Peter Knight

A

The Queen Elizabeth
Hospital King’s Lynn
NHS Foundation Trust

3

The Queen Elizabeth Hospital
Gayton Road

Kings Lynn
Norfolk
PE30 4ET
www.gehkl.nhs.uk
08 May 2019
Mrs J Lake

HM Senior Coroner for Norfolk
Carrow House

301 King Street

Norwich

NR1 2TN

Dear Mrs Lake
Regulation 28 - in the matter of Mr Peter Knight (deceased)

I'm writing to say that | am now able to respond to your Regulation 28 report dated 18
March with respect to the Transfer of Patients Policy. In order to do this | attach a timeline of
the key events which have taken place since Mr Knight’s sad death and a copy of the policy
itself which was ratified at the Clinical Governance Committee meeting on 7th May.

| can also advise that | have visited the Knight family to apologise for the care and
subsequent death of Mr Knight and for the way the family was treated. it was totally
unacceptable. I have asked HS anc the family to attend our next Board meeting to
share their experience if they feel they can do so. We have also promised to keep in close
touch with the family throughout this difficult time.

| hope that this reply gives you some level of assurance of the seriousness the Trust has
applied and the learning needed in going forward.

Yours sincerely

15 May 2019

Caroline Shaw
Chief Executive Officer

cc Cc -

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

Page 2 of 2

INAS)

The Queen Elizabeth
Hospital King’s Lynn

NHS Foundation Trust

Re Peter Knight (dec) - died 6 June 2018 - The Transfer policy

Timeline of the development of the Transfer Policy

Ww

7th September 2018 - Transferring the Critically III Patient Training study event
- Facilitated by P| - Attended by Anaesthetic Doctors, Operating
department assistants, Nurses from all areas. The “Do not transfer patients on
Hi Flo airvo2 machine due to no battery back-up” decision post Mr Knight’s

case was added in to the programme information.

Qt October 2018 - BEB attended clinical governance meeting with the
proposed Transfer of the critically ill Patient Policy. It was discussed at this
meeting that the Transfer of patients (Trust-wide policy) required review as
well and it was decided that the two policies should be combined a well as

improved.

| with GE senior management nurse) to discuss the Transfer

of Patients policy. BB suggested that it needed to reflect intra- (within)
hospital transfers much more. PF (retired Associate Director
Patient Experience) had previously worked on the policy so set up
meeting with, for as soon as possible.

16th October 2018 - Matron] sent out Risk Assessment Matrix for
transferring patients to all Ward mangers and Matrons.

25t October 2018 -J met with i «0 go through the policy.

Suggestions were made and taken away to look for information to go in to the
Policy. We discussed which items could be added - Red Bags from nursing
homes, DNAR status on transfer, Mental Health Patients, Obstetric patients.

HB contacted Project Management Office to find out about Red Bags for
patient from nursing homes to see if this needed to go in the policy.

2nd, 15th, & 26t November 2018 - email discussions about the Escort Flow
Chart and documentation used for transfer of patients was shared amongst
key personnel for comment. It was decided that there was so much to look at
that a Task and Finishing group should be set up -H. lead on this.

11.

The Queen Elizabet
Hospital King’s Lynn
NHS Foundation Trust
HB contacted other hospitals to obtain different transfer policies across the
region as it had been discussed at the Clinical Governance meeting that the
policy might be better split in to Intra and Inter hospital policies. This view was
overturned after great discussion within the Task finishing group set up to

move things forward.

17th December 2018 - A meeting was finally set up following several attempts
in order to ensure attendance of key personnel in the group as a Task &
finishing group. It was felt imperative that the medical Associate Chief Nurse
(ACN) ACN fF Corporate Nurse,
Consultant Nurse Respiratory Specialist Nurse were all
needed which delayed the initial meeting date.

15th January 2019 - The Inquest hearing took place. Conclusion - Accidental
Death. HM Coroner for Norfolk required the hospital to write in March 2019
with regard to the up-to-date position in respect of the outstanding policy

that is being reviewed.

Meetings were arranged on 24th December, 7th January, 21st January
(postponed due to clinical pressures), 28t January, 4th February, 10th February,
14th March, 15t March, and 21st March 2019. Input from areas such as
Assessment areas, X-ray, Porters, Respiratory ward, Critical Care, and the

Practice Development Team were included.

The group researched and designed a handover sheet for all intra-hospital
patients as the current documentation did not meet requirements. The guide
for registered nurses to assess if the patient requires an escort was also
amended and more detailed for patients with a lower News 2 score. The guide
also suggests equipment for transfer of patients. The group decided that one
document for all transfers would be of benefit and add in electronic links to
specific documents separate from the policy would work well. This will enable
specific documents to change and the policy link will always be as up to date
as possible. This has delayed completion of the policy due to some policies
being accessible on the intranet. Many emails were shared between meetings

with various versions of documents for comment.

NHS:
The Queen Elizabeth
Hospital King’s Lynn

NHS Foundation Trust

13. 28% March 20) 9 - i ct 0

appraise where the policy is at and recommendations given to Julie to assist

with electronic versions of documents for the policy.

14. 1st April 2019 - ‘Guide for Escort required for patient Transfers in hospital’
and ‘Patient Transfer Handover SBAR! tool’ out to trial during April in the high
risk areas of Assessment Zone, Acute Medical Unit, Surgical Assessment unit
and A&E before going Trust Wide. These areas found that the SBAR forms are

working well and will to continue using the new forms beyond the pilot stage.

15. 26th April, the new Transfer of Patients Policy (Inter- and Intra-Hospital
Transfer) reached the final draft stage for approval at the Clinical Governance

Committee for ratification on 7th May.

16. Full launch of the adapted SBAR patient transfer tool Trust-wide in June
following the pilot feedback and audit results (audit completed audit 3'¢ May).
In addition a further compliance audit and use of the document will be carried

out two months after the Trust-wide launch.
Additional Points

e The task and finish group has been meeting regularly with various subject
matter experts since 17tt December 2018 to review all internal documentation

and current practice regarding patient transfers.

e During the review it has escalated in to a huge amount of work which involved
reviewing all the documentation used, requesting documentation from other
acute trusts to use as comparisons, including a review of the Oxygen use
policy, what the risks were and what was needed to improve and educate staff
throughout the Trust.

e Part of this was the review of the current transfer stickers which are used by
staff when transferring patients and the redesign of these using an SBAR
format for safe handover of patient care, now been completed.

* Situation, Background, Assessment and Recommendation

7
Vie int

The Queen Elizabeth
Hospital King’s Lynn
NHS Foundation Trust
e The transfer policy involves inpatient transfers and transfers out of hospital to
various locations so have required a lot of input from a number of key people.
We needed rigour when correlating all the information required and wanted to
make sure it was safe and accurate so have needed the time to do this.

e Benchmarking during this review period has revealed that other acute trusts
have been using battery packs for oxygen-necessary transfers and these have
proved problematic and given rise to incidents, leading to the conclusion that

there is no easy cure-all technical solution.

e Initial feedback from the acute areas referred to above has been positive and
identified that although the new SBAR handover sheet and system has slowed
the transfer process a little it has been agreed that it has flagged up problems
that could have become incidents.

e None of the feedback from the acute areas will mean that the finalised policy

will need to be altered in any way.

e The Medical Records Committee have approved the SBAR form and have
adopted and barcoded it.

The Transfer Policy Task and Finish Group

3rd May 2019