifesaving intervention irrespective of critical care capacity from the time the PFD was issued. There have been no significant adverse events from this protocol to date but the performance will continue to be monitored. The next steps for this protocol are: 1. Formal Ratification by the Mid Trent Critical Care Network by the Network Clinical Group in May 2017 2. Formal Ratification by NUH in May 2017 Communications This protocol has been shared with the Mid Trent Critical Care Network Clinical Leads, Sheffield Teaching Hospitals and the local Medical Directors. In addition to the local work on this PFD, the Faculty of Intensive Care Medicine and Intensive Care Society have been contacted. A redacted version of the PFD has been published at: https://www.ficm.ac.uk/sites/default/files/ficm-pathway-for-urgent-neurosurgical- procedures.pdf All critical care units in the country have been contacted to make them aware of the expectations around care for patients requiring life-saving neurosurgical interventions. Other concern 1 - Radiology access NUH hosts the EMRAD consortium of 7 trusts that allows all radiological imaging to be viewed in all participating organisations which include NUH, Sherwood Forest Hospitals, Leicester, Northampton, Kettering, Lincoln and Chesterfield. Currently Derby hospitals have a separate electronic image system which can be viewed by NUH clinical teams and the images can then be transferred between Trust systems. Other concern 2 - Input from Stroke Consultants NUH and SFH currently contribute to a shared consultant on-call rota for stroke services. Previously the on-call stroke consultant has been available for decisions related to possible thrombolysis (clot-busting therapy) and discussion of thrombolysis-related complications in stroke patients. From now the service will describe that the on-call consultant is available to discuss any atypical course or acute complication of stroke, including those where urgent neurosurgical or neuroradiological intervention may be indicated where the referral is made by a registrar or above. Summary I believe that the steps outlined above will reduce to the lowest risk achievable the possibility of a similar occurrence in the future. Signed: Date: 29.03.17 (Consultant/Deputy Medical Director)
Sheffield Teaching Hospitals INHS | NHS Foundation Trust Chief Executive’s Office 8 Beech Hill Road SHEFFIELD $10 2SB Tel: 0114 2712436 Fax: 0114 2712580 Our ref: 30 March 2017 Mrs Heidi Connor Assistant Coroner Nottingham Coroner’s Court The Council House Old Market Square Nottingham NG1 2DT Dear Mrs Connor Response to Regulation 28: Report to Prevent Future Deaths | write further to your report dated 18 January 2017, following the inquest into the sad death of Teresa Dennett. | would firstly like to express our sincere condolences to Mrs Dennett’s family, for whom | appreciate this will have been a most painful and distressing time. We take very seriously the findings of the report, which we have considered carefully. Our response to the specific concerns and recommendations within the report is outlined below. Key concern The Society of British Neurological Surgeons (SBNS) Care Quality Statement (2015) is designed to provide a clear pathway for the referral of patients for time-critical neurosurgery. Indeed, following this and one other recent Regulation 28 report, Professor Sir Bruce Keogh, National Medical Director, NHS England, wrote to all NHS Medical Directors on 27 February 2017 reiterating the importance of adhering to the SBNS national guidelines for the transfer of neurosurgery patients. We note that in his letter, Sir Bruce Keogh has advised that local protocols should reflect these national guidelines. The Consultant Neurosurgeon at Sheffield Teaching Hospitals (STH) was adhering to the SBNS guidelines in providing advice to King’s Mill Hospital that Nottingham University Hospital (NUH) should treat the patient. The guidelines state: ‘Neurosurgical units should not refuse admission for a het 7 oe ield ott ¥ Fis \ Hospitats in hospital and in the community Charity proud to make a difference Chair: Tony Pedder OBE Chief Executive: Sir Andrew Cash OBE patients requiring emergency surgery referred from their catchment population. The lack of critical care beds must not be a reason for refusing admission for patients requiring urgent surgery.’ Equally, in advising that a ‘consultant to consultant’ referral was required, the Consultant Neurosurgeon at STH was following the SBNS guidelines. However, we agree that in this situation, to avoid any further delay we should simply have accepted the patient and adhering rigidly to the national guidelines was not in the patient’s best interests at that time. As a result of this situation, in addition to reviewing and discussing with [ij HEM the protocol developed by NUH, we have drafted our own local protocol for the admission of patients requiring emergency neurosurgical procedures, and | attach a copy of this for your information. This protocol has been shared with NUH. The protocol is in line with the SBNS guidelines and, importantly, also includes the following statement: ‘if a hospital outside of our usual catchment area contacts the on call neurosurgical team because they are having difficulty accessing care at their local unit and we understand that time critical surgery is required, we should accept the patient ourselves for immediate transfer. We should then contact the referring hospital’s usual neurosurgical unit to establish that transfer to Sheffield is the most appropriate course of action.’ This draft protocol is in the process of being discussed with all relevant staff and, once agreed, it will be shared widely with all of the trusts within our neurosurgery catchment area as follows: e Rotherham NHS Foundation Trust e Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust e Barnsley Hospital NHS Foundation Trust e Chesterfield Royal Hospital NHS Foundation Trust ¢ Lincoln County Hospital (United Lincolnshire Hospitals NHS Trust) The new protocol will be communicated through the Working Together Partnership which includes STH along with all of these trusts with the exception of Lincoln, with whom we will communicate separately through our respective Medical Directors. Other concerns 1. Radiology access for neurosurgery District general hospitals referring neurosurgery patients to Sheffield transfer images through the Picture Archiving and Communication System (PACS). Through PACS, images can be viewed securely from any location on an STH laptop and can be available for a neurosurgery consultant in Sheffield to view within five minutes. In the vast majority of cases, images are available to view within half an hour at most. This is dependent however on the availability of the radiographer at the peripheral hospital to upload the images. 2. Input from stroke physicians Images used in the diagnosis of stroke by the STH stroke service can be seen immediately by the on-call stroke physician from home. Hospitals served by the stroke service in the region around Sheffield have 24/7 telemedicine access to the advice of a specialist stroke physician. We are now working to finalise and communicate our local protoco! for the admission of patients requiring emergency neurosurgical procedures, which has been produced in response to your report. Please be assured that this is being undertaken as a matter of priority | hope that the above comments address the concerns set out in your original communication, but we would be happy to answer any outstanding queries as necessary. Yours sincerely Sir Andrew Cash OBE Chief Executive
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