Barry Tucker

Veronica Hamiiton-Deeley, DL. LL.B
Her Majesty’s Senior Coroner

for The City of Brighton & Hove

The Coroner's Office

Woodvale

Lewes Road

Brighton

BN2 3QB

East Sussex Healthcare NHS

NHS Trust

Eastbourne District General Hospital
Kings Drive

Eastbourne

East Sussex

BN21 2UD

Tel: 01323 417400
Website: www.esht.nhs.uk

Your Ref: VHD/TS/TUCKER

29 March 2018

Dear Madam
Trust Response to Regulation 28 Report - Barry John Tucker

In response to the Regulation 28 Report you made at the conclusion of the inquest into the
above named'’s death on 17 March 2017 [inquest heard on 11, 12, 16 January 2018] please
find herewith the Trust’s Response.

Documentation
In preparing this Response we have considered:

e The patient's concurrent medical records;

e Review of clinical guidelines/ best practice;

e Face to face discussions with all staff involved;

e Staff statements/written accounts;

e Patient/family account of event and perspective obtained through discussion with them;
e Group discussion (After Action Review);

° Staff support for investigation;

e Staff feedback from incident and findings.

Brief background:

Mr Tucker was a 71 year old man admitted to Eastbourne District General Hospital (EDGH)
to undergo a robotically assisted radical cystectomy and ileal conduit formation for bladder
cancer on 11" September 2017.

Four days later he was discharged home with open access to the Urology Assessment Unit.
Mr Tucker was readmitted on 16" September.. The next day he underwent surgery at
Brighton and Sussex University Hospital (BSUH) and an emergency laparotomy (surgical
opening of the abdominal cavity) was performed. He was subsequently transferred to the
Intensive Care Unit (ICU) post operatively where his condition deteriorated further.

Mr Tucker died on 17" September 2017. The cause of death was recorded as 1a. multiple
organ failure, 1b. small bowel ischaemia due to septic shock and bronchopneumonia, ‘1c.

papillary transitional cell carcinoma of the bladder and 2.superior mesenteric artery

atheroma.

The post mortem findings did not highlight a problem from the initial surgery undertaken at
EDGH. It is unclear if the rapid decline in condition could have been predicted or identified
earlier had there been improved documentation with patient information and consultant

input.

Key Time Line Events:

[ July 2017 Mr Tucker was seen at BSUH with symptoms of haematuria
and. following investigations a diagnosis of invasive
transitional cell carcinoma of the bladder was made. The
Multi-Disciplinary meeting between BSHU and East Sussex
Hospitals NHS Trust determined the most appropriate course
of action was surgery for Cystoprostatectomy (removal of the
bladder and prostate) which would be undertaken at
Eastbourne District General Hospital (EDGH).

20° July 2017 Reviewed by the Consultant Anaesthetist and a nurse for pre
assessment and was deemed fit for surgery.

41° Admitted to EDGH to undergo a robotically assisted radical

September cystectomy and ileal conduit formation for bladder cancer.

2017

12 September
2017

18:45

Mr Tucker was transferred to the private patient unit.

14"
September
2017

On the morning round, the surgical fellow noted Mr Tucker
was nauseous however, his abdomen was soft and non-
tender.

Mr Tucker underwent an oesophago duodenoscopy (OGD)
the procedure notes that there was moderate oesophagitis
and the stomach was full of thick liquid and food and
therefore the procedure was abandoned and advised to
rebook OGD.

15"
September
2017

Mr Tucker was discharged home with open access to the
Urology Assessment Unit. (The blood results and all
observations were within normal limits)

There is no record of the discharge advice given.

16°

September
2017

Mrs Tucker telephoned the Urology Assessment Unit at
EDGH for advice as Mr Tucker was reporting back and
abdominal pain despite taking the prescribed analgesia.
Advised to return to EDGH for stronger pain relief.

16" 20:40 Mrs Tucker contacted the unit again and was advised that Mr
September Tucker should return to EDGH and an emergency ambulance
2017 was offered.

16" 21:30 Paramedics discussed with the on-call Urology Registrar to
September return to EDGH. Unfortunately there was rapid deterioration
2017 so he was taken to the nearest A&E at BSUH

17th 04:00 Mr Tucker underwent surgery at BSUH and an emergency
September laparotomy (surgical opening of the abdominal cavity) was
2017 performed.

47" Mr Tucker was transferred to ICU post operatively where
September condition deteriorated further.

2017

17* 20:35 Mr Tucker died. Cause of death recorded as multiple organ
September failure, small bowel ischaemia due to septic shock and
2017 bronchopneumonia, papillary transitional cell carcinoma of the

—

bladder and superior mesenteric artery atheroma.

Coroner’s Concerns:

(1) Mr Tucker received no pre-op preparation

Trust Response

According to the records, Mr Tucker was seen in the pre assessment clinic at EDGH on
20th July 2017, both by the nurse and anaesthetist in preparation for his surgery. It is
documented in the anaesthetist’s letter to the consultant, GP and patient, that Mr Tucker
needed to contact the GP for blood pressure monitoring.

Mr Tucker was pre-operatively assessed at EDGH and saw a nurse and consultant
anaesthetist.

There is no record of what patient information leaflets were given. The Trust
acknowledges that good record keeping was below par in this instance and has
undertaken to retrain staff about the importance of recording all instances of doctor —
patient contact.

(2) The urology consultant was away during his admission and he had no senior
input.

Trust Response

The consultant responsible for the care of Mr Tucker was on annual leave and therefore
no other senior clinician was appointed to cover. There was an experienced doctor
seeing Mr Tucker each day while he was on the ward. This doctor was a surgical robotic
fellow who had completed his training and was applying for consultant posts. He was
experienced in robotic surgery and was working at the level of a consultant. In addition

3

there was a urology consultant of the week in place who was available for additional
support and advice or contact with the visiting BSUH consultant. There is no record in
the patient notes of any escalation to the urology consultant of the week and this was
most likely due to no concerns identified by the doctor to escalate.

Mr Tucker was reviewed by a Consultant Anaesthetist on 14 September 2017.

[ Recommendation Action Source of assurance | Lead Dea | Date
action embedded in dlin | comp
practice e _|leted

Patients must be] Discussed at| Observed at safety | Clinical Feb | 1 Feb

assigned to a | Clinical huddle on ward lead 2018 | 2018

consultant who _ is |} Governance

present (to see the | meetings

consultant of the week

to cover for annual or

study leave)

Patients must  be/| Job plan to be/ Audit of notes in 31 Clinical Job plan

reviewed by a} amended to| months to — ensure | lead amended

consultant daily post- | include daily | consultant review has Feb 2018 for
operatively. rounds taken place audit May
2018

(3) The Enhanced Recovery Nurse Specialist was also away during his admission. He
never met her or received any paperwork from her.

Trust Response

There is an Enhanced Recovery (ERAS) nurse in the Trust with expertise in this type of
surgery; however, they were on annual leave during Mr Tucker's stay. This nurse would
have visited Mr Tucker while he-was on Michelham ward to ensure he was progressing

well.

[Recommendation Action Source of | Lead Deadline | Date
assurance comp
action leted
embedded in
practice

Review the request] Ward team to be]|ERAS support | Head of | May 2018

for funding a second | aware of ERAS nurse | evident in | Nursing

ERAS nurse and if not | leave and provide the | patient notes

possible ensure that
appropriate
mitigations and leave
cover arrangemenis
are put in place.

expertise. Application
for second ERAS
nurse to division

and process for
leave cover to
be monitored

(4) He never received a copy of the leaflet “Enhanced Recovery after having a

Cystectomy”

Trust Response :
There is a care pathway document for Cystectomy patients which contains detailed
discharge planning information, including prompts and checks which assist in
documenting the key stages of the post-operative period and plan of care. That care
pathway documentation was not used and the nursing and medical notes do not contain
a great deal of detail of Mr Tucker's post-operative progress. The Trust acknowledges
the learning opportunity presented here and has implemented the action plan below.

Recommendation Action Source of | Lead Deadlin | Date
assurance e compl
action eted
embedded

: in practice

The Cystectomy Pathway | The pathway | Audit of | Lead May

patient documentation must | documentation it | documentatio | consulta | 2018

be updated and used for all| to be reviewed | n at 3 months | nt

surgical cases no matter | and circulated to surgeon

what ward to include the | key

latest Cystectomy Enhanced | stakeholders

Preparation Event and

Recovery Pathway (CEPER)
guidance and ensure clear to
what patient information is
provided and when (with sign
off to state completed) and
the discharge process/
requirements;

(5) Mr Tucker’s hospital notes arriving from Michelham Ward were suboptimal,

lacking continuity, incomplete and unhelpful

Trust Response

The Trust acknowledges that the hospital records were not entirely optimal. However,
Nursing care records are documented daily, per shift and Mr Tucker's medical post-
operative care rounds were also recorded in his patient notes. There was a plan noted
however, it was not always confirmed that it was completed. Mr Tucker was transferred
to ITU post operatively and all relevant documentation was completed. Mr Tucker was
then transferred to the private patient unit on 12 September 2017 at 18:45.

The nursing care plan from the private patient unit documents the following: bloods
tomorrow; hourly urine measurements; Fortisip supplements; light diet; physiotherapy;
pain team review; stoma team review.

Hourly measurements of urine are noted on the fluid chart 12/9/17 but the fluid
input/output is incomplete on 13/9/17.

The pain team reviewed Mr Tucker on 14/9/17 when he reported no pain, but was
experiencing nausea and vomiting. Analgesia was amended and adjustment to anti
emetics.

A note was made to check pain levels on mobilising and to contact the pain team if
further adjustment required.

There are daily ward round records from the medical team, which provide a
comprehensive record of the post-operative round which reflects the key stages in post-
operative recovery, however they contained limited detail as to how Mr Tucker
progressed against the plan.

The post-operative daily round documentation has since been amended to include
more detail.

(6) Eastbourne DGH’s system for recalling patients to the Urology Ward following
discharge, if they need to go by ambulance, is flawed.

Trust Response

lf Mr Tucker was stable when the ambulance crew assessed him, he could have
returned to EDGH where he had recently been cared for. The policy for South East
Ambulance NHS Trust is to take patients to the nearest emergency unit to ensure swift
access to investigations, imaging and surgical interventions if a patient is highly clinically
unstable, as Mr Tucker was. The crew on scene did contact EDGH who had agreed to
accept Mr Tucker; however the ambulance crew could not get the ambulance down a
long drive and had to call for 4x4 vehicle for this. During the time the crew were on
scene, Mr Tucker deteriorated further and the operational manager who also attended
the scene made the decision to take Mr Tucker to the nearest hospital which was Royal
Sussex County at Brighton.

There was no delay in transfer due to communication between the Ambulance Service
and Eastbourne Hospital.

The delay on scene was due to the complex extrication from the home to the Ambulance
and the clinical condition of Mr Tucker.

(7) There is no coherent discharge planning protocol in place for enhanced recovery
procedures in respect of urology patients

Trust Response
A protocol is in place and the discharge process has been reviewed.

e Post-operatively Mr Tucker was discharged from ICU to the private patient unit
(patient choice). This is not a specialist Urology Unit, which would have been more
suitable for his post-surgery care.

e The discharge notification document did not include the nausea and vomiting and
oesophago duodenoscopy (OGD) required to be completed at out-patient clinic. Mr
Tucker's bloods or clinical observations upon discharge did not indicate sepsis.

© There is no record of any concerns that were escalated to the ESHT on call
consultant or the BSUH surgeon. The team caring for Mr Tucker did not have/identify
any concerns other than the nausea and vomiting which they felt was being managed
appropriately.

e There are documented care records on 13/9/17 by the physiotherapist who stated
that the patient was asleep and there was a plan made with Mrs Tucker to walk with
the patient later in the day.

e Mr Tucker's bowels should have been starting to work again before discharge.

e Bowel sounds were noted. Stoma was noted to be healthy and abdomen was soft.
The nursing notes note a small bowel movement on 14/9/17.

e On 14/9/17 the physiotherapist reported that patient declined to walk or practise
stairs. Cough was noted to be strong and dry and no further input from physiotherapy

was required.

e Mr Tucker was reviewed by the medical team, physiotherapist, acute team and
stoma nurse prior to discharge.

e The discharge planning documentation was completed in the care record.

e The gastroenterology team were consulted and changed the OGD plan although the
documentation around this change of plan is poor.

e There is no record of the post-operative discharge information given to Mr Tucker.

As a result of the learning taken from this episode of care, the Trust will be implementing
the action plan below.

—

Recommendation Action Source of | Lead Deadline Date
assurance comp
action leted
embedded in

. practice

Patients undergoing Private patient Admissions Micheiha | Feb 2018 Feb

major urology cancer unit advised not to | monitored m unit 2018

surgery should be cared | accept bookings administra

for on the urology ward, | for these patients tor

with more experienced

doctors and nurses.

These patients are not

suitable for private

patient unit.

Urology specialty Conduct urology | Completed Specialty . | April 0218

documentation audit to specialty audit to | audit lead

identify themes and review core

improvements in criteria and

documentation. determine if

accurately reflects
care records.
Action identified
gaps/learning.

The urology specialty to | Key personnelto | Audit May Clinical 1 Doctors For

agree a robust process be identified to 2018 lead identified audit

for ensuring Electronic complete 1 Feb 2018 | May

Discharge notification is | documentation for 2018

signed/checked by a discharge and

senior doctor; audit over 3

. months

| trust the above Response sufficiently answers the matters raised in the Regulation 28

Report.

Should you require any further information please do not hesitate to let me know.

Yours sincerely

[pink bos

Dr Adrian Bull
Chief Executive