Susan Elliott

NHS:

City Hospitals Sunderland
NHS Foundation Trust

Ref: KWB/DC/VH Sunderland Royal Hospital
Kayll Road
19 September 2018 Sunderland
Tyne & Wear
SR47TP
Private & Confidential Tel: 0191 569 9688
Derek Winter DL (Internal ext: 42404)
Senior Coroner for the City of Sunderland a
Civic Centre WWW.chsit.nhs.u
Burdon Road
Sunderland
SR2 7DN

Dear My Lint,

Regulation 28 Report — Ms Susan Joan Elliott

| write further to your correspondence dated én August 2018 regarding your concerns identified
during the inquest into Ms Susan Joan Elliott’s death.

| enclose with this letter an action plan which confirms: a) the actions that will be taken by the
Trust in response to your concerns; b) the target dates for completion of those actions; and c)
the Officers with responsibility for progress of the actions.

You will recall that one of the witnesses in his evidence at Ms Elliott's inquest, suggested that
Ms Elliott's radiograph of 4" August 2017 was “reported and ignored”. | would like to reassure
you that following a thorough internal investigation, | can confirm that both the radiograph and
the associated radiology report were viewed on our electronic system (Meditech) between 4°"
and 5 August 2017 by three different members of medical staff who considered the report
alongside Ms Elliott's clinical presentation and status.

The radiology report was also viewed during the Emergency Department (ED) consultant’s
routine review of abnormal results on 9" August 2017. He immediately rang Ms Elliott's
medical team to discuss the report with them who in turn contacted the Trauma & Orthopaedic
(T&O) team, who advised that as Ms Elliott was at that stage mobilising well and not reporting
pain, she could be discharged home as planned, but if she developed worsening pain she
should return to hospital and have a CT scan. This advice was clearly outlined in Ms Elliott’s
discharge letter.

Our investigation has highlighted that interpretation of the radiology report was influenced by a
falsely reassuring clinical picture, as Ms Elliott's examination and radiographic findings were
not a typical presentation of a hip fracture and were therefore falsely reassuring to all those
involved in her care. Additionally, undisplaced intracapsular fractures of the proximal femur are
notoriously difficult to diagnose on initial radiograph and the early discomfort felt by the patient
can improve if the fracture is not grossly unstable, which can lead to false reassurance that no
fracture is present.

a The path to excellence Part of:
——— South Tyneside and Sunderland

Lr Healthcare Group

Ms Elliott appeared to improve in terms of her mobility and pain during her hospital stay, so no
further investigations or imaging/CT scan were arranged prior to her discharge from hospital,
as they were not thought to be necessary based on her clinical presentation. However, in
hindsight, the clinicians have acknowledged that Ms Elliott should have had definitive imaging
(CT) performed in the ED on 4" August 2017, as both the radiograph and the clinical history
were suggestive of hip fracture at that time, despite her physical presentation.

At the inquest, the same witness also made reference to new protocols about the treatment of
patients presenting with similar conditions such as Ms Elliott, but did not produce any
documents. | would like to assure you that we do have an “Emergency Department Injured
Elderly Non-Weight Bearing (NWB) Guideline/Pathway”, which was developed in 2015. This
guideline provides clear recommendations for cross sectional (CT) imaging and reporting,
where pain or dysfunction suggests an occult fracture. | have provided a copy of this guideline.

The guideline is now included in the T&O junior doctor induction programme and the
importance of all referrals being discussed at the trauma x-ray meeting is also stressed within
this training. Our internal investigation has acknowledged that we need to review and relaunch
this pathway across the Trust in order to raise clinicians’ awareness and this has been
addressed within the action plan.

Our investigation has acknowledged that there were missed opportunities early in Ms Elliott's
admission to diagnose her hip fracture, despite the clinicians involved recognising that she had
suffered a fall with subsequent hip pain requiring significant opiate analgesia and a reduction in
mobility. This meant that the ED Injured Elderly NWB Guideline was not followed, early
definitive cross-sectional imaging was not arranged, and the lack of clinical suspicion of a
fracture meant that Ms Elliott’s hip fracture remained undiagnosed by a number of clinicians
throughout her first hospital stay in August 2018.

There was also a delay in the initial abnormal radiology report being reviewed by the ED team,
as well as differing interpretations of the contents by clinical staff involved in the patient’s care.
When specialist advice was requested from the T&O team, telephone advice only was given,
with no clinical examination or senior review of the imaging.

Therefore, our investigation has acknowledged that surgery was an earlier possibility for Ms
Elliott, had there not been a delay in diagnosing her hip fracture. The Trust has a clearly
defined Hip Fracture Pathway which would have meant that had Ms Elliott's fracture been
confirmed on 4" August 2017, she would have proceeded to theatre for definitive surgery either
on that day or the following day. She would also have been considered for a fascia iliaca
compartmental block in ED, for more effective pain management. This would have reduced the
amount of time she suffered pain and mobility problems, but was unlikely to change the
unfortunate outcome for her.

As you will note from the enclosed action plan, the Trust is addressing the shortfalls highlighted
during our investigation and the inquest, in order to prevent future deaths in similar
circumstances. Progress of the actions detailed within the action plan will be overseen by

Sar Executive Director of Nursing, Midwifery and Allied Health Professionals,
who will keep me briefed and report to the Trust’s Clinical Governance Steering Group.

| trust this information provides assurance to you that the Trust has taken appropriate action to
mitigate any future patient safety issues with regards to the diagnosis and management of hip
fractures.

| would also like to take this opportunity to offer my sincere condolences to Ms Elliott's family
on behalf of myself and the Trust.

Yours sincerely

Ken Bremnér ——a

Chief Executive

Enc