Frances Gibb

INAS)

Brighton and Sussex

21 February 2020 University Hospitals

NHS Trust

Our ref: C9/19/95

Miss Veronica Hamiiton-Deeley Brighton and Sussex University Hospitals NHS Trust
HM Senior Coroner for Brighton and Hove Level 6, Trust HQ
The Coroner's Office Royal Sussex County Hospital
Woodvale Eastern Road
Lewes Road Brighton
Brighton . BN2 5BE

BN2 3QB

Tel: EK Senior Executive Assistant)

Dear Miss Hamilton-Deeley
The late Mrs Frances Gibb

Thank you for your Regulation 28 report of 10 December 2019, and for sending your Record of
Inquest.

May | begin my expressing my sympathy and condolences to the family of Mrs Gibb at this
difficult time.

We cannot agree that lessons have not been learnt in relation to NEWS within the Trust.
During his evidence at the inquest, HE described how electronic patient observations
(Patientrack) are now embedded in the Trust and are working very well. The roil out of
electronic patient observations began in July 2019 and to date, all Adult and Paediatric
inpatient areas now have the system in place. Later this month the system will be put into the
Maternity Department and then to the Emergency Department in May (following other digital
changes we are making).

Level 9A ward, the ward on which Mrs Gibb was a patient, introduced the system in October
2019 and, as Mimi stated in his evidence, it is used effectively by all clinical staff. The
Matron for Abdominal Medicine and Surgery has conducted a review and can confirm that:

1. 100% of the staff on Level 9A have been trained to use Patientrack.

2. The system automatically calculates the NEWS score and prompts staff with regard to
the frequency of required observations — defined by the previous observations results.

3. Monitors at the Nurse Stations give the Team Leaders visibility of the NEWS scores of
all the patients live.

4. |-Pads are taken on the Ward Rounds so the doctors have up to date NEWS scores at
all times.

5. This system also incorporates the Sepsis 6 Tool and other triggers to prompt staff if
patients score in one parameter.

6. Both nurses who cared for Mrs Gibb engaged in an After Action Review (AAR) with the
Ward Matron and have reflected a great deal on Mrs Gibb’s care. They have learnt and
acknowledged where we could have done better. The nurse who was caring for Mrs
Gibb when she deteriorated recognises that she should have put out a MET call at
21:00 hours due to the sudden change in Mrs Gibb’s NEWS score.

7. Mrs Gibb was being reviewed by a doctor at that time she deteriorated and the staff
prioritised Mrs Gibb back to bed — believing that this may have been a vasovagal
episode in the chair. She needed to be hoisted back to bed as she was too unwell to
stand and the MET call was put out as soon as Mrs Gibb was safely returned to bed as
her NEWS score did not improve.

8. The case has been discussed (anonymously) at Matron led teaching sessions for all
the staff on Level 9A ward to ensure the important learning points have been shared
widely.

9. We also now hold an AAR after all MET calls to ensure any learning is identified and
shared, and that any issues are resolved. A robust governance process has been put in
place in the Surgical Division to ensure shared learning.

10. All new staff to the ward have received training on both NEWS and the importance of
escalation of care.

11. We have increased the number of Band 6 Nurses on night shifts on Level 9A ward from
1 to 2 so the junior staff have more support with clinically deteriorating patients.

12. The Trust now has a Critical Care Outreach service 24 hours a day (this began on 22
July 2019) and Patientrack can also be viewed remotely by the Critical Outreach team.

Patientrack has greatly improved the process in the Trust for tecording and acting on patients’
observations as now the respiratory rate, heart rate, blood pressure, oxygen saturations,
inspired oxygen, temperature, conscious level and pain score are entered directly onto |-Pads.
The system automatically calculates the NEWS score and then prompts a Low/ Medium/ High
response which must be acknowledged by the staff caring for the patient. If a patient requires
a review, response is escalated via the hospital bleep system to the appropriate person. Ifa
patient has a high NEWS score (7 or more) the Patientrack prompt requires staff to consider
whether a MET call is required. All clinical staff can log in and access Patientrack on any
computer throughout the Trust. The latest NEWS score is also displayed within PANDA. You
are welcome to visit Level 9A ward to see the system in use. Miss Stone, Head of Medico-
legal Service would be happy to arrange this for you.

Additional support

The Critical Care Outreach team (CCOT) provide a 24 hour service at the Royal Sussex
County Hospital (as well as the Princess Royal Hospital) and provide additional support to
ward areas as part of the Medical Emergency Response Team (MET). CCOT lead the ACUTE
course teaching for trained nursing staff and contribute learning on acute patient deterioration
to the nurse induction programme and the annual clinical updates.

Radiology .

As confirmed i EE si2temen for the inquest, the initial CT report missed an
embolus lodged in the superior mesenteric artery which was not causing radiological bowel
changes at the time. confirmed that this was not an easy diagnosis to make and
having shown the scans to some of his Consultant Radiological colleagues, not all of them
identified the embolus on the imaging. As acknowledged by [Min his statement for the
inquest, perception errors such as these unfortunately do occur in the field of radiology and
any misses are discussed by the team in regular discrepancy meetings. did not state
that he was under any particular pressure when he reported Mrs Gibb’s scan, and he could not
recall any particular interruption or distraction that night. However, the Chief of Service for the
Central Clinical Services Division has reviewed the case and has shared it within the Division
for learning. | can confirm that junior radiologists working overnight have access on site to
Consultant Radiologists up to 9pm with telephone contact available overnight from 9pm-8am.
The team have been reminded of this and that they must seek assistance from a Consultant
whenever they need extra support.

The actions the department have taken include:

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1. All Radiologists including trainees have been reminded to look specifically at the SMA
when the request is for a queried ischemic bowel.

2. The Protocol has changed so the reconstructions are thinner in two plains to enable
better visualisation of the region.

3. All overnight scans are reviewed by a Consultant the following morning for those
reported by pre Fellowship of the Royal College of Radiologists (FRCR) Part 2b
trainees overnight.

4. Any scans reported by post FRCR Part 2b trainees can be reviewed the following
morning by a Consultant at the trainee's discretion.

5. Mrs Gibb’s case has been re-presented in our REAL (Radiology Events and Learning
through case review) meeting.

Thank you again for raising your concerns following the inquest. We do listen, and we do act
and make improvements to the systems in place at the Trust.

Yours sincerely

— —_ Chief Medical Officer and Deputy Chief Executive

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