Gwendoline Halfpenny

NHS

University Hospitals
of North Midlands

NHS Trust
Your Ref: AAH/sasg/1574-2016 Executive Suite
. Trust Headquarters
Our Ref: INQ/067/17 Springfield
Date: 30 January 2018 City General Site
Newcastle Road
Stoke on Trent
STRICTLY PRIVATE & CONFIDENTIAL ST4 6QG
Mr A Haigh
No 1 Staffordshire Place Tel: 01782 676612
Stafford ,
ST16 2LP Ena: as
Dear Mr Haigh

Gwendoline HALFPENNY

Further to my letter dated 18 December 2017, | am pleased to provide a response to your report under
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of
Gwendoline Halfpenny.

Recorded Circumstances of the Death

On 1 September 2016 Mrs Halfpenny fell and broke her left arm. Treatment included codeine. On 6
September 2016 she was admitted to County Hospital with bowel problems. A decision was made for her
to be transferred to the Royal Stoke University Hospital but no bed was available there until the afternoon
of 8 September. Her condition deteriorated and at about 6.00am on 9 September she underwent major
surgery. She did not recover and died at the hospital on 13 September 2016.

Concerns

During the course of the inquest you felt that evidence revealed matters giving rise for concern. In your
opinion, matters for concern are as follows:

1. Soon after her arrival at County Hospital Mrs Halfpenny would have benefitted from surgical input.

There was no surgical cover at County Hospital. Remote advice from RSUH is not the same as a
surgical presence and | wonder if there should be a mid-grade surgical doctor at County Hospital.

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2. Back in September 2016 when this death occurred the MEWS systems operated at County
Hospital and RSUH differently. This has subsequently been remedied. However, | was told at the
inquest that there are still different policies and equipment at County Hospital than those at RSUH.
The hospitals have been part of the same Trust for a considerable period now and | wonder if
there should be greater efforts to achieve consistency.

You reported this matter under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Action Taken

The University Hospital of North Midlands NHS Trust has taken the issues highlighted during the inquest
seriously and indeed, | am grateful to you for raising potential for areas of improvement.

1. At the time of the integration of UHNS and MFST and the re-modelling of services following the
closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of
work to ensure that services were reviewed and realigned to those sites more suitable to provide
the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-
patient services at the County Hospital under the care of general surgery (including gastro-
intestinal (Gl), breast and vascular surgery). However, day case surgeries under other specialities
continue to provide a service from this site, so senior surgeons are available.

In February 2015 a Standard Operating Procedure (SOP) to address the surgical referral system
was introduced and provides the following:

a. Whilst consultant surgeons will no longer have County Hospital as their main base site,
there will be consultant Gi and urology surgeons on site daily Monday to Friday with
vascular and breast surgeons on site up to 4 days a week.

b. Efforts will be made to see non-urgent in-patient referrals on the same day that they are
received.

c. Referring clinicians are able to find out which consultant is on-site and where they are via
contacting extension 4541; following this, referrers will be asked to make verbal contact
with the on-site consultant and follow this up with a written referral.

In light of the concerns that you have raised, this SOP will be re-shared and re-communicated to all staff
via our daily and weekly communications.

2. As outlined above, on integrating what were two separate hospitals, much work was undertaken to
standardise and formalise processes and polices as far as possible with the assistance of external
agencies. Nevertheless, it is recognised that this is an on-going process. It should also be noted
that County Hospital and Royal Stoke University Hospital have very different surgical functions so
efforts regarding consistency need to be balanced against these functions taking to account the
available funds.

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We have now appointed a Deputy Medical Director with specific responsibility for County Hospital
and it is hoped that this will speed up any remaining issues.

| sincerely hope that this report provides you with assurance that the University Hospital of North Midlands
NHS Trust has taken the matters arising from the inquest touching upon the death of Gwendoline
Hafpenny seriously. The Trust strives to provide a high standard of care to all patients and | am grateful to
you for raising these matters on this occasion and | am grateful for the subsequent opportunity for us to
review our processes.

| understand that Mrs Halfpenny was a volunteer at what was Mid Staffs NHS Foundation Trust and my
sincere condolences are extended to the family at this very difficult time and my apologies are also
heartfelt as Mrs Halfpenny didn't receive the standard of care and dignity at the end of her life that she
deserved.

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly.

Yours sincerely

YES coy

PAULA CLARK
CHIEF EXECUTIVE

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