Constance Connolly

King’s College Hospital

NHS Foundation Trust

Your ref: 00692-16 Legal Services
Our ref: HPOLAT/5154 King’s College Hospital
Denmark Hill
London SE5 9RS

17 August 2017

Tel: 020 3299 3320
. . Fax: 020 3299 3706
Senior Coroner Andrew Harris

Southwark Coroner's Court
1 Tennis Street
Southwark SE1 1YD

By email only

Dear Senior Coroner Harris

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS:
CONSTANCE CONNOLLY (DECEASED)

We write further to the above Report dated 22 June 2017 and detail the Trust's
formal response below.

As a preliminary point, we note that none of the concerns raised in the Report
caused or contributed to Mrs Connolly's death in light of the Conclusion reached at
the Inquest hearing on 24 May 2017, namely “Natural causes contributed to by
unintended consequences of necessary medical treatment”. The Report in particular
states that no failures of care contributed to Mrs Connolly's death.

However, there are learnings from this case, and as a Trust, we are committed to
ensuring appropriate changes are implemented to continue to improve patient care.

There were two Trusts closely involved in Mrs Connolly's care prior to her death on 8
March 2016, namely our Trust and Guy’s and St Thomas’ NHS Foundation Trust
(“GSTT”). Whilst we do not directly comment on the care provided by GSTT, we
note relevant discrepancies in the evidence that arose during the Inquest Hearing.

Matter 1

The doctor who ordered the scan did not conduct any follow up to see that it
had been performed. The Consultant chest physician said that handover of
care was “dangerous time” and that it was his duty to do so.

Trust response

Mrs Connolly was planned for admission to King's College Hospital (“‘the Hospital”)
following her presentation to the Emergency Department (“ED”) team with
symptoms suggestive of a stroke. A CT head scan was undertaken, and an MRI

head scan was advised as the next step. By this stage, she was planned to be an in-
patient and under the care of the Medical rather than the ED team. As such, her care
was transferred to Acute Medicine and the request was submitted for an in-patient
MRI scan to be performed.

Prior to the MRI scan request being processed, Mrs Connolly (with the support of her
daughter) self-discharged, as both wished to continue care under the GSTT
Palliative Care team who were managing her community care.

One of the junior doctors in Medicine therefore telephoned a member of the GSTT
Palliative Care team that evening to update them. The junior doctor believes he
spoke with the GSTT Clinical Nurse Specialist (“CNS”). The junior doctor was
informed that the CNS was due to visit Mrs Connolly the following day with one of
the Palliative Care Consultants. This visit did subsequently take place.

As Mrs Connolly had self-discharged before the MRI scan request could be
processed, the request was transferred to an outpatient appointment by the
Radiology staff, who noted the discharge on the patient tracking system, and Mrs
Connolly was placed on the waiting list for the next available appointment. Sadly, the
appointment fell on a date after Mrs Connolly had died. The Medical team
communicated to the Palliative Care team, as well as Mrs Connolly and her
daughter, of the importance of having an MRI scan.

The Trust agrees follow-up of patients in terms of proposed investigations is the
responsibility of the team who has ordered the investigation(s). An outpatient MRI
scan appointment was made, but this should have been communicated more clearly
to the GP. The “virtual review’, as described below under Matter 2, should facilitate
clearer communication to health care colleagues, patients and families.

Matter 2

The referring doctor notified the GSTT Community Palliative Care team of the
need to organise a MRI scan, on the understanding that the team was taking
over care. The Consultant in the Palliative Care team explained that their rote
was to advise the doctor responsible for care, which was at the time, the
General Practitioner.

Trust response

Given Mrs Connolly had self-discharged with an MRI scan pending and indicated (in
addition to her daughter) that she wanted her care to remain under the GSTT
Palliative Care team, the Trust assessed that after already communicating with the
GSTT Palliative Care team, that team would now take the care forwards. This was
on the basis that the GSTT Palliative Care team’s role has not been explicitly
clarified. It is, however, accepted that investigation and management of an MRI scan
would not ordinarily be undertaken by a Palliative Care team.

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It is also accepted that if a formal Discharge Notification to the GP had been
completed at the time Mrs Connolly self-discharged, the GP would have been made
aware of the Trust’s advice for Mrs Connolly to undergo an MRI scan. Unfortunately,
the Discharge Notification generated related to her presenting complaint only (for
reasons explained below under Matter 3) and was not updated with the CT scan
result, which raised the issue of additional investigations. Notwithstanding this, an
outpatient MRI scan appointment was booked by the Trust, albeit on a date that fell
after Mrs Connolly had died.

This case has highlighted the importance of clear communication on the specific
rales to be played by members of healthcare teams in arranging and being
responsible for follow-up investigations.

It is now possible for the Trusts and local GPs to view records of patients at GSTT
and vice versa through the Local Care Record, which shows key documents and
discharge summaries.

Steps have been taken to ensure that regardless of patients self-discharging, a
formal Discharge Notification is always sent to a patient's GP, setting out all relevant
tests/assessments performed and any follow-up arrangements if applicable.
Responsibility sits with the admitting Consultant and Ward Managers, and this will be
included in the junior doctors’ induction information package.

Finally, as mentioned above under Matter 1, the Trust is committed to ensuring the
post-take Consultant undertakes a “virtual ward round” of any patient who has self-
discharged during the take period, and reassures themselves they have received
appropriate follow-up by way of signposting, appointments or otherwise.

Matter 3

The discharge note to the GP from A&E indicated a diagnosis of stroke
(presumed before CT scan), did not mention the CT finding of cerebral lesions
that may be metastases, nor the need for EMI scan and further investigation to
confirm diagnosis, nor the booking of a MRI scan.

Trust response

ED GP Discharge Notifications are generated from information populated in the ED
tracking system (Symphony) with an_ initial ‘working diagnoses’ list. They are
generated at 0300 hours the night after patients are seen in ED and sent in batches.
Investigation results are only included automatically into GP letters from the Trust's
Electronic Patient Records system once the test results are verified. With CT head
scans, there is a requirement to be verified by Neuroradiology, which would have
occurred the next morning.

In this case, as Mrs Connolly attended the Hospital's ED as a blue light “stroke call”,
she was assessed and managed as such by the Stroke team with a reasonable

working diagnosis of “CVA , cause unknown/stroke” recorded by the ED team at the
time of her attendance. This explains why there was a “diagnosis” of stroke on the
ED Discharge Notification.

Further, the verified CT scan report was not available when the ED GP Discharge
Notification was sent and so it was not pre-populated.

The ED GP Discharge Notification states in a footnote that radiology results take 24
hours to be reported as well as the fact that the preliminary working diagnosis may
change following patient admission and further investigation.

Finally, the MRI scan is not mentioned on the ED GP Discharge Notification, as this
decision was made in conjunction with the admitting Medical team.

We accept this pathway can be improved and as mentioned above, the “virtual
review’ of all self-discharged patients will ensure we provide appropriate care to all
our patients and that this is Consultant-directed.

The ongoing steps to improve the Trust’s communication with patients’ GPs and
other healthcare colleagues are outlined below, specifically pertaining to the ED
environment:

e There is currently a national recommendation from the Royal College of
Emergency Medicine to improve and standardise communication from all
Emergency Departments to GPs by October 2017 (the "ECDS” or Emergency
Care Data Set). The ED’s IT team are working to implement this and this will
include a mandatory ‘suspected and confirmed diagnoses’ step on all ED
discharge letters to GPs with details of who wrote the discharge notification
and the identity of the senior clinician overseeing the patient's care.

¢ The Trust is developing a Trust-wide best practice guide on Discharge
Notification and clinic letter writing for clinical staff, in collaboration with the
local CCGs. This will include clarification that a discharge notification is
required for all patients who self-discharge.

*® The ED tracking system (Symphony) is planned for an upgrade, which is due
by October 2017. This will enable ED GP Discharge Notifications to highlight
and distinguish which investigations have been done (ideally with a result if
verified), which are booked and which are still pending.

The Hospital’s ED team are also due to appoint a new administrator to ensure
communication and follow-up of abnormal radiology results for ED patients occurs
appropriately and especially if reported as abnormal after they are discharged from
ED.

Matter 4

A member of the Palliative Care team rang the A&E department and was told
that the scan appointment was the next day 17"), When the patient and her
daughter attended the next day, she was told that there was no appointment.
Evidence was heard that the booking, which was on the basis of being an in-
patient, is automatically cancelled if the patient becomes an out-patient and
the clinical referral cannot be transferred to an outpatient appointment. A new
referral and form needed to be completed. So the patient went home, and no
further appointment was made.

Trust response

Whilst the Trust has no record of such a telephone conversation between the GSTT
Palliative Care Team and any ED clinician, we recognise the importance of
healthcare teams always accurately recording such conversations between teams.

At the time when the in-patient MRI scan was requested on the evening of 16
February 2016, the scan was simply classified as “pending”. These requests remain
as pending until assessed by the Radiology team in daytime hours. In this case, the
request was placed on the waiting list for the next available appointment on 17
February 2016. It was clear to the Radiology team that Mrs Connolly was no longer
an in-patient at the Trust, and as such the appointment was rescheduled as an
outpatient.

We are, as described above, now setting up a “virtual review’ of self-discharged
patients to ensure any investigations or follow-ups can be appropriately actioned.

The Trust is committed to continually improving its services so that patient safety
remains the priority. On behalf of the Trust, we would like to express our deep
condolences to Mrs Connolly's family, and wish them well for the future.

Please do not hesitate to contact us should you require any clarification or further
information.

Yours sincerely

KCH

Legai Services

The Royal College of Emergency Medicine

Patron: HRH Princess Royal

7-9 Bream’s Buildings Tel +44 {0}20 7404 1999
London Fax +44 (0)20 7067 1267
EC4A 1DT www.tcem.dc.uk

Dr Andrew i

Southwark Coroners Court
1 Tennis Street
Southwark

SE1 1YD
27 Suly 2017

Dear Dr Harris,
Re: PFD report touching the death of Constance Connolly

Thank you for asking us to consider the case of Constance Connolly. We appreciate
that this case raises important issues for the Royal College of Emergency Medicine.
We have previously been concerned about the governance of on-going care for
patients after they leave the emergency department. To this end, we have recently
issued guidance to our Fellows and Members about ensuring test results are followed
up in two documents, ‘Management of Investigation Results in the ED' and
‘Management of Radiology Results in the Emergency Department’.

While these guidelines promote good governance about investigations that have
already been performed, these do not address all of the issues identified in the
report. In addition, we are preparing a safety alert for September 2017, reminding
Members and Fellows to ensure follow up arrangements are adequate for patients
discharged from the emergency department. We are considering, through our
Quality in Emergency Care Committee, whether there is a need for further guidance
about on-going care for patients discharged from the emergency department.

Yours sincerely,

Gordon Miles
Chair, Quality in Emergency Chief Executive
Care Committee

Excellence in Emergency Care
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