Patricia Forshaw

Wrightington, Wigan and Leigh NHS:

NHS Foundation Trust

Legal Services Department
Trust HQ

Royal Albert Edward Infirmary
Wigan Lane

Wigan

WN1 2NN

Tel: 01942 822937/2172
Fax: 01942 822170

Web: www.wwLnhs.uk

Mr Alan Walsh

HM Area Coroner
Manchester West
HM Coroner's Office
Paderborn House
Howell Croft North
Bolton

BL1 1QY

26" October 2017
Dear Mr Walsh

Regulation 28 Response: Patricia Forshaw (Deceased)
Thank you for your Regulation 28 report dated 8" September 2017.

I understand that an Inquest relating to the death of Patricla Forshaw took place on 21* August 2017.
I have been fully advised of the circumstances relating to Mrs Forshaw’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 Forshaw:

1. The telephone number on the card given to the Deceased when she was discharged from
hospital related to appointments only but the purpose of the number is ambiguous and when
the Deceased’s husband telephoned the number on the card in the early hours of 20" October
2016 he believed he was speaking to the Emergency Department, particularly in view of the
fact that he was given advice to give paracetamol to the Deceased.

2, The telephone call from the Deceased’s husband to the hospital in the early hours of 20"
October 2016 and the advice to give paracetamol was not recorded in any hospital records.

Furthermore, the consultation with the Nurse who removed the dressing and who was aware
of the Deceased requiring a blanket because she was cold and also aware of the offensive
smelling discharge from the wound, did not record that information in the notes and did not

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bring the information to the attention of the doctor at the time of his consultation with the
Deceased.

3. BB accepted that, having heard the evidence of the family at the Inquest, routine
observations (pulse, blood pressure, respiratory rate, temperature) and blood Investigations
should have been conducted when the Deceased presented to the Out Patient appointment on
21* October 2016. EEE gave evidence that there has been some discussion between
Consultants in the emergency department and there was mention that there should be a policy
for checking routine observations in patients attending Clinic for wound review, particularly
where there was an indication of infection. However [J confirmed that there was no
formal policy in place.

4. The evidence heard at Inquest confirmed that there had been a discussion between
Consultants in the Emergency Department in relation to the treatment and care of Mrs
Forshaw but the treatment and care of Mrs Forshaw had not been escalated as a formal report
for consideration of a Serious Incident Review. Accordingly a Serious Incident Review had not
taken place in relation to Mrs Forshaw’s death, although it was accepted that, in retrospect, a
Review should have taken place to enable any recommendations to be formalised within the
Governance framework.

I appreciate that, in light of these concerns you have requested that the Trust conduct a review of
policies, procedures and protocols In relation to:- : ee

I. The information on appointment cards
Il, The notes to be recorded by nurses, either in relation to telephone calls made to the hospital
by or on behalf of a discharged patient or in relation to nurses conducting a preliminary
examination prior to consultation with a doctor.

III. _ Routine observations and blood Investigations in relation to patients attending hospital,
particularly the Emergency Department or Out Patient Clinic, where there Is evidence and
diagnosis of wound infection.

IV. | The reporting and escalation of incidents in the Emergency Department leading to
consideration of a Serious Incident Review and appropriate action within the Governance
framework.

I propose to respond to each of your concerns and recommendations in turn.
Appointment cards

For your information and assistance I enclose a blank example of the appointment card which would
have been completed and given to Mrs Forshaw following her review In the Accident and Emergency
Department on 19" October 2016. This card would have been populated with Mrs Forshaw’s name
and the date of her appointment in the Out Patient Clinic, which I believe was on 22™ October 2016.
As you will see under the name of the Hospital at the top of the card there is a telephone number. At
the bottom of the card it Is stated;

"Uf the condition for which this appointment has been made has cleared up, there is no need
to attend (please inform reception on above number)”

The number at the top of the card is therefore intended to be used if the appointment is no longer
required or if the date needs to be changed. I apologise if Mrs Forshaw or her husband found this

information to be ambiguous. I am aware that the Trust’s outpatient appointment card is to be
updated to include advice for patients to contact NHS 111 or their GP If their condition deteriorates.

I also understand from the Clinical Director for Emergency Care that a Memo has been sent to all
Emergency Care staff to notify them that if a patient or relative calls the department for advice, the
caller is to be told that if they have any questions about their/the patient's condition or treatment they
are to consult their GP, call 111 or to re-attend Accident & Emergency. The Emergency Care Staff
have been informed that under no circumstances should they be providing any medical or treatment
advice.

The Emergency Care Staff will also be notified that calls should not be put through to the minors or
majors area in the Accident & Emergency Department as even though these calls are answered by a
medical professional, the advice given is not always recorded in a patient’s notes and as such there is
no audit trail. The Accident & Emergency Department is not to be treated as an advice line and this
information will be re-iterated to all Emergency Care Staff.

Records/notes

I appreciate that Mrs Forshaw‘s medical notes did not include a record of any discussion she had with

_. the nursing staff either whilst waiting for her out patient appointment or during her initial nursing

review before her examination by the Doctor. However, I understand that when [EEreviewed
Mrs Forshaw in the outpatient clinic a description of her wound was recorded in the notes and it was
noted that there was swelling around the wound, together with slight pretibial erythema (redness to
the skin overlying the tibia). As a result of these signs of infection prescribed
Clarithromycin as an antibiotic and arranged a further review appointment four days later. A letter was
sent to Mrs Forshaw’s GP outlining this management plan.

All of our nurses are aware of their duty to ensure patient records are accurate and to document
relevant information as appropriate. However I understand that a notification has been circulated to
all nursing staff by the Matron for Unscheduled Care to reiterate the requirement for nurses to
document in the patient's notes any relevant care or treatment provided. The Clinical Director for
Emergency Care will inform all the Consultants of this issue and this matter will also be discussed at
the Clinical Governance Meeting. I have also been informed that this notification will be incorporated
into the ongoing local induction for nursing staff.

I can therefore assure you that If there is any information or history which is brought to the attention
of the nurse by a patient, all nursing staff have been notified of the need to inform the reviewing
Clinician so that this can be considered when determining the appropriate course of treatment.

Routine Observations

I appreciate that during the course of the evidence at Inquest, HENNE candidly acknowledged that
routine observations should have been conducted on Mrs Forshaw and had they been done, and if her
results had triggered the sepsis pathway, she would have been admitted and commenced on IV fluid
and IV antibiotics.

Both ae .: reassured me that all clinicians working In the outpatient clinic are
very aware of the sepsis pathway and conduct routine observations and blocd investigations where
appropriate when a patient is displaying clear signs of infection. Following careful consideration and
discussions between senior Emergency Care clinicians, they do not consider that it would be possible

to implement a formal policy or standard operating procedure for conducting routine observations on
patients in the Outpatients Clinic. Unfortunately patients and their symptoms do not fit into clearly
defined categories as to when observations are required and when they are not. Patients attend with
a vast range of symptoms and as such, the standard practice at WWL is for the clinician to examine
the patient, consider their presentation and determine the treatment and advice to be given on the
basis of their clinical judgment. I do not believe this is out of line with the procedure followed at all
other NHS Trusts.

HEE has confirmed that he did not, in his clinical judgment based on Mrs Forshaw’s
presentation on 22 October, consider her to be showing clear signs of infection which warranted
routine observations and blood to be taken. [EEE impression of Mrs Forshaw’s presentation
was one of localised wound infection. I have been assured that the clinical staff in the Outpatient
Clinic are very aware of the Trust’s sepsis guidelines and trigger the sepsis pathway whenever
required.

HB has discussed Mrs Forshaw‘s care at a meeting of the Emergency Care Consultants to
heighten awareness of wound Infection and sepsis and to gather feedback from the senior Consultants
in relation to routine observations; this senior opinion has been incorporated into this response.

Mortality review / Governance process

As you may be aware one of our Consutlant Paediatriclans conducts a weekly mortality review to
consider the care and treatment provided to all in patients who have died during the course of the
week, In Accident & Emergency a similar mortality review is undertaken by I have been
informed that at the clinical governance meeting on 27 September 2017 it was confirmed that the
criteria of this review Is now to be widened to consider whether the patient has attended the hospital
at any time in the previous four weeks. This will enable the Consutlant conducting the Mortality
Review to identify whether there is anything of significance from these previous presentations to be
considered when reviewing the care provided.

In Mrs Forshaw’s case, such a review would have identified her attendance to A & E and her
subsequent attendance at the Outpatient clinic in the 48 hours prior to her death. Consideration would
therefore have been given to whether there was anything which could/should have been done at
these presentations to have altered the outcome for Mrs Forshaw and the decision could then have
been taken as to whether this matter required further investigation and escalation through the
governance procedures at the time of Mrs Forshaw’s death. I apologise that this did not happen and 1
hope that the improvements made to the mortality review process provide reassurance that any
future deaths in the Accident & Emergency will now undergo a greater level of scrutiny to ensure that
lessons can be learnt wherever possible and improvements made to the care provided to patients.

Continued action

As noted above several changes have already been put in place following Mrs Forshaw’s sad death
and the following actions will be taken:-

e Emergency Care Staff are to be notified that calls should not be put through to the minors or
majors area in the Accident & Emergency Department. Guidance has already been issued to
staff to confirm that patient's or relatives calling about a patient's condition or treatment
should be directed to their own GP, advised to call 111 or re-attend Accident & Emergency.
Under no circumstances should treatment advice be given.

¢ Nursing staff will continue to be notified at local induction sessions of the requirement to
document in clinical notes any relevant care and treatment provided

* The Accident & Emergency weekly mortality review will now include a review of any hospital in
or outpatient attendances in the last four weeks prior to the final attendance, to consider any
significant issues relevant to the patient's care and treatment.

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 Forshaw’s death. I can reassure you that WWL has and will continue to learn lessons from Mrs
Forshaw’s care and the Trust is constantly seeking to improve the service we offer to our patients.
Please can I pass my sincere condolences to Mrs Forshaw'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

Andrew Foster CBE
Chief Executive