Ann Swoffer

INHS|

University Hospitals Birmingham
NHS Foundation Trust

Trust Headquarters

Executive Office of the Chair & Chief Executive Level 1

. Queen Elizabeth Hospital Birmingham
Chair > 0121371 4315 Mindelsohn Way, Edgbaston
Chief Executive > 0121 3714311 Birmingham
Executive Manager : 0121 3714312 B1S 2GW
Fax : 0121 371 4316

Tel: 0121 627 2000

Ref; DRLTR/HUNT 1403 2019

14 March 2019

Mrs Louise Hunt

HM Senior Coroner

Birmingham and Solihull Districts
Coroner’s Court

50 Newton Street

Birmingham

B2 5DB

Dear Mrs Hunt

Inquest touching the death of Ann Swoffer
Response to Regulation 28 Report to prevent future deaths

| write in response to the Regulation 28 report made by you following the Inquest into
the death of Ann Swoffer, which concluded on 22 January 2019.

University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully
considered the concerns raised within your report to prevent future deaths and
responds as follows (using the numbering in your report):

1. | heard clear evidence that the practice and procedures in place at Good Hope Hospital at
the time were not consistent with accepted practice or national guidelines. This raises a
considerable concern as to why the practise was so different and what monitoring is in place
to ensure consistent practices in accordance with national guidelines are in place.

3. The department caring for the deceased at the time were not following accepted practice or
BSG guidelines. It is essential that the person who leads the restructuring of the practices

and protocols is an expert and can ensure that the necessary details are considered and
implemented. Consideration needs to be given as to who should lead the restructure and
review.

| recognise that you heard evidence that practice at Good Hope Hospital was out-
with appropriate guidelines. This was also presented as such in the Trust's SI report.
A subsequent review has identified that the guidelines are recognised and used by
the clinical team at Good Hope Hospital. The default position is that oesophageal
dilatation should not be undertaken unless there are specific indications, which
should then be fully documented in the medical record, which unfortunately did not
occur in Ms Swoffer’s case.

Chair: Rt Hon Jacqui Smith Chief Executive: Dr David Rosser

The national guidelines for the diagnosis, staging and management of oesophageal
cancers are adopted on all sites within the Trust. To summarise, the national
guidelines recommend that:

a, tumours are not dilated for diagnostic purposes
b. enteral feeding is considered for patients with nutritional compromise (British Society of
Gastroenterology guidelines 2011).

The guidelines allow for some discretion to endoscopically cross the tumour where
this may be the most effective route for nutritional support, or on occasion to identify
the distal extent of the tumour; information that may be required to determine the
potential for curative management. The Trust's endoscopists, including those at
Good Hope Hospital, avoid oesophageal dilatation whenever possible, due to the
risk of tumour perforation which would render the patient inoperable for cure, as well
as exposing them to other complications including sepsis.

In the event that it is deemed necessary to dilate an oesophageal cancer, the team
that currently service Good Hope and Heartlands Hospital have published excellent
outcomes in one of the largest oesophageal cancer stenting series in the UK, with a
perforation rate of just 0.8% (Surgical Endoscopy 2017 31:2280-2286). This
compares favourably to the published literature which report the frequency of this
complication to be approximately 3%. It is also the case that oesophago-gastric
services across all Trust sites have good cancer outcomes benchmarked and
publicly available in the national oesophago-gastric cancer audit.

The Trust has an established, standardised upper gastrointestinal cancer pathways
agreed and updated through a specialised multi-disciplinary structure which has
been in place for over 10 years across different sites. These have been consolidated
into a single pathway in place across all sites at the Trust since September 2018.

The Trust now have in place a single MDT to support decision making in oesophago-
gastric cancer care, however for the purposes of care delivery there are currently two
teams. The work to establish a single service for all aspects of care is in train and
will be in complete by June 2019. The core team members include clinical nurse
specialists, dieticians, accredited consultants and a single management structure.
This will provide even greater consistency of management, including a single
location for surgery. This realignment is being overseen by the Executive Director
Strategic Operations, working with Divisional Directors and Clinical Service Leads for
the upper gastrointestinal surgical departments based at the Trust.

2. The deceased deteriorated as a result of a late perforation over the August Bank Holiday
weekend. Junior staff did not identify the problem and did not escalate this to senior staff. |
was told a ‘work force issue’ meant senior staff were not present in the hospital at the time.
Patients who become ill at the weekend need to receive the same standard of care as in the
week. Consideration needs to be given to how this can be addressed.

At the time of Ms Swoffer's admission, there was a consultant available on call at
Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on
site in Birmingham Heartlands Hospital. There was however no escalation to the
consultants available over the weekend. We have worked with the clinical teams to
ensure there is appropriate communication with senior medical staff regarding
emergent complications regardless of time of day, or day of week. We have further
increased routine on site attendance by a range of consultant staff over the
weekend, to facilitate access to consultant opinions and help clarify lines of
communication outside the times they are present. For example, at Good Hope
Hospital there were no planned gastroenterology consultant ward rounds over the
weekend at the time of the deceased’s admission. This has been changed so that a
gastroenterology consultant attends for a ward round over the weekend.

4. There is a general concern that all sites with the Trust are not integrated and are not
following the same protocols. It is important that any patient receives the same standard of

care based on current guidance.

The long term goal of the Trust is full integration of service delivery, creating single,
multisite departments across all specialities. This process has begun in a number of
areas, for example upper gastrointestinal cancer services as described above. A
unified, cross-site operational structure will be established by May 2019.

A short-term goal includes alignment of protocols and guidelines across all sites,
itself a significant task that is nevertheless proceeding at pace. in some
circumstances the Trust will choose to maintain different but acceptable protocols
until there is unification of service delivery. This reflects the fact that choices
between valid standards of care are often determined by particular local operational
considerations. In these circumstances a single protocol will be established upon
service unification.

| would like to assure you that all protocols in place across our sites are based upon
current national guidance and are subjected to a rigorous review process, overseen
by a multi-disciplinary review team. Therefore, irrespective of differences in the
detailed protocol in use, patients can expect the same outcome based standard of
care.

! would like to assure you that the concerns raised within the Regulation 28 Report
have been taken extremely seriously which | hope is demonstrated by the steps we
have taken and will continue to take going in the future.

Yours sincerely

Dr David Rosser
Chief Executive