Roger Saxby

St George's University Hospitals NHS

NHS Foundation Trust

St George's University Hospitals
NHS Foundation Trust
Blackshaw Road

London

SW17 0QT

Ms Veronica Hamilton-Deeley

Her Majesty’s Senior Coroner for the City of Brighton & Hove
The Coroner's Office

Woodvale

Lewes Road

Brighton BN2 3QB

30 April 2018

Dear Ma’am
RE: The late Mr. Roger Saxby

| am writing further to the joint Prevention of Future Deaths report which was issued to
Brighton and Sussex University Hospitals (BSUH) and St.George’s University Hospitals
NHS Foundation Trust (SGH) on 8 December 2017, which first to came to our attention
on 16 February 2018. We had previously responded to the Regulation 28 report that
was addressed solely to St George’s and we were unaware at the time that you had also
issued a joint report to both Trusts. Thank you for allocating the additional time to
respond to these further concerns as set out at paragraph 5 of the report.

For ease of reference, | will respond to the concerns directed at St.George’s in the order
raised.

e That on arrival at St George’s the start of thrombolysis was delayed.

Mr Saxby arrived at St.George’s at 16:45 hours on Friday 28 July 2017 and underwent
thrombolysis at 19:00 hours. Colleagues from both the vascular and interventional
radiology (IR) teams have reviewed Mr. Saxby’s pathway and they are absolutely
confident that thrombolysis in this case was commenced as soon as it was safe and
practical to do so. Mr. Saxby had to be assessed and clerked, and prepared for theatre
including being consented for the procedure Having reviewed the theatre list for 28 July
2017, the IR service has confirmed that the IR suite was not available to take a patient at
around 17:00 hours in any event as_ they had an on- going case at the time. As soon as
the case was completed and the IR suite was cleaned and prepared for the next case, the
IR on call team sent for Mr. Saxby. Mr. Saxby arrived in the IR suite at 18:30 hours. He
would have required consenting again, transfer onto the angiography table, monitoring to
be established, preparation for the procedure and routine checks performed (Local Safety
Standards for Invasive Procedures - the LocSSIP checklist). The Interventional
Radiologists gained access to the arterial system and started imaging at around 19.00
hours. Considering the time of arrival and the steps required before thrombolysis can be

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commenced, | would like to assure you that treatment appears to have commenced as
promptly as could reasonably be expected without compromising patient safety.

e After he received his thrombolysis at SGH, it became clear that the discussion
about what should happen to him next was completely unstructured.

The clinicians involved in Mr Saxby’s care have reiterated that they were clear about the
actions and plans. There was good communication within the team and they had
conveyed the plans to Mr Saxby at each stage. Most regrettably, as you were made
aware at the inquest, the clinical notes made by the vascular team were lost and this
lamentable situation has meant that they have been unable to demonstrate that there
was clarity and structure in the care plan.

As | have alluded to in the initial PFD response letter, the trust has been moving towards
fully electronic records in stages. When this is fully rolled out, such incidences of loss of
paper notes will be greatly reduced.

e None of those involved in his case demonstrated any sense of urgency

HR 92s reflected deeply on the care provided to Mr. Saxby and discussed this
with his peers, including the clinical lead for Vascular — |
= accepts that in retrospect, it may appear that there was no sense of urgency
at the time, however, in dealing with the reality of what was before him, he did not feel it
appropri time to undertake the amputation over the weekend. His peers,
| who has independently reviewed the decision not to amputate at the
weekend, agree that this was a reasonable decision taking into consideration Mr.
Saxby’s clinical presentation and the plans that had to be made for his on-going
rehabilitation needs.

In respect of all other aspects of decision making, the clinicians involved would like to
reiterate that there was an appropriate sense of urgency as it was always the plan to
amputate over the weekend should Mr Saxby become unstable or unwell, or on the
Monday morning if the proposed transfer had not taken place at the weekend.

The clinicians involved have conveyed their deep regret about the eventual outcome that
Mr. Saxby suffered, but they genuinely felt that they were doing what was right and in
the best interests of Mr. Saxby at the time.

HE Would like to assure you and the family that the issue ii had
never entered his mind as you had intimated at the inquest. and his
colleagues are absolutely clear that they would put their patients’ best interests before
their employers interests without hesitation. As Chief Executive of St. George’s, | whole-
heartedly commend and support this position.

e There was insufficient discussion with Mr Saxby
Prof Loftus has indicated that he saw Mr. Saxby on five occasions over the 48-hour

period and Mr. Ben Patterson saw the patient more often than that. J) bas

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confirmed that on two occasions he had discussions with Mr. Saxby specifically about
amputation and where it should take place.

Again, the loss of key records has put the clinicians in the most unfortunate position of
not being able to corroborate these discussions. This is a source of great regret for the
clinicians and the trust.

e Having had one “most unusual” transfer from hub to hub there was apparently
no thought that another “most unusual” transfer from hub to hub might not be
in Mr. Saxby’s best interest.

| believe the Brighton trust has provided an explanation for why Mr Saxby needed to be
transferred to St.Georges. | will address here the issue of the transfer back to Royal
Surrey County Hospital (RSCH). As per the evidence heard at the inquest, the transfer
back was discussed with the referring team at RSCH and it was agreed that it would be
in Mr. Saxby’s best interests to have the amputation closer to home to prevent a
prolonged period in a London hospital. The vascular service has confirmed that the
repatriation of patients following amputation is extremely difficult and can take many
weeks, and this hinders the commencement of any planning for proper rehabilitation and
social care that Mr Saxby would have needed at home.

National guidance, including “The Provision of Vascular Services 2015” document, and
the “Next Stage Review’ supports the delivery of care close to home to improve access
to care, and patient and carer experience of the health service.

e There should never need to be a hub to hub transfer and certainly not two of
them within 36 hours of each other

A hub to hub transfer is, as you have heard, an uncommon event. In this case, Mr.
Saxby’s transfer was accepted by St. George’s because interventional radiology cover
was not available at the Royal Surrey County Hospital at the weekend and so transfer
was accepted by St. George’s to give Mr.Saxby the best chance of salvaging his leg.
However, despite best efforts by the interventional radiology team, it was recognised that
he was going to need an amputation and, for the reasons explained above, the decision
was made, in conjunction with the RSCH, and with Mr. Saxby’s full agreement, for the
transfer back to RSCH. The subsequent catastrophic turn of events for Mr. Saxby has
been a source of the deepest regret for the clinicians and trust.

Going forward, having discussed and reflected on this case, it is the clinicians’ and the
trust’s view that to refuse to accept patients from another hub in similar circumstances
as that of Mr Saxby will not be in any patient’s best interests, and in fact is more likely to
cause patient harm and death However, once a patient is accepted, a transfer back to a
hub hospital will only take place in exceptional circumstances and after due
consideration.

Thank you for raising these concerns which has given us the opportunity to deliberate
carefully about future hub to hub transfers. The vascular and interventional radiology

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services are committed to patient safety and the learning from this case will always
inform future decision making in similar situations.

| hope this response addresses the further concerns you raised by way of the joint PFD
report. Please do not hesitate to contact me if | can be of further assistance.

Yours sincerely

SIO

Jacqueline Totterdell
Chief Executive

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