Thomas Smyth

NHS

888. COMMUNICATE. Milton Keynes
COLLABORATE. CONTRIBUTE. University Hospital

NHS Foundation Trust

Our ref: 20191203JH Standing Way
Date: 03 December 2019 witoneeren
MK6 SLD

Mr Tom R Osborne 91908 660033

HM Senior Coroner www.mkhospital.nhs.uk

HM Coroner's Office
Civic Offices

1 Saxon Gate East
Central Milton Keynes
MK9 3EJ

Dear Mr Osborne

REGULATION 28 REPORT TO PREVENT DEATHS -— Mr Thomas Henry Smyth

Dear Mr Osbourne,

1 am writing in response to a Regulation 28 Report, issued to me as Chief Executive of
Milton Keynes University Hospital NHS Foundation Trust on 28 October 2019. The report
requires a formal response by 16 December 2019 and this letter is intended as that formal
response.

The inquest that the Regulation 28 Report followed was into the death of Thomas Henry
Smyth, aged 86. You reached a narrative conclusion which read: The deceased was
admitted to Milton Keynes University Hospital on 12th July 2019 following a fall at his
nursing home. A CT scan revealed a subdural haematoma and the neurosurgeons advised
that his anticoagulation medication should be stopped. It was inappropriately restarted on
13th July 2019 and this resulted in his clinical deterioration and he died from the subdural
haematoma on 3rd August 2019 at Mallard House Milton Keynes.

Following the conclusion, you stated matters of concern that form the basis of the
Regulation 28 Report. Those concerns read: During the course of the evidence | heard from
consultants and more junior staff that they were unaware of certain facts relating to Mr.
Smyth at the time that they were dealing with him and making decisions relating to his care,
and yet the information was recorded in the electronic notes and records. It appears to me
that staff are having difficulty accessing vital information that should be clearly available to
them. | would ask that you carry out a review of the notes system to see whether or not it is
being used correctly, whether staff members have been adequately trained with regard to
its use and whether changes should be made as to how information is recorded and

As a teaching hospital, we conduct education and research to improve healthcare far our Chief Executive: Joe Harrison
Pattents. During your visit students may be involved In your care, or you may be asked to. Chai + Sil Lloyd
participate In a clinical tial, Please speak to your docter or nurse If you have any concerns. dirman: Simon Lloy

TheMKWay NHS
222. COMMUNICATE. Milton Keynes
COLLABORATE, CONTRIBUTE. University Hospital

NHS Foundation Trust

retrieved. Unless the system is working effectively i anticipate that further lives will be put at
risk.

| would like to address those concerns and set out what we have done and are continuing
to do to ensure that our electronic notes system is safe and effective.

You may recall that we introduced an inpatient Electronic Patient Record (which we refer to
as eCARE) in May 2018. The supplier of the system, Cerner, is used in more than 20
hospitals across the UK as well as in hospitals and health systems globally.

To ensure the system was introduced safely, and with the minimum of disruption to patients
and patient care, we undertook an extensive programme of staff training in the lead up to
the eCARE system going live across hospital inpatient areas (including the Emergency
Department and Maternity — some areas, including Critical Care and Paediatrics, are in the
next phase of the roll-out). This programme included individual and team training; dedicated
staff to support wards and departments on the use of the system after go-live; training for all
temporary staff; and training materials, including videos, as well as individual and team
support remaining readily available.

The Trust also appointed a Chief Clinical Information Officer (a consultant vascular
surgeon) and a Chief Nursing Information Officer (an experienced senior nurse), to ensure
appropriate clinical oversight and input into all aspects of eCARE — from its introduction to
ongoing training and future developments.

We have a robust governance process and structure in place to oversee the development,
implementation and continued performance of eCARE, including staff training and use of
the system. This structure reports to a main board (the Health Informatics Programme
Board) which | chair as Chief Executive. This board has oversight of risks and issues and
works to ensure that these are mitigated and managed appropriately.

In the care of Mr Smyth, the Emergency Department Doctor notes Mr Smyth was on
Apixiban in the free text area of the eCARE record. It would be optimal if this were recorded
in the medication history section of the eCARE record. The Pharmacist subsequently
reviews and inputs an accurate medication history. By the time Mr Smyth is clerked by the
Trauma and Orthopaedics Senior House Officer, the Apixiban is clearly in the medication
history and this is included in the SHO’s note.

As a teaching hospital, we conduct education and research to improve healthcare for our Chief Executive: Joe Harrison
patients. During your visit students may be Involved in your cara, or you may be asked to ;
participate in a clinical trial. Please speak to your docter or nurse if you have any concerns. Chairman: Simon Lloyd

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CASE COMMUNICATE. Milton Keynes
COLLABORATE. CONTRIBUTE, University Hospital
NHS Foundation Trust

Mr Smyth had a Venous Thrombolytic Embolism (VTE) assessment to assess whether
prophylaxis was required to prevent Deep Vein Thrombosis/ Pulmonary Embolus. The
Doctor who completed this recognised that Mr Smyth should not have VTE prohylaxis due
to his intracranial bleeding; however they do not check the box on the electronic form that
says ‘concomitant use of anticoagulants’. If they had checked this box the Doctor may have
thought to stop the Apixaban.

Apixaban is given to Mr Smyth twice a day on 14 and 15 July, and one dose is given on 16
July. A VTE assessment is completed by a different Doctor on 16 July but ‘concomitant use
of anticoagulants’ is again not identified.

Apixaban was then stopped on 16 July as Mr Smyth's condition deteriorated; and Apixaban
was not administered again during admission.

Although documentation in the free text area of the eCARE record is appropriate, it is not
best practice, as there are more secure designated (and specifically designed and included)
sections of eCARE in which to include issues that may raise a medication alert or other
safety alert in the care and management of individual patients.

In this particular case, it is clear that important and relevant information was indeed
recorded in the clinical record. Members of staff did not consistently review key elements of
the record when assessing Mr Smyth; for example, the medication chart does not seem to
have been reviewed daily when clinicians assessed Mr Smyth's condition. Review of the
medication chart and observations is a key clement of routine rounding and this will be
reinforced with staff. This will be addressed in training — with additional training in ED and
Trauma and Orthopaedics. This specific case will be used for learning in plenary sessions
during the year to reach a wide medical and multidisciplinary audience.

It should be noted that the electronic system used by the Trust to communicate with
neurosurgical colleagues in Oxford (OARS) offers huge advantages over the informal
paper-based system which came before it. There is now a thorough audit trail of all
communication between local doctors and those in the tertiary centre, with automaied alerts
to the lead clinician when an individual patient's record is updated.

It is important to recognise that electronic health records — whether within a hospital (such
as eCARE) or within a clinical network (such as OARS) — offer very significant benefits in
relation to accessibility, governance and patient safety. Electronic prescribing in particular

As a teaching hospital, we conduct education and research to Improve healthcore for our Chief Executive: Joe Harrison
patients. During your visit students may be involved in your care, or you may be asked to oc;
participate in q clinical tridl, Please speak to your doctor or nurse If you have any concerns. Chairman: Simon Lloyd

TheMKWey INHS)

CASS. COMMUNICATE, Milton Keynes

COLLABORATE: CORHIBUTE! University Hospital
NHS Foundation Trust

has major advantages. Where care does not go according to plan and deficiencies in note
keeping and communication are identified, it is imperative that we do not persuade
ourselves that the medical records of old were better: lost records, illegible entries,
medication charts in pharmacy, two different perspectives on the same conversation
between centres with no written record of either.

| am satisfied that with the actions proposed, and the governance structure in place to
manage the use of and risks associated with eCARE, the risk of future recurrence is
appropriately mitigated.

If you require any further information or evidence, please do contact my office without
hesitation.

With kind regards

Yours sincerely

Rrofessor Joe Harrison
Chief Executive

Copy

FS Medical Director

As a teaching hespltal, we conduct education and research to improve healthcare for our Chief Executive: Joe Harrison
Patients. During your visit students may be involved in your care, or you may be asked to A cy
participate in a dlnical trial. Please speak to your dactor or nurse If you have any concerns. Chairman: Simon Lloyd