Patricia Palin

INHS'

The Shrewsbury and

Telford Hospital
"NHS Trust

Trust Headquarters

Royal Shrewsbury Hospital

Mytton Oak Road

: Shrewsbury

Mr Heath Westerman , Shropshire
Assistant Coroner SY3 8XQ
HM Coroners Service Our Ref: SW.djp

Shirehall . Tel: 01743 261001
Abbey Foregate - ite:
Shrewsbury
SY2 6ND

Date: 11 September 2018
Dear Mr Westerman

Re: Regulation 28 Patricia Palin deceased

Further to my letter of 21 August 2018, | would like.to once again offer my sincere apologies for the
delay in responding to your Regulation 28 report. | note that the first point related to another
organisation and so | will address each of the points you have set out in turn, which relate to
Shrewsbury and Telford Hospitals NHS Trust.

1. Too few Doctors were on duty in general to cover patient needs and there did not seem
to be a programme in place for trying to get a third Doctor to replace the Doctor who
phoned in sick.

The Trust does have a process in place for trying to backfill vacant shifts in the
Emergency Department. At the first instance we will attempt to contact our own doctors via
the Departmental Consultants or Medical Staffing representative making contact. We will also
advertise via external agencies at the same time to ensure that every attempt is made to fill
the gap. | attach a copy of the flow charts used to backfill vacant shifts.

However, on occasion if the sickness is short notice, as with any organisation, it is less simple
to get cover. However, we do everything in our power to ensure the shift is covered. Due to
the fragility of the workforce both in the locality and nationally, we usually already have
numerous requests out to agency, as well as our own staff picking up additional shifts,
therefore it is not always possible to cover when staff call in at the last minute to cancel their
shifts. . ,

2. Ertapenem was not in stock and led to some 2 hours 25 minutes delay in
administration. Other suitable drugs were in stock, but not considered.

The Doctor prescribing the Ertapenem was not made aware that it was not available in the
department, so was unable to consider an alternative. The outcomes of the Root Cause
Investigation were discussed with the team for learning to ensure communication is improved
in the future. Furthermore, the drug is now stocked in the Emergency Department, to avoid
recurrence in the future. ;

3. Whilst there was a general awareness of the dangers from sepsis from the
Hospital witness evidence:
a) Red flags of sepsis were missed
b) Leg bandages were not removed to allow for a full top to toe examination
c) Sepsis 6 care bundles were not followed in accordance with guidelines

Proud To Care ee Make It Happen ee We Value Respect & Together We Achieve

Proud To Care ae

The Root Cause Analysis was shared with the staff involved in order for lessons to be learnt
by the individuals involved in Mrs Palin’s care. This was reflected by Dr Roywno attested to
this in the Inquest hearing. In addition to this the Trust has carried out work on Sepsis and
much more is planned through the Trust. In the last few years our organisation partnered with
Virginia Mason Hospital in America, in order to improve patient safety and care. As part of
this, one of the Value Streams has focused on Sepsis and improving care for patients with this
condition. Some of the improvements which are being rolled out include:

e Revised Sepsis Screening Tool - a revised version was created by Surgical Assessment
Unit (SAU) staff, which increased compliance to 100% in that area.

e New Sepsis Trolley — the SAU team introduced a bespoke sepsis trolley to store all of the
items required to provide timely treatment for patients who are diagnosed with sepsis
generating greater efficiency and reliability based on ‘set up reduction’.

° Sepsis Box - the box placed all the items required in one place in order that a diagnosis
can be obtained quickly (Ward 28).

The Critical Care Outreach Team have also developed a new Sepsis Web page on the
Trust Intranet with information and links. On this the team will be doing a ‘Spotlight’ of the
month to highlight good practice from various wards around the hospital to raise awareness of
sepsis, this should keep sepsis awareness fresh and in the minds of everyone.

However, given that Mrs Palin's delays were based in the Emergency Department | wish to
you update you on the work which has taken place and the on-going plans to improve sepsis
care in ED specifically. Our Critical Care Outreach Team commenced a programme of sepsis
education in both Emergency Departments, as of last week; to date 20 staff have been
trained. The education is targeting all clinical staff in the department, however this is limited to
availability of staff due to work load. The training sessions are taking place daily, 7 days a
week. The feedback has been really positive from all staff. The areas covered within the
teaching session are recognition using visual signs, as well as recognition using the
’ Sepsis screening tool. The Team then look at the Sepsis Six pathway in detail and discuss the
importance of delivering this within the one hour time frame. Finally reference cards are
provided to staff to keep highlighting the sepsis six pathway and signs/symptoms.

Alongside this we are reviewing the trolleys in the department, with the-possibility of trialling a
trolley that will allow for us to put everything into the trolley for immediate care of the septic
patient, this includes antibiotics and fluids. The existing trolley in place does not carry
everything required for immediate care. :

We are also developing a Patient Group Directive which will allow Senior Band 5 Nurses and
Band 6 Nurses to deliver the fluids and antibiotics within the one hour required time frame in
the event that a Doctor is not available to meet the demands of the one hour time frame.
This is a huge step for us and one that has been welcomed by all the nursing staff within the
ED. Both ED’s have Practice Education nurses who will continue to ensure all staff are up to
date with their sepsis training. ‘ ;

Sepsis Champions have also. been chosen to be a link within the ED, and they will work
closely with the Critical Care Outreach Team to continue the education and provide support
for all staff within the ED. The Team are also in the process of working with the

Medical Teams to ensure that all the Doctors are trained in Sepsis recognition and treatment.

Critical Care Outreach will continue to support the education and training in these areas for as
long is required.

Make It Happen

&! We Value Respect ro Together We Achieve

| hope that | have been able to assure you that whilst we recognise that Mrs Palin’s care was not at
the standard we aspire to provide to our patients, we are taking all the necessary steps to improve the

care we provide to our patients in the future.

This is not something which we can do overnight and will take some time and constant review,
to ensure that the improvements we are making, are successful.

Please do contact me if you have any further questions at this time.

Proud To Care & Make It Happen i 4 We Value Respect [2 Together We Achieve

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SHROPSHIRE & TELFORD LOCAL MEDICAL

ca oD COMMITTEE
4 Representing all General Practitioners in Shropshire and Telford & Wrekin L
Chairman: Secretary:
Dr.S. Hodson Dr. LF. Rummens
Riverside Medical Practice Cambrian Medical Centre
Roushill Thomas Savin Road
Shrewsbury Oswestry
Shropshire
SY1 IPQ SY111GA
Tel: 01743/352371 Tel: 01691/652929/653143
Fax: 01743/244055 Fax: 01691/668709/679130
E.mail: simon.hodson@nhs.net E.mail: ian.rummens@nhs.net
IFR/kth 9" August 2018

H. Westerman
Assistant Coroner

HM. Coroner’s Service
The Shirehall

Abbey Foregate
Shrewsbury

SY2 6ND

Sir,

I am Dr Ian Rummens. I have been a general practitioner, in Oswestry, since 1983,
and Secretary of Shropshire and Telford Local Medical Committee since 1986.

I am writing in response to the Regulation 28 Report regarding Patricia Violet Palin,
deceased. I will respond to item 1 in the Matters of Concern. This deals with the issue
of access to patient information held in the GP record by Shropdoc personnel. Similar
issues apply to access of information from the GP record by staff working in hospital,
particularly A&E.

In 2010 the Summary Care Record (SCR) was introduced. This is an electronic record
of important patient information created from the GP record. It allows approved staff,
working anywhere in the NHS, to access this information about a patient using the
NHS Spine Web Portal.

The basic SCR record only contains a list of prescribed medication, previous adverse
reactions to drugs and allergies. A SCR is created automatically unless the patient
chooses to opt out. They are continually updated, every time the patient’s record is
changed by the practice, as long as the user is logged on using an NHS smartcard
which is now almost invariably the case. Not every GP computer system used across

-2-

the UK is compatible but almost (and possibly all) Shropshire practices use compliant
systems,

As far as I am aware, Shropdoc personnel have been able to view a patient’s SCR for
some time. They need to have an NHS smartcard that allows this but I don’t think
there is any problem with this. I assume that this applied in Patricia Palin’s case.

I think the relevant issue is the addition of more clinical information by the GP
practice, particularly for frail and vulnerable patients with chronic medical conditions.
This allows a more comprehensive picture of a patient’s problems to be obtained
which can only contribute to their subsequent care. This requires the express consent
of the patient and for this to be recorded electronically on the patients GP record.
Once this happens, coded items and supporting free text is added. This includes:

e Significant medical history (past and present)

e Reason for medication

e Anticipatory care information (such as information about the management of
long term conditions

e End of life information

e Immunisations

Sensitive information (like fertility treatments, sexually transmitted diseases) are not
automatically included but any information the patient would like included can be
added manually.

It seems likely that if this additional information was available to Shropdoc, and
passed on to the hospital, it would have contributed to Mrs Palin’s care.

From 2017, the General Medical Services contract requires GPs to identify patients
with moderate or severe frailty, and promote the inclusion of additional information in
those patients with severe frailty by seeking their permission to add it. In this context,
frailty is defined by the electronic Frailty Index (eFI). This is a number, automatically
generated by the practice computer, based on a number of indices, for example:

Moderate Frailty is defined by an eFI score of 0.25 —0.36. These will be people who
have difficulties with outdoor activities and may have mobility problems or require
help with activities such as washing and dressing.

Severe Frailty is defined by an eFI score of > 0.36. These will be people who are
often dependent for personal care and have a range of long — term
conditions/multimorbidity. Some of this group may be medically stable but others can
be unstable and at risk of dying within 6 — 12 months.

Practices should have a rolling program of identifying their patients who are severely
frail, interviewing them and seeking their consent to create an enhanced SCR.
Inevitably, a number will not give consent. For patients lacking capacity to consent,
there are GMC guidelines which can be followed, to allow a decision to be made that
is in the best interests of the patient.

3.

I’m afraid I don’t have figures for the proportion of Shropshire and Telford patients
with severe frailty who have an enhanced SCR. The CCGs may be able to provide
these. Clearly, GPs have a responsibility to encourage uptake in this group. In
addition, there seems little doubt that there are potential benefits in all patients classed
as frail having an enhanced SCR, and that could be extended further. As far as I am
aware, there are no plans by the Government to extend the requirement beyond those
with severe frailty. GP workload and manpower issues limit the capacity of practices
to do more but I will write to practices encouraging GPs to discuss the benefits of
allowing an enhanced SCR with all their patients with chronic illness.

I remain, your obedient servant
¢

tc

LF. Rummens

nance NAN Y

cc. J.P. Ellery
Senior Coroner
H.M. Coroner’s Service
The Shirehall
Abbey Foregate
Shrewsbury SY2 6ND