Katherine Derbyshire

Satford Royal ETZEL
Wises besandation Meet

yg AUG 20

Chief Officer

Salford Royal NHS Foundation Trust

Stott Lane

Salford

M6 8HD
Telephone: —_ 0161206 6116

Email:

Date: 4" August 2017

STRICTLY PRIVATE AND CONFIDENTIAL
Mr. T W Brennand

HM Area Coroner

Coroner Area of Manchester West

Ground Floor

Paderborn House

Howell Croft North

Bolton

BL1 1JW

Dear Mr. Brennand

Re: Mrs. Katherine Anne Derbyshire (Deceased)
Response to Regulation 28: Report to Prevent Future Deaths to Salford Royal
NHS Foundation Trust.

Thank you for your Regulation 28 letter dated 16" June 2017, which you issued to Salford
Royal NHS Foundation Trust (“SRFT”) and The Royal Albert Edward Infirmary, (Wrightington
Wigan and Leigh NHS Foundation Trust (“WWL”) following an Inquest held on 19" May
2017 touching the death of Mrs Katherine Anne Derbyshire.

Your letter raised a number of issues, summarised in the comment below;

At the inquest the case raised issues as to the nature and extent of communication between
the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary
requiring ongoing dialysis treatment and care

Response of Salford Royal NHS Foundation Trust

Background
Mrs Derbyshire was admitted to WWL on Friday 11" November 2016 and was referred to
SRFT renal team on Monday 14" November 2016, the referral was accepted by the renal

registrar and a management plan recommended. She was placed on the waiting list for
admission as a category 1 transfer (transfer within 48 Hours). There is evidence of
discussions between WWL and SRFT teams on the 17" and 20" November 2016. By the
20" November 2016, when a bed became available, Mrs Derbyshire was sadly too unwell to
transfer and a decision was taken to change to a palliative model of care. Although there is
evidence of discussions between teams, this should have been more frequent.

At the time of Mrs Derbyshire requiring treatment, the systems in place to provide specialist
renal inpatient care to the population of Wigan borough, was via a 24 hour a day 7 day a
week telephone advice and referral service.

The current arrangement for patients can be strengthened in two ways;

e Electronic referral pathways
e Replication of a consultant led ‘in reach’ service.

Electronic Referral Pathways
SRFT are developing an inter-hospital online referral system which aims to standardise
advice and guidance as well as providing prompts for specific information. The system will
automate the following:
e explicit request to provide date of last organ support with automatic alert to consider
options if >72 hours
e clearly assigns responsibilities to SRFT or local trust depending on the individual
circumstances

This system will be the primary referral mechanism; however, local Trusts can continue to
refer via telephone. All telephone referrals will be inputted into the electronic referral system
and advice will be provided, documented and responsibilities assigned via this system. This
will enable e-referrers and telephone referrers to receive the same standardised advice and
guidance with the appropriate safety prompts. The time scale for implementation is
planned for September 2017.

In Reach

Salford Royal NHS Foundation Trust (SRFT) is the lead provider in the north sector of
Greater Manchester, covering the following six CCG areas: Salford, Bolton, Wigan,
Wrightington & Leigh (WWL), Bury, Rochdale, and Oldham.

An ‘in reach’ model of care is in place in Pennine Acute (Oldham & Bury) and Royal Bolton
Trust. In reach involves a Specialist Consultant attending the local hospital to provide renal
advice or management at the local hospital for inpatients. WWL and SRFT have not had
such an arrangement in place. However in recent weeks SRFT and WWL have worked
collaboratively to address this gap and discussions are in their final stages. Consultants
have been recruited and subject to the human resource checks it is expected they will be
available to commence an ‘in reach’ service at WWL from 7" August 2017. This replicates
the model of medical care currently provided to Bolton, Bury, Rochdale, and Oldham for
patients requiring renal input.

We hope that this response provides assurance to you and Mrs Derbyshire’s family that
Salford Royal NHS Foundation Trust and Wigan Wrightington and Leigh NHS Foundation
Trust have worked hard and continue to focus on ensuring that lessons have been learned
and improvements have been or can be made.

Please do not hesitate to contact us if you require any further information in relation to our
response.

Yours sincerely

hls cere

Chief Officer Salford Care Organisation

Wrightington, Wigan and Leigh INHS

NHS Foundation Trust

Legal Services Department
Trust HQ

Royal Albert Edward Infirmary
Wigan Lane

Wigan

WN1 2NN

Tel: 01942 822937/2172
Fax: 01942 8224

Web: www.wwi.nhs.uk

Mr Timothy Brennand
Assistant Coroner
Manchester West

HM Coroner’s Office
Paderborn House
Howell Croft North
Bolton

BL1 1QY

31 July 2017

Dear Mr Brennand
Regulation 28 Response: Katherine Anne Derbyshire (Deceased)
Thank you for your Regulation 28 report dated 16" June 2017.

I understand that an inquest relating to the death of Katherine Anne Derbyshire took place on 19"
May 2017. I have been fully advised of the circumstances relating to Mrs Derbyshire’s death and have
read your report. I am grateful to you for bringing these concerns to my attention.

I would like to take this opportunity to respond to the issues raised in your report and to advise you of
the actions already undertaken by Wrightington, Wigan and Leigh NHS Foundation Trust (“the Trust”)
and the ongoing action in respect of this matter.

Tam aware that you have the following concerns regarding the care provided to Mrs Derbyshire:

1. Although Mrs Derbyshire was correctly assessed for transfer to Salford Royal for ongoing
dialysis, no transfer in fact took place. By the time a bed became available on 20" December
2016, Mrs Derbyshire’s condition had deteriorated to the extent that transfer could not take
place. Whilst there was evidence of an active plan of management in the treatment and care
of the patient as between the two hospitals, that plan did not provide for action to be taken in
the event of the deterioration of the patient as observed in this case;

2. At the RAEI it would have been possible to have considered haemofiltration as a temporary
measure, however the evidence suggests that this possible alternative was not considered
earlier and the reason for the deferment of an alternative temporary dialysis at RAEI was the
expectation of a bed becoming available at Salford Royal Infirmary. There is no evidence that
the clinical needs of the patient had been triaged in a manner that effected transfer at an

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Chairman: Robert Armstrong No
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Chief Executive: Andrew Foster CBE

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appropriate stage of her treatment and care. The quality of communication between 14" and
20" December 2016 raises a fundamental issue of concern in the appropriateness of her
treatment and care, in light of the fact the patient was last dialysed on 4 December 2016.
There was no evidence available at Inquest as to when RAEI was informed by Salford Royal
Infirmary that a bed was or would be available for the patient.

3. This case raises issues as to the nature and extent of communication between the two
hospitals and the management of patients admitted at RAEI requiring ongoing dialysis
treatment and care.

As you will be aware, renal care is a regionalised service with the specialist renal team based at
Salford Royal Infirmary (SRFT). It may be of some assistance if I briefly set out below the chronology
of Mrs Derbyshire’s care and the daily discussions with the renal team at SRFT:-

12/11/2016 - Mrs Derbyshire was admitted to RAEI and diagnosed with presumed blockage and a
suspected intra-peritoneal infection. Antibiotics were commenced for suspected bacterial peritonitis
(as per Hospital microbiology guidelines). Plans were made to discuss with renal team at SRFT
regarding the problems with peritoneal dialysis.

13/11/2016 — Mrs Derbyshire was transferred to Billinge Ward. No medical review undertaken as this
was the weekend, however nursing monitoring was undertaken regularly, all Mrs Derbyshire’s care
needs met and her medications were given as prescribed.

14/11/2016 — Mrs Derbyshire’s condition and treatment was discussed with the peritoneal sister and
the renal SpR at SRFT. The renal advice was that Mrs Derbyshire did not require urgent dialysis in
light of her Us & Es. The renal SpR agreed with the WWL clinician that Mrs Derbyshire required
transfer to SRFT for care optimisation. WWL were informed that the SpR would liaise with the ward to
facilitate the transfer; however it was noted that there were currently no beds available. SRFT advised
WWL to get a CT scan given Mrs Derbyshire’s drowsiness and to be careful when administering IV
fluids as she was at risk of overload. This advice was followed.

15/11/2016 — Mrs Derbyshire’s condition and treatment was discussed with the renal SpR at SRFT. It
was advised that urgent dialysis was not currently required on the basis of Mrs Derbyshire’s test
results. WWL were informed that Mrs Derbyshire was on the list for transfer however no bed was
currently available. The treatment plan noted to provide a daily update to the renal team at SRFT, or
sooner if there were any acute changes.

16/11/2016 — Mrs Derbyshire’s condition and treatment was again discussed with the renal SpR at
SRFT. It was confirmed Mrs Derbyshire’s observations were stable, her blood results were noted and
she was not currently fluid overloaded. SRFT confirmed that there were still no beds available to
facilitate the transfer, however stated that they would transfer at the earliest opportunity. WWL were
advised to continue the current treatment plan and fluid management.

17/11/2016 — Again Mrs Derbyshire’s condition and treatment was discussed with the renal SpR at
SRFT. It was noted that SRFT still did not have any available beds, however WWL were reassured that
Mrs Derbyshire was on the transfer list and would be contacted as soon as a bed became available.
The renal SpR advised that Mrs Derbyshire be given oral bicarbonate, this was therefore commenced.
It was noted in the treatment plan that Mrs Derbyshire may not be a suitable candidate for ICU and
haemofiltration.

18/11/2016 — WWL were contacted by SRFT at around 15.30 and informed that a bed was available
for Mrs Derbyshire. The ward booked an ambulance from the North West Ambulance Service (NWAS)
for the transfer immediately at 15.30. Unfortunately there was a delay in the ambulance arriving on
time. By the time the ambulance was available to transfer Mrs Derbyshire, WWL were informed by
SRFT that the renal team would not accept the patient as it was after 9pm and so the ambulance
transfer was to be re-arranged for the following morning.

19/11/2016 — Mrs Derbyshire’s condition and treatment was discussed with SRFT. WWL were told that
there was now no bed available for the transfer of Mrs Derbyshire and were informed that there were
two other patients now on the transfer list above Mrs Derbyshire, indicating that these patients had
more urgent clinical requirement for the renal beds at SRFT.

20/11/2016 — A further discussion was had with the renal SpR at SRFT in relation to Mrs Derbyshire’s
condition and treatment. It was noted that Mrs Derbyshire’s condition had now deteriorated to the
extent that she required dialysis. Unfortunately, there were still no beds available for a transfer to
SRFT. WWL were advised to speak to their ICU department for consideration of haemofiltration.

Mrs Derbyshire was reviewed by I (ST7 Intensive Care) at 12.30 hours on 20 November
2016. SE noted that haemofiltration would be a temporary measure and would be unlikely to
have helped Mrs Derbyshire to return to her previous state. Mrs Derbyshire’s condition and treatment
was discussed with [J (Consultant Intensivist) and with (Consultant in Renal Medicine at
SRFT) and on the basis of a risk-benefit analysis the conscious decision was taken that further renal
therapy would not be in Mrs Derbyshire’s best interests. The decision included consideration of Mrs
Derbyshire’s very poor functional baseline leading up to her hospitalisation, her poor quality of life on
such treatment and the fact that she was close to the end of her life. Given the overall clinical picture,
the benefits regarding the institution of renal replacement were limited, and were not likely going to
increase the length or quality of Mrs Derbyshire’s life.

There were also significant risks associated with the commencement of renal replacement therapy in
ICU, these included the risk of haemorrhage, hypothermia and line infection. Following discussion with
Mrs Derbyshire’s son, the medical team at WWL and the renal physicians at SRFT on 20 November
2016 it was agreed not to institute renal replacement therapy either in ICU at WWL or at SRFT.

At 13.00 on 20/11/2017 WWL were informed by SRFT that a bed was available for Mrs Derbyshire
however following the discussions as noted above, it was decided that palliative care at RAEI was the
best option.

I appreciate that there were significant difficulties in facilitating the transfer of Mrs Derbyshire’s care
to SRFT due to the unavailability of a bed. This may have been compounded by the centralisation of
services and the demands on NHS resources. However, I appreciate that this is not acceptable and did
not represent the best quality of care for Mrs Derbyshire.

WWL is committed to working in partnership with other NHS Trusts to offer the best possible care to
all patients. I have therefore been informed that our Medical Director, [Nas taken this
issue forward with i the Medical Director at SRFT. There is ongoing communication
between the Medical Directors to progress this matter.

A working group is also to be set up to include clinicians from both Trusts, led by i a
Consultant in Acute Medicine at WWL, to prepare a pathway to facilitate the safe transfer of patients
as soon as a bed becomes available and to ensure that there continues to be effective communication
with SRFT.

An in-reach service is also to be implemented, this will be a service offered by SRFT where Renal
Consultants will undertake 2.5 sessions of direct clinical care to in-patients at WWL every week. This
will ensure that in-patients receive specialist renal assessment and treatment and will help reduce the
length of stay of renal patients and free up acute bed stock faster and more frequently.

The two Trusts are also working together to implement a system which will enable the instant and
electronic referral of patients to the on-call Renal team (based at SRFT). The system will allow timely
advice to be provided and will ensure that all conversations between the referring Trust and the Renal
Centre are clearly documented.

It is very clear from Mrs Derbyshire’s records that there was a high level of daily communication with
the renal team at SRFT to discuss Mrs Derbyshire’s condition and treatment and to enquire if a bed
was available for transfer. The Trust therefore, respectfully disputes the suggestion that the quality of
communication with SRFT between 14 and 20" November 2016 raises a fundamental issue of
concern. The advice of the renal team at SRFT was requested daily, the recommended treatment plan
was Clearly documented in Mrs Derbyshire’s notes and was followed accordingly.

In response to your concern regarding the lack of evidence of a plan for the action to be taken in the
event of the deterioration, please be reassured that when Mrs Derbyshire’s condition deteriorated on
20" November 2016, her treatment was again discussed with the renal team at SRFT and only at this
stage was the advice given to discuss haemofiltration with ICU. The Intensive Care team promptly
reviewed Mrs Derbyshire and as noted above, made a difficult risk-benefit assessment to decide on
the appropriate treatment for Mrs Derbyshire, following consultation with her family and all the
clinicians involved in her care. Prior to this deterioration, Mrs Derbyshire’s condition did not require
urgent dialysis and whilst consideration was given to haemofiltration, as noted in Mrs Derbyshire’s
notes on 17 November 2016, it was concluded that Mrs Derbyshire was not suitable for this
treatment. Mrs Derbyshire’s condition was being closely monitored and the advice of the renal team
followed whilst awaiting transfer to SRFT.

Continued action

As noted above significant discussions have already taken place between WWL’s and SRFT’s Medical
Directors and the following actions will be taken:-

e Aworking group to create a pathway to facilitate the safe transfer of patients and to consider
any further action which can be taken to avoid delays in the transfer of patients to SRFT

e 2.5 weekly in-reach sessions to be provided by SRFT renal consultants for in-patients at WWL.

e On-Call electronic service to be introduced to facilitate the instant referral of patients to the
on-call team to allow timely advice to be provided.

The above actions will be monitored via the Trust’s Quality and Safety Committee which is chaired by
a Non-Executive Director and attended by several members of the Executive team, including the
Medical Director and Director of Nursing.

I hope the above response is a testament to how seriously the Trust considers the concerns raised by
Mrs Derbyshire’s death. I can reassure you that WWL will continue to work with SRFT and other
Trusts to try to avoid delays in transferring patients. Unfortunately however, if a patient requires
transfer to another Trust for specific treatment, WWL cannot facilitate this transfer until a bed
becomes available. The Trust then offers the best treatment to optimize care in the interim.

In Mrs Derbyshire’s case there was an unfortunate delay in a bed being available at SRFT, the Trust
therefore provided the best care they could to Mrs Derbyshire, in accordance with the advice of the
renal team at SRFT to treat her condition whilst awaiting the transfer. Very sadly Mrs Derbyshire’s
condition deteriorated to the extent that a transfer was no longer a suitable option. Our priority then
was to make her last couple of days as comfortable as possible. I pass my sincere condolences to Mrs
Derbyshire’s family for their loss.

If you have any comments or suggestions in relation to the proposed actions above, I would be only
too pleased to hear from you.

Yours sincerely

AULE

Andrew Foster CBE
Chief Executive