Michael Giles

Office of the Chief Medical Officer 

PA – 

Divisional Medical Director: 
Emergency Medicine 
PA – 
  01905 763333 ext.39345 
  

Divisional Medical Director: 
Surgery 
PA –
  01527 505740 
  

Divisional Medical Director: 
Specialised Clinical Services 
PA – 
  01905 733448 


Divisional Medical Director: 
Speciality Medicine 

Divisional Medical Director: 
Women and Children 

  01905 733211 ext.39818 
  

  01905 761499 
  

Our Ref: 2078/SAK/MLR 

20th December 2017 

The Coroner 
G U Williams LLB 
HM Senior Coroner 
Worcestershire Coroner’s Court 
The Civic, Martins Way 
Stourport on Severn 
Worcestershire, DY13 8UN 

Dear Mr Williams, 

Ref:  Regulation 28: Report to Prevent Future Deaths 

Following  your letter to  the Chief Executive Officer, Michelle McKay, I write in response to  your Regulation 28 
Report issued 30th October 2017 surrounding the death of Michael Edward Giles. 

You raised 4 matters of concern.   

1.  You’ve invited the Trust to consider standardising the handover process across the hospital and to put in 
place a protocol whereby the identity of the person responsible for ensuring the handover takes place is 
clearly recognised. 

The events surround this tragic case and your regulation 28 letter was discussed with the trainees in early 
November 2017.  The conclusion from the trainees was that they were confident that the processes now 
in  place  were  robust  and  they  had  not  experienced  any  near  misses  as  a  consequence  of  inadequate 
handover.  There is a standardised structure for handover which follows SBAR.  This is an acronym for 
Situation,  Background,  Assessment,  Recommendation.    With  reference  to  identifying  a  responsible 
person  is  a  little  more  fraught.    Handover  takes  place  at  multiple  levels  whilst  the  patient  remains  an 
inpatient.    For  example;  between  nursing  staff  during  shift  changes,  from  allied  health  professionals  to 
nursing staff following procedures and interventions, between junior medical staff as part of a shift hand 
over as well as between senior medical staff as part of the transfer of care and responsibility. 

The  importance  of  hand  over  in  a  structured  manner  continues  to  be  the  subject  of  our  attention  and 
indeed was the focus of discussion by our Director for Medical Education when he met with the trainees.  
To facilitate and support the transfer of clinical information the nursing staff also undertake a structured 
process  “board  round”  takes  place  every  morning  on  the  ward  between  senior  clinicians  and  the  ward 
nursing staff. 

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD 

 
 
 
 
 
    
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
  
  
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 2. 

Invited the Trust to put in place the requirement that all complex cases who are admitted onto the ward on 
a Friday or over the weekend, particularly where they have undergone invasive procedures, are routinely 
subject to a senior doctor review. 

There is already an expectation that all patients need to be reviewed 7 days per week.  For those 
pateients with high dependency needs the expectation is that they are seen and reviewed by a consultant 
twice daily (including acutely ill patients directly transferred and other who deteriorate).  An audit of our 
practice from March 2017 shows that we were able to meet this requirement 93% of occasions.  The 
overall proportion of patients who required a daily consultant review and were reviewed by a consultant 
was 68%.  In order to improve this further working practice by consultants has been reorganised to 
facilitate a higher proportion of patients being seen at least once every 24 hours.   
In order to keep the risks to a minimum for patients undergoing invasive procedures we are already 
reviewing where these can be done, i.e. limiting it to where there are areas with the required expertise for 
care after the procedure. 

3. 

Invited the Trust to consider a protocol to ensure that during the crisis period of a patient’s admission 
there is a nominated individual to take the lead and to ensure optimum care is given. 

In all cases when patients take a turn for the worse the most senior Doctor is responsible for taking the 
lead in ensuring optimum care is given.  It is not possible to have a protocol to identify a nominated 
individual because the required leadership depends on the underlying condition.  Thus what is required in 
Emergency Department and who should take the lead might be very different to the needs surrounding a 
post-operative event or indeed during a period of convalescence whilst on the ward.  The key to such 
events is identifying changes to the patient’s condition in a timely manner before any event occurs.  To 
this end, we audit all patients brought to intensive care unexpectedly or patients requiring the emergency 
team during the day time. We assess for the adequacy of care and the appropriateness of timely 
escalation prior to this.  We have also started human factors training. 

4.  We have invited the Trust to put in place addition training so that record keeping is consistent complete 

and clear. 

We recognise the importance of good clinical record note keeping.  As part of this, we have undertaken 
an audit to assess our baseline and thereby assess the impact of interventions to improve this.  I have 
attached the audit which demonstrates areas of good practice as well as areas in need of improvement.  
We’re also working with the communications team to develop a clinical records keeping video to drive up 
standards.  I anticipate that this will be available in February.  I’ve also attached a leaflet that will be 
forwarded to all in the Trust that utilise patient’s notes.  The attached has yet to be finalised and is merely 
to provide an indication of the direction of travel.  I anticipate that this will be available in February 2018.   

I hope that the details of the actions that we are taking, provides you with the assurance you are seeking in 
order to prevent future deaths.   

Best wishes. 

Yours sincerely, 

Chief Medical Officer 
Enc. 

cc. 

Michelle McKay 

Chief Executive Officer