Dennis Teesdale

CareQuality Pee
Commission no inal nformation

Gallowgate
Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161

West Sussex Coroner Fax: 03000 616171

Record Office

3 Orchard Street
Chichester
West Sussex
PO19 1DD

1 August 2017
By email: hm.coroner@westsussex.gov.uk

Care Quality Commission
Our Reference:

Dear HM Coroner

Prevention of future death report following inquest into the death of Mr
Dennis Allen Teesdale

Thank you for sending CQC a copy of the prevention of future death report
issued following the Inquest into the death of Mr Dennis Allen Teesdale

The trust declared Mr Teesdale’s death as a serious incident and the Director of
Nursing reported this to CQC in a telephone call in October 2016. After reporting
to us verbally, the trust also included details of the death in their monthly
monitoring report for October 2016. We received this report on 16 November
2016. This read; “Major Harm Incident: 1D16653. A major oncology patient
developed signs of peritonitis post-surgery. The patient was transferred to BSUH
and subsequently died. Care was provided at both Trusts, and the QVH
investigation is underway”.

Following an initial investigation, the trust's Medical Director chaired a meeting
with the maxillofacial consultants on 7 December 2016 to review the events
leading to Mr Teesdale’s death. This included a mortality and morbidity review,
which noted consultant involvement, discussion of the ultrasound scan, delay in
CT scan and co-location of services discussion. At this stage, the trust reviewed
national enteral feeding guidance (2015) and began to make changes to trust
policies to bring it in line with national guidance, reviewed an audit of the last 10
years of PEG insertion at QVH, which determined that the trust was not an outlier

for morbidity or mortality, and began to review training standards for PEG
placement.

The trust carried out a root cause analysis (RCA) investigation and agreed to
share this with CQC as soon as it had been approved by the local Clinical
Commissioning Group (CCG). We received this on 11 July 2017. The trust
attributed the delay in sharing the RCA to delays in it being reviewed and
approved by the CCG.

The trust uploaded the completed RCA to the Strategic Executive Information
System (STEIS), on 23 February 2017. STEIS is NHS England's web-based
serious incident management system, through which healthcare providers record
incidents. It was re-submitted to the CCG on 31st March 2017, due to a change
in formatting requirements, but with unchanged content. In preparation for, and
during, the inquest touching on the Mr Teesdale’s death, conducted by the
Assistant Coroner for West Sussex on the 17th and 18th May 2017, it became
apparent to the trust that the original RCA was not sufficiently rigorous to
examine the care provided to the patient properly. The trust subsequently made
additions to the RCA, incorporating issues raised by the inquest, concerns raised
through the Section 28 Report to Prevent Future Deaths, and the reflections of
staff involved. CQC’s National Professional Advisor for Surgery,

reviewed the revised RCA on 18 July 2017 and described it as,
“Extremely comprehensive’.

We requested a number of other documents from the trust, including care
records, policies and procedures, which the trust supplied willingly and within the
requested timeframes. At an engagement meeting with CQC on 29 June 2017,
the trust provided us with a 12-page action plan giving evidence of ongoing
learning and changes to practice as a result of Mr Teesdale’s death. The trust
sent CQC an updated version of the action plan on 10 July 2017. We reviewed
this and found it to be very comprehensive.

The trust have carried out 16 percutaneous endoscopic gastrostomy (PEG) tube
insertions since Mr Teesdale’s death, with two of these taking place since the
inquest. The trust’s lead cancer nurse is auditing all PEG insertions since
January 2017 to provide assurances patients have received safe care and
treatment. The trust have shared their audit tool with us, and we saw that this will
allow the trust to provide assurances around areas including multidisciplinary
involvement, risk assessment, and contraindications. CQC will request that the
trust send us a copy of the completed audit by 30 September 2017. We will
subsequently review the audit to obtain assurances of safe care and treatment.

We last inspected the registered provider, The Queen Victoria Hospital NHS
Foundation Trust, on 11 and 12 November 2015, with an unannounced visit on
23 November 2015. We rated the provider as Good overall, with an Outstanding
rating for the caring domain. However, we issued the trust with two requirement

notices where they were not meeting the requirements of the Health and Social
Care Act (Regulated Activities) Regulations 2014. One of these related to a
breach of Regulation 18(1) Staffing. The inspection report stated, “Sufficient
numbers of suitably qualified, competent, skilled and experienced persons must
be deployed in order to meet the requirements of the patients out of hours”. This
related to out-of-hours medical cover.

The trust subsequently produced an action plan to address areas for
improvement. The action plan showed that the trust increased anaesthetic
consultant on-site out-of-hours presence, with on-site anaesthetic consultant
cover from 8am to 8pm on weekdays and 8am to 5pm at weekends. These
changes were funded and described in job plans, in addition to existing on-call
commitments, in July 2016.

Since our last inspection, we have maintained regular contact with the trust
through regular engagement meetings and monthly quality monitoring reports.
Since the monthly monitoring report for October 2016, which we received on 16
November 2016, subsequent reports did not contain any new information
regarding Mr Teesdale’s death. CQC receive very little direct feedback on the
trust from patients, and most of this is positive. Our next scheduled inspection will
take place in 2018-19 as part of CQC’s national second wave of NHS trust
inspections.

In response to the matters of concern raised following the inquest:

(2) There are no facilities or clinicians (radiologist or gastroenterologists who
normally undertake such procedures) available to place a PEG prior to surgery,
thereby requiring oral maxillo-facial surgeons of variable and unclear experience
to undertake the procedure peri-operatively.

The trust provided us with data showing that they undertook 33 PEG insertions in
the 12 months prior to the incident. The lead consultant carrying out Mr
Teesdale’s procedure had performed nine of the 33 PEG insertions. The second
consultant assisting with the procedure had recently commenced a locum post at
the trust, and this was the first PEG insertion he had assisted with since his
appointment at the trust. We asked the trust how they were assured of the
competencies of the locum consultant. The trust told us they had obtained
assurances of the locum consultant's competencies through the application
process and medical HR checks to gain evidence of previous experience. The
trust told us that where these processes did not provide sufficient assurances of
a consultant's competency to carry out particular work, then the consultant would
complete a period of supervised practice as part of their induction. CQC’s
National Professional Advisor for Surgery has confirmed that no national
guidance currently exists that dictates PEG insertion must specifically be carried
out by radiologists or gastroenterologists. CQC’s National Professional Advisor
for Surgery feels it is appropriate that there is no national guidance to dictate the

specialty of medical professionals carrying out PEG insertion. He is of the opinion
that competence, not specialty, is important and gave an example of a specialist
nurse being trained to run the PEG service at another acute NHS Trust.

The RCA investigation stated the trust places approximately 30 - 50 PEGs per
annum, and over 360 in the last ten years. The lead surgeon in this case has
placed 76 of these. This is the first death directly attributable to a complication
from PEG placement.

Two consultants undertake PEG insertion at the trust, with one consultant
operating the scope and a second consultant inserting the trochar. The trust
changed its policy following Mr Teesdale’s death to ensure that only consultant-
grade staff undertook PEG insertions (although the trust have informed us that
two consultants carried out the PEG insertion for Mr Teesdale). For assurances
around the competency and training of consultants following learning from this
incident, we would respectfully refer to point (5) of this response.

Regarding the issue of the PEG being placed peri-operatively, the trust is
obtaining an external review of its current PEG practices as part of the action
plan following learning from Mr Teesdale’s death. A review is currently being
carried out by surgeons from other trusts, including a consultant gastro-intestinal
surgeon. We will obtain assurances around any further changes to practice
following the review as part of our routine engagement with the trust.

(3) Written guidance by the surgeons for insertion of PEGs was not followed, with
little reflection as to whether this was an acceptable procedure given Mr
Teesdale's previous extensive surgery at or around the point where the PEG was
inserted with concomitant poor gastroscopic trans-illumination.

We asked the trust to provide us with the reasons consultants did not follow trust
policies for the insertion of PEGs. The trust provided a detailed clinical
explanation; however, they recognised that the treating consultants had failed to
document the reasons for this decision in the patient notes. The trust told us the
treating consultant was unaware that upper abdominal surgery was listed as a
contraindication in the QVH PEG guidance.

The trust introduced a “PEG Pathway” document following learning from Mr
Teesdale’s death, which has been in use since 5 June 2017. We saw that this
provides clear guidance to clinicians on the decision to insert a PEG. This
document is to be completed for every patient having PEG insertion, and there
are clear prompts and contraindications to guide consultants. The trust also
revised their Enteral Feeding Guidelines in March 2017 and circulated these to
relevant medical staff on 23 May 2017 following approval at the trust's Clinical
Governance Group. This was to ensure all treating consultants were aware of the
trust policy, including contraindications for PEG insertion.

The trust's action plan includes plans for a prospective PEG audit to provide
themselves with assurances staff are following the new Enteral Feeding
Guidelines and PEG guidance. This includes assurances around multidisciplinary
documentation, PEG Pathway completion, consent and NPSA stickers. However,
the audit is not yet in place as only one PEG has been inserted since the new
PEG Pathway was introduced. We will monitor this point on the action plan
through our ongoing engagement with the trust.

(4) No risk assessment was undertaken as to whether a PEG insertion would
have been appropriate, given that a non-invasive alternative of a feeding tube for
enteral feeding was available.

We asked the trust for a copy of any risk assessment undertaken before Mr
Teesdale's surgery. The trust told us there was no risk assessment documented
in the medical notes. Since this incident, the trust has developed and introduced
a PEG pathway (please see point (3) for further details) and amended the enteral
feeding guidance. We saw that the PEG Pathway prompts consultants to carry
out a risk assessment if there are any contraindications. The trust confirmed that
all consultants are expected to carry out an individualised risk assessment and to
document this in the patient's notes if the PEG Pathway indicates a need for risk
assessment.

Although the trust carried out two PEG insertions since the inquest, only one of
these took place after they introduced the new PEG Pathway on 5 June 2017.
The trust confirmed the PEG Pathway was followed for this patient. We will
continue to monitor the trust's prospective PEG audit, which will capture this
information, as part of our ongoing engagement with the trust.

(5) No formal ‘training’ programme for the insertion of PEG or independent
competency based assessment

Following learning from Mr Teesdale’s death, one of the points on the trust’s
action plan was to “explore training courses for clinicians putting in PEGs
(technical skills)’. There is also an action to include PEG training in trainee
inductions from 31 July 2017. For trainee doctors who started working at the trust
before this intake, the trust told us learning from Mr Teesdale’s death has been
shared at the quality and governance committee meetings, which have
representation from junior doctors as well as consultants.

A further action is to obtain external oversight of the PEG service (technical and
organisational), and we saw from the trust's action plan that The Queen Victoria
Hospital NHS Foundation Trust is currently working with consultants from a
neighbouring trust to deliver this.

CQC’s National Professional Advisor for Surgery has informed us that currently,
no nationally recognised training courses for PEG insertion exist. His view is that
it would be very difficult to provide a comprehensive training course given that
there are not large numbers of PEG tubes inserted nationally. The important
aspect is that trainees are able to gain experience as available and that they do
not undertake independent practice until signed off as competent. We would
therefore expect registered providers to use their own competency assessment
to provide themselves with assurances that all staff carrying out the procedure
are competent and skilled to do so.

The trust told us that in-house training records provided assurances on the
competencies of doctors trained to carry out PEG insertion by colleagues in the
trust. For consultants joining from other trusts, the trust’s application process and
medical HR checks provided evidence of previous experience. The trust told us
that where these processes did not provide sufficient assurances of a
consultant’s competency to carry out particular work, then the consultant would
complete a period of supervised practice as part of their induction.

CQC will monitor the trust's progress against the action plan as part of our
ongoing engagement with the trust.

(6) The post-operative management of Mr Teesdale did not follow the written
guidance for the management of abdominal pain after PEG insertion. This
resulted in a delay in seeking appropriate advice, timely intervention and optimal
treatment of this complication.

The RCA investigation showed that an ultrasound scan on 18/10/2016 showed a
rectus sheath haematoma, which demonstrated a potential cause of the
abdominal pain. The RCA states, “This may have distracted staff from obtaining
the most indicated radiological examination — a CT scan’.

Following learning from Mr Teesdale’s death, we saw that the trust updated its
Enteral Feeding Guidelines. The revised Enteral Feeding Guidelines were
approved by the trust's Clinical Governance Group in March 2017 and circulated
to relevant medical staff on 23 May 2017. We saw that the revised guidelines
included specific guidance on post-operative pain, with an emphasis on early
escalation and transfer for CT scan. This included a warning triangle to alert
doctors to this section of the guidance, with the following wording, “If there is pain
on feeding, or prolonged or severe pain post-procedure, or fresh bleeding, or
external leakage of gastric contents, stop feed/medication delivery immediately,
obtain senior advice urgently and consider CT scan, contrast study or surgical
review’.

At an engagement meeting between CQC inspectors and the Director of Nursing
at The Queen Victoria Hospital NHS Foundation Trust on 29 June 2017, the
Director of Nursing provided assurances she had discussed in detail the

Regulation 28 Report to Prevent Future Deaths relating to Mr Teesdale with ITU
nursing staff. The Director of Nursing gave reflective structured feedback to ITU
nursing staff, and reported that the ITU nurses feel confident to escalate any
concerns around deteriorating patients to the site practitioner and the director on
call. In a follow-up engagement telephone call on 17 July 2017, the Director of
Nursing was able to give an example of how an ITU sister had challenged a
consultant anaesthetist and requested a CT scan for another patient. This
demonstrates the confidence of ITU nursing staff to challenge consultants and
escalate concerns where applicable.

We will monitor the trust's prospective PEG audit through our routine
engagement. The audit will provide assurances staff have followed trust policy
and escalated any deteriorating patients following PEG insertion in a timely way.

(7) Mr Teesdale’s transfer was delayed because of a reluctance to transfer in the
immediate post-operative period complicated by the associated logistical
difficulties of doing so given his major surgery.

The RCA investigation showed Mr Teesdale’s condition deteriorated around
02:00 on 19 October 2016. The RCA investigation recognised, “The decision to
defer referral until the morning ward round was made with the knowledge that a
transfer out of normal working hours would present a logistical challenge”.

The trust's revised Enteral Feeding Guidelines (March 2017), described in point
(6) of this response, address the urgent need to transfer patients when there are
signs of post-operative peritonitis following PEG insertion. The revised Enteral
Feeding Guidelines state the following:

“Interventions in signs of localised peritonism / pain:

Stop feed, check length

Clinical examination

Blood gas, inflammatory markers

Erect AXR/CXR

Early review with hourly observations

Early consideration of CT scan

Interventions in signs of spreading / generalised peritonism
Stop feed, check length

Clinical examination

Blood gas inflammatory markers

Erect AXR/CXR

CT scan as soon as patient can be transferred safely
Early discussion with general surgeons”

The revised guidance addresses the need to seek advice from general surgeons
as early as possible and to transfer the patient for an urgent CT scan as soon as
they are stable enough for transfer.

The RCA investigation showed doctors contacted Brighton and Sussex University
Hospitals NHS Trust (BSUHT) in the morning of 19 October 2016, when the
decision was made to transfer Mr Teesdale. The trust told us the reason Mr
Teesdale was not transferred until 2.10pm the same day was because BSUHT
requested that they carry out plain film x-ray and an enema on Mr Teesdale
before transfer. This resulted in a delay, as the RCA reports that Mr Teesdale
was in too much pain to tolerate an enema, and staff subsequently had to
abandon the procedure.

The trust's adherence to their revised Enteral Feeding Guidelines, including early
escalation and transfer when clinically indicated, will be monitored through their
prospective PEG audit. CQC will monitor the trust's PEG audit as part of our
routine engagement.

(8) As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical
specialist experience to assist when patients develop complications. As a
consequence, there was no specialist available to assess Mr Teesdale’s
abdominal pain as detailed in guidance of post-operative pain following PEG
insertion. No effort was made to seek such expert advice during ‘daytime working
hours’.

Following learning from Mr Teesdale’s death, the trust has changed its practices
around ITU medical staffing. At an engagement meeting between CQC
inspectors and the trust's Director of Nursing on 29 June 2017, the Director of
Nursing informed us that a consultant anaesthetist is now the clinical decision-
maker in ITU. The provision of on-site clinical specialist expertise to respond to
post-operative pain, in the form of on-site consultant anaesthetist cover between
8am and 8pm, Monday to Friday, and 8am to 5pm on Saturdays and Sundays,
with on-call consultant anaesthetist cover outside these hours to assess and
provide guidance on post-operative pain in ITU patients, has provided us with
assurances the trust has taken action in relation to this concern to prevent future
deaths.

(9) Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial
surgeon with unknown general surgical experience who did not recognise or
manage the severity of a surgical complication.

The trust provided us with details of the out-of-hours medical staffing during Mr
Teesdale’s post-operative stay at Queen Victoria Hospital. These were an ST6
anaesthetics registrar (resident on-call), ST3 maxillofacial registrar on-call, (the
STR registrar provided out of hours medical care to the patient). ST plastic

surgery (on-call), CT plastic surgery (resident on-call). There were consultants
on-call in anaesthetics, maxillofacial surgery, plastic surgery and ophthalmic
surgery.

CQC's National Professional Advisor for Surgery is of the view that, as there is
no general surgeon on site, the trust should have immediate access to the
appropriate advice from a general surgeon as and when required. The trust has
this through their service level agreement (SLA) with Brighton and Sussex
University Hospitals Trust (BSUHT). This SLA was in place at the time of Mr
Teesdale’s death, however, QVH staff did not escalate quickly enough. We would
respectfully refer to point (7) of this response for actions the trust has taken to
prevent similar delays in escalation and transfer for other patients.

(10) There was no recognition of how unwell Mr Teesdale was on the consultant
surgical ward round at or around 0900 on the 19" October 2016, despite
considerable evidence present at the time that Mr Teesdale had developed multi-
organ failure.

The trust told us they use an S-BAR (Situation, Background, Assessment,
Recommendation) tool as part of the decision-making tree in ITU. The RCA
showed that the ultrasound scan findings on 18 October 2016, which
demonstrated a diagnosis of rectus sheath haematoma as a potential reason for
Mr Teesdale's abdominal pain. The RCA states, “This provided an unconscious
bias, which prevented medical staff from considering other reasons”.

The trust's revised Enteral Feeding Guidelines (March 2017), described in points
(6) and (7), now address the signs of peritonitis in more detail and provide more
specific guidance to staff to help them earlier detect and escalate urgent
complications before they cause the patient to deteriorate further.

(11) Poor communication between nursing staff, anaesthetic staff and surgical
staff making it difficult to provide an overall consistent and systematic approach
to the management of Mr Teesdale in such a small High Dependency Unit with
an inconsistent presence during the day.

The trust took action to ensure an increased consultant on-site presence
following a requirement notice issued by CQC following our last inspection in
November 2015. These actions are described in the opening paragraphs of this
letter.

In an engagement meeting between CQC inspectors and the trust’s Director of
Nursing on 29 June 2017, the Director of Nursing told us the trust recognised that
failings in communication and documentation were themes that contributed to Mr
Teesdale’s death. Following learning from Mr Teesdale'’s death, the trust included
items on its action plan to improve multidisciplinary communication and
documentation. These were documentation training, multidisciplinary

communication training, and an audit of multidisciplinary contribution to electronic
patient records.

CQC will monitor the trust’s progress against these actions as part of our ongoing
monthly engagement to provide assurances of satisfactory improvement in this
area. 4

(12) There are no haematology or biochemistry services at QVH. A courier
service is required for emergency laboratory tests. This has the potential to either
not request ‘bloods’ and/or a delay in obtaining results. Similarly, there is no ‘out
of hours’ radiology service and there is no CT scanner on site to assist ina
diagnosis (which was required as part of the management guidelines prepared by
QVH).

All patients having major surgery at QVH have an individual pre-operative
assessment with a surgeon. This determines their suitability for surgery at the
hospital, in view of the available on-site facilities. This is recorded in the patient
record.

We saw the trust's SLA with BSUH, which showed that urgent specimens are
received and processed at the lab ready for testing within 1 hour of leaving QVH.
This is an essential pass/fail requirement. The trust told us this target is
monitored as part of monthly key performance indicators (KPIs), and the KPIs
show this target has always been met. The Director of Nursing reported that the
trust regularly meet with BSUHT to monitor performance in this area.

As part of the trust's action plan produced following the inquest into Mr
Teesdale’s death, the trust has put forward a business case for a CT scanner on
site. CQC will monitor the trust’s progress against this action as part of our
ongoing engagement.

Should you require any further information please do not hesitate to contact me.
Yours sincerely

Head of Hospital Inspections

10

Re Philip Dunne MP
Minister of State for Health

Department
of Health Richmond House
79 Whitehall
London
SW1A 2NS

Tel: 020 7210 4850

Our reference: PFD-1086888

Ms Karen Henderson

HM Assistant Coroner West Sussex.
Record Office

Orchard Street

Chichester

PO19 IDD

= A, bho eras [8 Sealer 2017

Thank you for your letter of 7 June 2017 to the Secretary of State about the death
of Mr Dennis Teesdale. I am responding as these matters fall within my portfolio
and I am grateful to you for allowing extra time for the Department to determine
our response.

I was very saddened to read of the circumstances surrounding Mr Teesdale’s death.
Please pass my condolences to his family and loved ones.

Your Report detailed several, serious areas of concern in the care and treatment
provided to Mr Teesdale at the Queen Victoria Hospital, East Grinstead. I can
appreciate how distressing these circumstances must be for Mr Teesdale’s family,
and I am truly sorry that the NHS failed to provide adequate care and treatment to
Mr Teesdale.

You issued your Report to the Queen Victoria Hospital NHS Foundation Trust,
NHS England and the Care Quality Commission (CQC). As the matters you raise
concern specific service quality and patient safety issues, you were right to do so.
In addition, my officials have made enquiries with NHS Improvement, which has
lead responsibility for patient safety in the NHS in England, as well as oversight of
NHS providers.

In light of this incident and the concerns raised, I understand the Surrey and Sussex
Quality Surveillance Group (QSG) agreed to establish a single item QSG to review
the safety and quality issues raised and the action taken to respond to this incident.

NHS England and NHS Improvement co-chaired the single item QSG, held on 3
August, which brought together the Trust, commissioners and regulators to review
the mitigation plans, gain assurance around the delivery of safe and sustainable
surgical services at the Trust and to identify any system support required.

I am advised that Professor Sir Bruce Keogh, Medical Director NHS England, has
responded to you with details of the action being taken following the meeting of
the QSG. You will therefore be aware that this includes enhanced governance
arrangements to monitor the implementation of the Trust’s action plan; temporary
cessation of PEG insertion at the Queen Victoria Hospital; and strengthening
partnership working between the Queen Victoria Hospital NHS Foundation Trust
and the Brighton and Sussex University Hospitals University Hospitals NHS Trust,
among other actions.

I am further advised that NHS England is satisfied that clinical outcomes at Queen
Victoria Hospital are, in general, within recognised limits and that current clinical
activity, subject to the restrictions and improvements identified, may continue
while the Trust addresses the issues raised in your Report.

I am informed that the Care Quality Commission will visit the Queen Victoria
Hospital to assess the existence and utilisation of relevant protocols particularly
surrounding the recognition and management of the deteriorating patient, and will
monitor implementation of the Trust’s action plan.

I understand that the Trust has responded to you on your concerns and I hope that
reply is helpful. I am aware the Trust has apologised for the failings identified in
the care and treatment provided to Mr Teesdale, and has detailed the steps it has
taken to learn from his deeply regrettable death.

I hope those responses provide some assurance to you and Mr Teesdale’s family
that the concerns you have raised have been considered carefully.

I would like to assure you that improving patient safety across the NHS is a key
priority for the government. We want to continue improving how the NHS
investigates and learns from mistakes when things go wrong, as we work towards
making the NHS one of the safest healthcare systems in the world,

MR

Department
of Health

The need for an unremitting focus on continual learning in the NHS, to prevent the
same mistakes from happening again, was reinforced in the Care Quality
Commission’s report of December 2016, Learning, candour and accountability: A
review of the way NHS trusts review and investigate deaths of patients in England
(www.cqe.org.uk/content/learning-candour-and-accountability). The review found
that learning from deaths is not being given sufficient priority and that Trusts need
to do more to engage bereaved families.

We are taking forward a national programme with system partners to support
Trusts to improve the way they learn from the deaths of people who were in their
care. This responds to the recommendations in the Care Quality Commission’s
report, all of which were accepted by the Secretary of State. In March, the
National Quality Board responded to one of the highest priority recommendations
by publishing National Guidance on Learning from Deaths
(www.improvement.nhs.uk/resources/learning-deaths-nhs-national-guidance/). The
guidance provides a national framework for Trusts on identifying, reviewing,
investigating and learning from deaths. It also places an important emphasis upon
the need for Trusts to be open with bereaved families and involve them
appropriately in any investigation.

We are also requiring individual Trusts to publish on a quarterly basis from 2017-
18 estimates of how many deaths they could have avoided had care been better.

Finally, I am satisfied that the regulators are alert to the risks you have highlighted,
and it is for NHS Improvement, NHS England and the Care Quality Commission,
working with the Trust and its commissioners, to ensure sufficient and appropriate
action is taken to address the concerns raised. My officials have asked to be kept
informed of developments.

I hope this reply is helpful. Thank you for bringing the circumstances of Mr
Teesdale’s death to our attention.

“Ai

PHILIP DUNNE

Queen Victoria Hospital INHS|

NHS Foundation Trust

Holtye Road | East Grinstead | West Sussex | RH19 3DZ
01342 414000 | info@qvh.nhs.uk
www.qvh.nhs.uk

26 July 2017
Dr Karen Henderson PAT AWE R
Assistant Coroner for West Sussex Ee a 4 i E
West Sussex Record Office ‘
Orchard Street 28 JUL 2017
Chichester
West Sussex
PO19 1DD (9 5 AS LER I LS aLED

Dear Dr Henderson

Thank you for your letter and the attached Prevention of Future Deaths report dated 6 June 2017,
relating to Mr Dennis Teesdale.

| joined Queen Victoria Hospital in November 2017 and soon after joining was made aware of the
circumstances surrounding the sad death of Mr Teesdale on 20 October 2017. | received regular
updates in relation to the inquest and soon after it concluded Dr Edward Pickles, QVH medical
director, briefed myself and the full Board on the inquest findings.

We have carefully considered the concerns highlighted in your report. My response is set out
against each of the concerns raised.

1. Mr Teesdale’s care was compromised by the isolated position and associated lack of
facilities and other sub-specialty medical and surgical clinical personnel able to assist in the
investigation and management of Mr Teesdale at Queen Victoria Hospital, East Grinstead.

Queen Victoria Hospital NHS Foundation Trust (“QVH”) is a specialist surgical hospital. We work in
close partnership with other provider trusts both providing services on other sites and benefitting
from the expertise of clinicians from other provider trusts who work on the Queen Victoria Hospital
site.

The death of Mr Teesdale was as a result of a complication of a percutaneous endoscopic
gastrostomy (“PEG”) tube, in a gentleman with head and neck cancer and significant comorbidities.
The insertion of this PEG was in contravention of our own guideline, which states that previous
upper abdominal surgery is a contraindication for PEG placement at QVH. Specialist opinion and
imaging were available through service level agreements and memoranda of understanding with
Brighton and Sussex University Hospitals NHS Trust (“BSUH’). Regrettably, in the case of Mr
Teesdale this resource was not accessed with sufficient urgency. The Trust sincerely apologises for
this and has learnt from this incident.

The Trust is committed to learning from serious incidents and has made changes to its systems to
minimise the risk of a similar incident recurring in the future, including change of PEG policy, and the
introduction of a PEG pathway checklist. The Trust does not, however, consider that the problems
in Mr Teesdale’s care were caused by a fundamental flaw with the QVH model of working, which is
overseen and approved by regulators and commissioners alike. A copy of the Trust’s updated action
plan is included with this response and further information is given below about the model of
working, QVH facilities and access to additional specialist clinical personnel.

Networked approach to patient care
QVH has formal contracts with a number of other providers as part of a networked approach to
patient care.

We have a particularly close working relationship with BSUH, which includes provision of specialist
input for paediatric services, acute medical and care of the elderly. A memorandum of
understanding between BSUH and QVH has been approved by the QVH board, and is in the
process of being reviewed and approved by the BSUH board. This sets out the nature of the future
partnership between QVH and BSUH, working together across burns, plastics, trauma and
maxillofacial surgery, mitigating co-dependency for both trusts.

Four days a week acute medical physicians are on site at QVH, with an SLA with BSUH. Outside of
these times the service is provided by the on-call acute medical team at the Princess Royal Hospital,
who provide telephone advice and take urgent referrals from QVH. The on-call cardiology team at
the Royal Sussex County Hospital, Brighton, provide this service for cardiology.

Plain radiography is available on-site 24/7, with ultrasound available seven days per week on site.
Consultant radiologists are available 12 hours per day, seven days per week. A mobile MRI
managed service is hosted on site. In the relatively unusual circumstance where a patient needs an
urgent CT scan, urgent CT scanning is provided by Princess Royal Hospital, Haywards Heath, with
a 45 minute transit time. Patients requiring both CT scanning and general surgical opinion are
transferred to Royal Sussex County Hospital, Brighton, with a one hour transfer time.

Admission policies and consultant pre-assessment minimise the risk of needing to transfer patients.
We closely monitor our transfers out for investigation and referral. Our current rate is 0.2% across
adults and paediatrics. This rate reflects the networked care we provide. Guidelines are in place to
support patient transfers when needed. Staff are mindful of the need to seek appropriate referral
when needed, and the learning from this case has reiterated the need for appropriate thresholds.

Oral and Maxillofacial Surgery service

The Oral and Maxillofacial Surgery (“OMFS”) service provides trauma, dento-alveolar, orthognathic
and head and neck oncology surgery. In April 2017 East Sussex Healthcare NHS Trust (“ESHT”)
brought together its inpatient and emergency service for Oral and Maxillofacial Surgery, with the
service at QVH, with consultant surgeons from ESHT operating at QVH. From May 2017, BSUH has
also requested that QVH support the trauma service for their patients in order to provide better safer
care. A consultant maxillofacial surgeon working at BSUH until June 2017 has now been appointed
to QVH, assisting in the understanding of the clinical pathways from both sites.

Head and neck oncology surgical service

The QVH head and neck oncology surgical service is commissioned by NHS England specialist
commissioners and serves patients from across the south east of England. This service is provided
in partnership with head and neck cancer multidisciplinary teams at Maidstone Hospital, BSUH and
the Royal Surrey County Hospital in Guildford. The service is supported by clinical nurse specialists
in head and neck oncology, speech and language therapists with specific experience of working with

head and neck cancer patients, physiotherapists and dietetics. Patient feedback on these specialist
support services is excellent, with 100% stating that they would recommend these QVH services.
The head and neck oncology surgical service participates in all relevant national and regional audits
and we ensure that we identify and act on any learning. In 2016 we performed 119 major head and
neck procedures, the majority requiring free flap reconstruction. The free flap success rate was 96%,
with a 30 day patient survival of 99% (National benchmark form the 2014 DAHNO database, 30 day
survival of 98.3%).

2. There are no facilities or clinicians (radiologist or gastroenterologists who normally
undertake such procedures) available to place a PEG prior to surgery, thereby requiring oral
maxillofacial surgeons of variable and unclear experience to undertake the procedure peri-
operatively.

There are six consultant OMFS head and neck oncology surgeons at QVH, all of whom are dually
qualified in medicine and dentistry. All six consultants have completed Basic Surgical Training, with
associated endoscopic exposure, with award of Fellowship or Membership of the Royal College of
Surgeons (RCS) in surgery in general, in addition to their specialist qualifications. Their training in
the placement of PEGs has been gained whilst training in maxillofacial surgery at QVH. Since the
incident, the Medical Director has discussed training, accreditation and best practice with a regional
centre specialising in PEG placement, and the Clinical Lead for Head and Neck oncology surgery
has attended a PEG placement list with experienced surgeons with a larger volume PEG practice at
Maidstone in order to review techniques and ensure practice at QVH is up to date.

A PEG insertion requires two operators, and has always been led by a consultant. We have
performed over 360 PEG insertions (30 — 50 PEGs per annum) in the last 10 years. Of these, 76
were performed by the lead surgeon in this case. The lead surgeon has been inserting PEGs for
over 20 years and has completed the procedure without major complication in over 100 cases.

The pathway for difficult PEG placements is for the patients’ referring hospital or the hospital of the
referring multidisciplinary team to place the PEG using radiology or gastroenterology specialists so
more complex PEG placements are not performed at QVH.

Notwithstanding the view that it is safe for QVH surgeons to continue to place PEGs, the
continuation of PEG placement by OMFS surgeons at QVH is currently under review. Alternative
pathways are being explored for the provision of PEG placement for enteral feeding for all our
patients via gastroenterologists or radiologists at the patients’ referring hospitals or the hospital of
the referring multidisciplinary team.

In addition, we are working with other PEG services to see if it is possible to develop a competency
based training and assessment and to provide assurance of the service. If appropriate training or
accreditation cannot be achieved then we will cease the service. This would mean a change to
patient pathways so that the PEG is placed at the patients’ referring hospital or at the hospital of the
referring multidisciplinary team. Assurance is currently being sought that this is available and will not
adversely affect the length of the patient pathway to the detriment of the patients.

3. Written guidance by the surgeons for insertion of PEGs was not followed, with little
reflection as to whether this was an acceptable procedure given Mr Teesdale’s previous
extensive surgery at or around the point where the PEG was inserted with concomitant poor
gastroscopic trans-illumination.

The Trust and the individual surgeons involved recognise and deeply regret that QVH guidance was
not followed in this case.

Considered reflection has been undertaken as part of the serious incident investigation and during
and after the inquest, and all QVH surgeons recognise that adequate gastric distention and trans-
illumination are important indicators in PEG practice.

A number of changes have been made to our process prior to the insertion of PEGs at QVH to
minimise the risk of this incident ever being repeated. The requirement for enteral feeding and the
decision as to the most appropriate route and any contraindications is now a documented decision
at the multidisciplinary team meeting prior to surgery. A PEG safety checklist has been introduced,
which includes stop points prior to the insertion, with a final check on contraindications and a stop
point if poor gastric distention or poor trans-illumination is achieved. The Enteral Feeding Guideline,
which includes the guidance on PEG insertion, has been re-written following this incident, widening
and clarifying the absolute and relative contraindications to PEG placement. The checklist requires
documentation of a risk assessment where the procedure is taking place in the face of a relative
contraindication.

4. No risk assessment was undertaken as to whether a PEG insertion would have been
appropriate, given that a non-invasive alternative of a feeding tube for enteral feeding was
available.

The Trust and the individual surgeons involved recognise and deeply regret that QVH guidance was
not followed in this case, with no documented risk assessment of why the guidance was not adhered
to.

All medical staff are fully aware of the requirement for risk assessment documentation. Additional
training and a process of audit have been arranged to support this. As set out above, the
introduction of the PEG safety checklist requires documentation of a risk assessment where the
procedure is taking place in the face of a relative contraindication.

On reflection the surgeon recognises that the widespread adhesions caused by Mr Teesdale’s
previous surgery would have resulted in high risk placement of PEG whether by gastroenterology or
radiology and may have best been placed by general surgery via a mini-laparotomy. This in itself
would have presented additional risks. A feeding tube (nasogastric or nasojejunal) would have been
an unsatisfactory route for provision of nutritional support in the context of oropharyngeal cancer
reconstruction.

5. No formal ‘training’ programme for the insertion of PEG or independent competency based
assessment.

The experience of QVH clinicians in placing PEGs and the changes underway since Mr Teesdale’s
death is set out above in response to point 2.

6. The post-operative management of Mr Teesdale did not follow the written guidance for the
management of abdominal pain after PEG insertion. This resulted ina delay in seeking
appropriate advice, timely intervention and optimal treatment of this complication.

The Trust and the individual clinicians involved recognise and deeply regret that guidance was not
followed in this case.

The guideline on care of patients following a PEG insertion has been re-written and all clinicians
involved in PEG placement and the care of patients following PEG placement have received and
noted the updated guideline. The guidance includes the requirement for warning stickers to be
placed on the patient’s notes and drug chart to alert staff.

The risks of PEGs will form part of induction training for new maxillofacial and anaesthetic doctors,
and PEG scenarios will be included in regular multidisciplinary simulation training.

7. Mr Teesdale’s transfer was delayed because of a reluctance to transfer in the immediate
postoperative period complicated by the associated logistical difficulties of doing so given
his major surgery.

Mr Teesdale needed transfer for a CT scan and there are clear patient pathways for this which were
not activated in this case.

The reluctance to transfer a patient immediately post-surgery meant the recommended investigation
for this clinical scenario was not undertaken. It is vitally important that we learn from the sad death of
Mr Teesdale, and we are ensuring all relevant staff are aware of the risks and post-operative care of
PEGs and the indications for transfer. In recognition of the potential reluctance to transfer, this will
be included in ‘human factors’ training for staff at QVH. Transfers from QVH for investigation and
referral are, and will continue to be, monitored, audited and shared through the clinical governance
processes of the Trust. Any potential delay in transfers are reported through the Datix system and
investigated appropriately.

8. As an isolated hospital, QVH has no ‘on-site’ clinical specialist experience when patients
develop complications. As a consequence, there was no specialist available to assess Mr
Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG
insertion. No effort was made to seek such expert advice during ‘daytime working hours’.

It is a matter of deep regret that guidance on timely referral and transfer was not followed in the case
of Mr Teesdale.

In general, specialist opinion and imaging are available through regularly and appropriately used
agreements with BSUH. We have reminded all relevant staff of the importance of timely referrals
and transfers, through local and hospital-wide multidisciplinary governance meetings and written
briefing, with learning from this case.

9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral maxillofacial surgeon with
unknown general surgical experience, who did not recognise or manage the severity of a
surgical complication.

The Trust recognises that clinicians did not escalate Mr Teesdale’s case appropriately during the
night of 18/19 October 2016. The Director of Medical Education, educational supervisors, Training
Programme Directors, Heads of School and the Dean of Health Education London and the South
East are aware of the findings of the Coroner and consultant supervised case based discussions
and portfolio reflection has been undertaken, with learning for the junior doctors involved.

Leadership of the critical care unit has been better defined with an improved system of handover,
and the on-site consultant presence has been extended recently, with consultant led handover for
junior night staff.

10. There was no recognition of how unwell Mr Teesdale was on the consultant surgical ward
round at around 0900 on the 19" October 2016, despite considerable evidence present at the
time that Mr Teesdale had developed multi-organ failure.

The Trust recognises that following the decision to refer Mr Teesdale to Brighton action was not
taken with sufficient urgency. All relevant staff have been reminded of the protocols and indications
for urgent transfer.

11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it
difficult to provide an overall consistent and systematic approach to the management of Mr
Teesdale in a small High Dependency Unit with an inconsistent consultant presence during
the day.

QVH has a five bedded critical care unit providing Level 2 and 3 care. The consultant in charge is
available to review patients on critical care on an immediate basis. The consultant is supported in
the critical care unit by an anaesthetic registrar. Consultant anaesthetists are resident in the hospital
12 hours per day on a weekday and 9 hours per day at weekends. As a direct result of this incident
we have moved from a model where the surgeons and the critical care consultants shared
responsibility for critical care patients, to one where the consultant in critical care is accountable and
leads decision making.

We have recently employed a consultant with Faculty of Intensive Care Medicine accreditation, to
lead the training and clinical governance of the critical care unit.

The Coroner drew attention to inconsistencies between the ‘snap shot’ medical reviews and the
more frequent reviews of the nursing staff. Since Mr Teesdale’s death, we have developed unified
multidisciplinary documentation as part of the enhanced recovery programme, and are auditing its
use. Multidisciplinary documentation will be further developed as we progress with electronic
document management.

12. There are no haematology or biochemistry services at QVH. A courier service is required
for emergency laboratory tests. This has the potential to either not request ‘bloods’ and/or a
delay in obtaining results. Similarly, there is no ‘out of hours’ radiology service and there is
no CT scanner on site to assist in a diagnosis (which was required as part of the
management guidelines prepared by QVH).

Blood pathology services are provided by Princess Royal Hospital, Haywards Heath. There are
seven routine transits of blood samples per day during the week, and four at weekends. If urgent
blood results are required outside of these routine transits, an urgent courier service is available at
any time, day or night, seven days per week. There is no evidence that this network arrangement
impacts on the likelihood of requesting bloods. No concerns regarding this long standing
arrangement have been raised by NHS England or the Care Quality Commission in their reviews. As
part of the SLA with BSUH for blood pathology services, the Trust requires assurance that urgent
specimens can be received and processed at the lab ready for testing within one hour of leaving
QVH. This is an essential pass/fail requirement. There are regular SLA contract review meetings
and neither BSUH nor QVH has reported that the urgent specimen sample time has been breached.

As explained in section 1 above, urgent CT scanning is provided by Princess Royal Hospital,
Haywards Heath, with a 45 minute transit time. Patients requiring both CT scanning and general
surgical opinion are transferred to Royal Sussex County Hospital, Brighton, with a one hour transfer
time. The number of urgent CT scans requested by the QVH per year is between 30 and 40.

Urgent consideration is being given to options for CT provision at QVH. If it would be helpful we
would be happy to update you on progress.

The Trust recognises that reluctance to transfer a patient immediately post-surgery meant the
recommended investigation for Mr Teesdale was not immediately undertaken. As described above,

a number of actions have been taken to ensure that the most appropriate form of investigation is
undertaken in future whether that is on or off site.

Actions taken
As Chief Executive | take full and personal responsibility to make sure that we are doing everything
we possibly can to avoid such a tragedy being repeated.

QVH has taken actions to prevent future deaths as described above and as set out in the action plan
arising from its revised root cause analysis. Since the inquest, the Trust has made further progress
against the action plan and adopted additional actions. Please find enclosed a copy of the Trust’s
updated action plan. The Trust will maintain communication with the family, the court, our
commissioners and the Care Quality Commission to confirm its progress against the updated action
plan.

| hope this response provides reassurance that the care provided by the Trust provides a safe
service to its patients. Please do not hesitate to let me know if any more information would be
helpful.

Steve Jenkin
Chief Executive
Queen Victoria Hospital, NHS Foundation Trust

QVH action plan following inquest touching on the death of Mr Dennis Teesdale

This plan uses the initials of individuals who are leading on actions. For those external to QVH, the following key has been added to indicate the roles
of those involved:

BSB Mr Brian Bisase Consultant Maxillofacial/Head & Neck Surgeon and Clinical Lead for Head & Neck Cancer
CP Clare Pirie Director of Communications

cs Clare Stafford Director of Finance

EP Dr Edward Pickles Medical Director

JCC Mr Jeremy Collyer Consultant Maxillofacial Surgeon TPD/STC Chair and Trainee Support Lead, HEKKS
JD Mr Jagtar Dhanda Locum Consultant Oral Maxillofacial Surgeon

JJ Dr Jey Jeyanathan Clinical Governance Lead, Critical Care

JMT Jo Thomas Director of Nursing

KCW Karen Carter-Woods Head of Risk

RL Dr Rachael Liebmann Deputy Medical Director

SJ Steve Jenkin Chief Executive

Exec __ Exec Directors of QVH

CS, EP, JT, SJ, Sharon Jones — Director of Operations, Geraldine Opreshko — Director of HR and OD

Action

Clinical — PEGs

Respon

Comp
sibility

leted
(Y/N)

Update on progress / status

RAG

Al Explore training course for clinicians Training, accreditation and best practice being
putting in PEGs (technical skills) EP/BSB 31 Jul 2017 | discussed with colleagues including those at
Maidstone and Tunbridge Wells and University N
College London Hospital. (see A2)
A2 Explore external oversight of PEG EP/BSB_ | Agree path by | BSB attended PEG list with clinicians Maidstone and
service (technical and organisational) 31 Jul 2017 | Tunbridge Wells 19 June 2017. N

EP discussion with Gastrointestinal Failure Unit,
University College London Hospital 12 June 2017.

A3

Explore alternative paths for PEG
insertion pre- and post-op (West Kent

EP has discussed with gastroenterologists at
Medway, Darent Valley Hospital and Maidstone.

& Medway multidisciplinary team — EP/BSB 31 Jul 2017 | Now requires NHS Specialist Commissioning and
Maidstone/Medway/Darent Valley NHSE discussion.
Hospital)
A4 | Guildford or Brighton multidisciplinary
team alternative path for patients of BSB 31 Jul 2017 | Surgeon not currently placing PEGs
lead surgeon involved in incident
AS | Tighten Enteral Feeding Policy BSB/EP 30 Jun 2017 | Completed
(section 10) regarding definition of
Surgical Opinion and PEG checklist
inclusion
A6 Pathway checklist for PEG patients BSB/EP 31 Jul 2017 | Completed and in use.
incorporating risk assessment and
requiring comply or document
rationale if not adhering to guidance.
A7 MDT documentation of enteral feeding Confirmation of implementation.
requirements and contraindications BSB Immediate Current audit of practice.
A8 | Ensure more robust documentation for Memorandum of Understanding in place.
general surgical service provided by EP + 1 Sep 2017 Plans to work with BSUH to develop into SLA as part
Brighton and Sussex University Exec of on-going partnership work
Hospitals Trust (BSUH)
AQ Decision on whether to continue to EP + 31 July 2017 | Decision to continue pending external oversight and
place PEGs at QVH Exec 2017 additional input.

Work underway with referring hospitals to review
implications for patients of alternative pathways.
QVH Board aware and in agreement.

A10 | PEG training in trainee induction and | BSB 31 Jul 2017 | Clinical tutor and simulation lead to incorporate into
in multidisciplinary simulation training. induction and critical incident training.

A11 | National Patient Safety Agency EP Immediate Re-circulated to Max-Facs and anaesthetics 23 May
(NPSA) RRR/2010 and Enteral 2017
Feeding Policy to be circulated

A12_ | Ensure prospective PEG audit in
place and capturing all necessary BSB/JD 31 Jul 2017 | Audit will capture NPSA stickers, multidisciplinary
information team documentation, Consent, Checklist.

B___| Co-location and critical care

B1 Brighton and Sussex University Exec Ongoing Memorandum of Understanding approved by QVH
Hospitals Trust (BSUH) Memorandum Board 6 July 2017
of Understanding progression with Sign off due from BSUH Board. Discuss at next
SLA review Brighton Partnership Board meeting.

B2 | Appointment of joint project manager | Exec 1 Oct 2017 Awaiting BSUH sign off of partnership Memorandum

of Understanding
B3 | Colocation of critical care (intensive Exec 30 Jun 2017 | Business case approved HMT 19 June 2017.

care, high dependency unit, step
down) and development of critical
care

Amalgamation commenced 26 June 2017.
Arrangement reviewed 26 July 2017.

B4 New trauma clinic progression and Exec 1 Sep 2017 Building work underway
revised trauma policy and pathways.
B5 Review service level agreement with EP/KS/ Plan by
Brighton and Sussex University JJ 31 Jul 2017
Hospitals Trust (BSUH) Intensive
Care Medicine and network
opportunities.
B6 Engage with Quality Surveillance SJ/EP/ 3 Aug 2017
Group JMT
B7 | Consideration of on-site CT scanning | Exec/CS | 31 Aug 2017 | Initial discussion at Executive Management Team.
provision Rapid review to be led by Director of Finance
Cc QVH clinical staff — general
C1 Presentation of Coroner’s report to EP 10 Jul 2017 | Complete
Joint Hospital Governance Meeting
(JHGM)
Review of multidisciplinary documention in critical
C2 | Documentation review, including EP care — to be presented to July CC governance
Enhanced Recovery Pathway, audit JHCG meeting | meeting.
and presentation Nov 2017 Next step to ensure this documentation integtrates
with Enhanced Recovery pathway (EPR)
documentation.
EPR audit in progress.
C3 | QVH specific Human Factors Training | EP 31 Dec 2017 | Localise HEE London and SouthEast training

C4 | Coroners / legal training EP Oct 2017 Training delivered by trust legal representative to
JHCGM.
Continuous programme of values, behaviours and
C5 | Multidisciplinary communication EP/JMT Review 1 Oct | communication.
training, including ability to challenge 2017
decision maker
al Documentation under review.
C6 | Ensure multidisciplinary EP/JCC Intial plan by | Requirements need to feed into informatics clinical
documentation, Enhanced Recovery 31 Jul 2017 | advisory group.
Documentation and patient alerts
maintained as move towards
Electronic Document Management.
Electronic document management
and sequential notes /
multidisciplinary input
D Serious incident route cause analysis (SIRCA) _
D1 SI RCA for Mr DT to be rewritten with | EP/KCW Complete
addendum
D2 _| SI RCA for Mr DT to be re-submitted KCW/EP Clinical Reviewed at 10 July Clinical Governance Group.
to CCG, after resubmission to clinical | /JMT Governance | Sent to Quality & Governance Committee
governance group (CGG) and Board Group: membership 13 July 2017.Resubmitted to CCG on
Quality & Governance sub-committee 10 Jul 2017 | August 24 agenda for presentation.
(Q&G). Quality &
Governance
Committee:
17 Aug 2017
D3 | Root cause analysis training to be JMT/KC Courses Head of Risk reviewing the current training courses
made available to relevant staff. Ww identified by | available and formulating proposal.

31 Jul 2017 _| Head of Risk and Risk Manager attended further

RCA training 25 / 26 July 2017. To develop
multidisciplinary trust RCA training.

D4 | Review of process for declaring SI JMT 24 Jul 2017 | New process outlined, documentation being
and RCA investigation, approval and developed.
changes to draft reflected in simple
flow chart and add to risk
management and incident reporting
policy approval via CGG.
D5 | Duty of Candour process and JMT Full Review undertaken.
responsibilities to be revised, including implementatio | Protocol drafted and shared with executive team 3
communication with patient/families n by 14 August | July 2017.
that have been transferred or 2017 Now being consulted on and then will be presented
discharged to other providers. throughout the trust
Draft completed.
D6 | ‘Responding to Deaths’ policy (as per For submission to Quality and Governance
NHSI/CQC) to be written as per EP/KCW 31 Jul 2017 | Committee 17/08/2017
Quality & Governance Committee
plans
Reporting of SJR reviews to Board of Directors with
D7 | Royal College of Physicians EP 1 Sept 2017 | commence September 2017 as part of Medical
Structured Judgement Review training Directors Report. Awaiting national training
for key individuals (as per CQC programmes.
Learning from Deaths publication).
Guidance for bereaved families and
carers required.
D8 | Review process for documentation JMT 1 Sept 2017 | Initial review of process undertaken. Head of patient

submission to outside / legal / coroner

experience drafting a protocol. First draft completed

scrutiny and due diligence.

will go to Executive Management Team 2017 August
2017.

D9 | Review of QVH accountability and JMT Quality & Requirements of clinical governance group and
process for scrutiny of RCAs Governance | Quality and governance Board sub-committee to be
Committee reflected in TOR and discussed at next meeting.
17 Aug 2017

E Engaging partner organisations

E1 Care Quality Commission JMT 23 May 2017 | Completed, contacted Zoe Nixon
Ensure update provided

E2 | NHS England JMT/ EP Initial contact made 23 May 2017.
Draft responses sent to Dr James Thallon, NHSE
Medical Director, with follow up discussion
18/07/2017

E3 NHS Resolution JMT Completed, already aware as they provided the
Trust solicitor. Report from NHS Resolution solicitor
to them.

E4 Lead Clinical Commissioning Group JMT 22 May 2017 | Completed, contacted Julia Layzell
Ensure update provided

ES Brighton and Sussex University SJ SJ —MG conversation 24 May 2017

Hospitals Trust (BSUH) — CEO
E6 | BSUH —- Med Dir EP EP — GF conversation 24 May 2017
E7 NHS Improvement JMT 22 May 2017 | Completed, contacted Mercia Spare.

EP in communication with Med Dir Dr lan Sturgess.
Draft responses sent to Dr Sturgess 17/07/2017

E8 | Strategic Transformation Partnership | EP STP meeting 6 June 2017. Not formal agenda item.
E9 Local trusts — Maidstone and SJ 24 May 2017 | Acknowledgements from ARP, GD
Tunbridge Wells, East Sussex
Healthcare Trust
E10 | Quality Surveillance Group SJ, EP, 3 Aug 2017, attendance confirmed.
JMT
F Communication
F1 Engagement with family, including Original duty of candour letter not sent until April
offer of involvement with EP 7 Jun 2017 | 2017 —no response. Brief meeting following inquest
investigations and actions; apology for (DON, MD).
areas below standard Letter following inquest sent 7 June 2017
F2 Share with family QVH response to
Coroner's private letter of concern and | EP 2 Aug 2017
Prevention of Future Deaths notice
F3 Response to Coroner's private letter
of concern EP/SJ 2 Aug 2017 ‘| Sent
F4 Response to Coroner’s prevention of
future deaths notice EP/SJ 2 Aug 2017 | Sent.
Share draft response and action plan Complete. Final documents to be shared.
F5 with Clinical Commissioning Group, EP/SJ/ wic
NHS Improvement, NHS England and | JMT 24 Jul 2017

Care Quality Commission (CQC)

6 July 2017

F6 Information for NEDs CP Immediate initial communication.
Board discussion 1 June 2017 and 6 July 2017.
31 July 2017 | Immediate initial communication.
F7__| Information for governors CP Follow up at council of governors 31 July 2017
F8 Communication to QVH staff Exec On-going All directors briefed senior teams in May 2017.
Reflective feedback session held with ITU staff.
Hospital management team discussed.
Discussed at JHCG meeting G 10 July 2017.
Trust-wide staff briefings arranged for August.
G Availability of documents
G1
Review availability of evidence JMT 31 Jul 2017 | Head of Quality and Compliance undertaking this
following CQC 2015 report review and review with critical care lead. Specific focus on
CQC action plan review. critical care and the well led domain.
G2__| Review the accessibility of the policies | JMT/EP/ 1 Sept 2017 | Head of risk to undertake review. Consider
and how easy it is to find individual CP introduction of policy of the month presentation at
policies on intranet. local governance meetings. Governance leads to
explore.
H Support for individuals
H1 Non-clinical group debrief EP 9 Jun 2017 Debrief held 8 June 2017 facilitated by senior
psychologist.
H2__| Sources of support to consultants EP 31 May 2017 | Emailed list and discussed.
H3 | Sources of support for trainees EP 31 May 2017 | Support leads, college tutors and educational

supervisors aware and engaged.

H4 | Sources of support for non-clinical JMT 31 May 2017 | Complete
staff involved in inquest
I Individual regulator issues
ih Internal investigation medical staff to EP 30 June 2017 | Supplied by RL 5 June 2017
examine other concerns
12 Case discussed with GMC EP: Email to Employment Liaison Advisor — South 30
30 June 2017 | May 2017
PFD and letter of concern forwarded to GMC ELA 22
June 2017
—— 29 June 2017
13 Care and individuals discussed with EP 30 June 2017 | Case discussed with NCAS. Local management
NCAS advice. Summary received 23 June 2017
14 Declaration of trainee involvement to EP Dean informed 24 May 2017. Appropriate action
HEKSS, Dean Head of School, 30 June 2017 | plan including declarations / CBD / reflections.
Training Programme Director, ES,
support leads.
1 Sept 2017
IS Internal MHPS management process _| EP Interviews arranged
1 Sept 2017
16 Letters of concern EP