Anita Loi

Private and Confidential   

Our reference: MAD M-070220-2 

PRIVATE AND CONFIDENTIAL 
Assistant Coroner Devonish 
H.M Coroner
2nd Floor
Davis House
Robert Street
Croydon
CR0 1QQ

15 May 2020 
Dear HM Coroner 

Director of Nursing & Therapies 
Ground Floor 
15 Marylebone Road 
London 
NW1 5JD 

E-mail:

 Tel: 0207 798 1436 
@nhs.net 
Web: www.clch.nhs.uk  

Re: Prevention of future death report following inquest into the death of Mrs Anita 
Loi 

I  am  writing  in  response  to  the  Regulation  28  report  to  Prevent  Future  Deaths  that  was 
received on 6 March 2020. I understand that you began an investigation into the death of 
Anita Loi on 28 November 2019 which concluded at the end of the inquest on 20 February 
2020. Firstly I would like to offer my sincere condolences to Mrs Loi’s family for their loss. 

I  would  also  like  to  express  my  regret  that  the  Trust  was  not  invited  to  participate  in  the 
investigation, or the inquest on 20 February 2020. 

I will respond to each concern raised in turn: 

(1) The Tissue Viability Nurse and District Nurses are a part of the same community
team  but  no  steps  had  been  taken  to  attend  to  the  management  of  Anita  Loi's  leg
wound despite repeated referrals by the GP and a call to the community team by the
family.

Our  Tissue  Viability  and  District  nurses  received  referrals  from  the  GP,  but  unfortunately 
there was a delay by the GP surgery in providing sufficient clinical information on the initial 
referral  to  aid  safe  triage  and  a  lack  of  timely  responsiveness  to  follow-up  requests  for 
information.  We  also  acknowledge  a  communication  breakdown  by  our  teams  that 
contributed to a delay in care. 

Your healthcare closer to home 

www.clch.nhs.uk 
@CLCHNHSTrust

 The Trust’s Single Point of Access Team (SPA) was contacted by telephone on 7 May 2019 
by  Dr 
  GP  at  Morden  Hall  Medical  Practice  referring  Mrs  Loi  to  the  Tissue 
Viability Nurse (TVN). The referral was forwarded to the TVN and triaged on 8 May 2019.  
The  TVN  called  the  GP  to  request  an  updated  doppler  scan  as  the  one  on  record  was 
outside  of  the  3-6  month  timeframe.  The  Single  point  of  access  team  (SPA)  team  also 
contacted the GP practice on 9 May 2019 with regard to the doppler report and followed up 
with an email as requested by the GP practice on the same day. A subsequent attempt was 
made to request the scan from the GP on 10 May 2019. The GP responded to confirm that 
the doppler report was from September 2018. There was a lack of timely responsiveness to 
follow  up  requests  made  by  the  SPA  for  information,  which  led  to  a  delayed  triage;  the 
referral  was  rejected  on  16  May  2019  and  the  GP  was  advised  that  this was  because  no 
further doppler or duplex scan was provided. 

A  doppler  scan  within  3-6  months  report  is  necessary  for  triage  as  it  is  important  to 
ascertain  the  vascular  status  for  patients  with  lower  limb  wounds.  This  assists  with 
identifying any vascular issues which require prompt referral of the patient to the secondary 
care  vascular  team  for  their  input.    We  acknowledge  that  the  request  for  a  doppler 
assessment should have been secondary to the assessment of the clinical  presentation of 
Mrs Loi. Additionally, when the referral was rejected by the TVN team, Mrs Loi should have 
been  internally  referred  to  the  District  Nurses  for  care  and  treatment  and  I  am  very  sorry 
that this did not happen. 

The GP made a referral to the District Nurses team on 31 May 2019 requesting a doppler 
assessment,  the  triage  nurse  spoke  to  Mrs  Loi’s  son  who  reported  that  her  legs  were 
swollen. The triage nurse advised that there was a waiting list for doppler assessments, as 
there  was  no  clinical  assessment  which  indicated  the  urgency  of  the  referral;  the  referral 
was not prioritised.  Mrs Loi’s son was advised that he would contact the GP practice with 
regard  to  going  there  instead.  The  triage  nurse  contacted  Mrs  Loi’s  son  again  on  3  June 
2019  and  he  advised  that  he  was  still  waiting  for  a  response  from  the  GP  Practice;  he 
advised  that  his  mother  did  not  have  any  wounds  that  required  dressing.  With  this 
information  the  triage  nurse  assessed  that  it  would  be  safe  to  wait  for  the  doppler  or  to 
request that it is carried out at the surgery. The triage nurse discussed with Mrs Loi’s son 
that the community nursing referral would be rejected.  

A  further  referral  was  received  on  20  June  2019  to  both  the  District  Nurses  and  TVN 
service. The TVN triaged the referral and noted that  there was reference to a burn wound 
which  was reported to have been on the foot for 6 weeks which previous referrals did not 
indicate. When the TVN triaged the referral it was mistakenly identified as a duplicate as a 
referral had also been made to the District Nurse Team and unfortunately this delayed the 
assessment.  The  District  Nursing  documentation  advised  that  a  visit  would  be  carried  out 
and the TVN service would be updated, However, there was a delay in follow up, for which I 
am sorry and I have followed up with the team to ensure processes are strengthened.  

The  District  Nurses  operated  on  a  business  continuity  basis  quite  often  which  meant  that 
patients had to be prioritized and visits delayed on occasion.  In this instance  Mrs Loi was 
not sufficiently prioritized, based on the information contained in the first two referrals. The 
prioritisation process did not appear to be risk based and there were communication issues 
between the TVN team and DN team which resulted in each team assuming that the other 
was visiting Mrs Loi.   

 
 
 
 
 
 (2) On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability 
Nurses Team to attend a meeting at the surgery with the practice clinicians to review 
unexpected deaths and to discuss this case. Neither team attended the meeting and 
to  date  have  not  engaged  with  the  GP  in  relation  to  this  death  despite  a  chasing 
letter. 

 clinical operations manager was contacted on  18 November 2019  by 
  Business  Manager  for  Morden  Hall  Medical  Centre,  to  attend  a  ‘Significant 
Event’  Case  Review  Incident. 
  advised  that  he  was  bringing  some  information 
together  to  enable  them  to  review  the  case  of  Mrs  Loi  who  passed  away  at  St  Helier 
Hospital in July having been admitted following a cardiac arrest. 
 advised that  Mrs 
Loi had been seen for treatment of her diabetes and had also been referred to the Trust for 
 requested details of the teams involved and clinical notes. 
treatment of leg ulcers. 
 or a member of her team would be welcome to attend, 
 replied on 20 November 2019  advising that 
however it was not mandatory.  
she would be unable to attend on that date as she would be on annual leave, however, she 
would enquire whether another manager would be able to attend in her place.
informed 
 that she would be unable to share the clinical records with him as there 
was  no  information  sharing  agreement  in  place  with  the  GP practice  at  that  time  however 
information would be shared by the person attending the meeting.  

 advised that 

On 8 December 2019, 
 to reiterate that she would be unable 
to attend as she was  on annual leave, and unfortunately the appropriate deputy was also 
unable  to  attend  due  to  sickness.  However, 
  requested  that  she  be  updated 
with the outcome of the meeting and to be advised if she could help further. There was no 
further communication following this.  

 emailed 

I’m sorry that we missed the opportunity to engage in this meeting as a result of the issues 
outlined  above.  We  acknowledge  that  engaging  in  this  meeting  would  have  been  a  good 
opportunity to review Mrs Loi’s care and we will put measures in place to ensure improved 
engagement with such meetings going forward. The Merton Community Service continue to 
attend  practice  meetings  and  will  be  strengthening  the  communication  between  the  GP 
practices to ensure that discussions are held whenever there is any confusion surrounding 
a patient’s care or unexpected death. 

(3)  Whether  there  are  appropriate  policies,  procedures,  protocols  in  place  for  the 
referral of patients to the service, and the response to such referrals. 

We have updated our Triaging Standard Operating Procedures to ensure a robust process 
for  the  management  and  response  to  referrals.  The  procedure  now  ensures  that  Triage 
nurses check if patients are open to other CLCH services. If the referral received is for more 
than  one  service  on  the  same  day  the  triage  nurse  must  make  contact  with  that  other 
service to initiate joint working and ensure that visits are allocated appropriately.  When a 
referral is received by more than one service, a meeting is held to ensure that the patient’s 
referral, clinical history is reviewed jointly and a plan of action on how best to manage the 
patient’s care is determined.  

We have now also undertaken a serious incident investigation and identified areas requiring 
improvement and put measures in place to ensure such events do not re-occur as outlined 
below: 

 
 
 
 
 
 
 
 1.  We have undertaken an urgent review and are improving the referral processes from 

primary care into DN & TVN teams.  

2.  We  will  commence  work  on  our  electronic  patient  record  system  to  strengthen  the 
reminder capability in EMIS Health, (Egton Medical Information Systems), to ensure 
that referrals are effectively managed and responsiveness is maximised.  

3.  We have urgently reviewed the referral form to provide clarity on clinical information 

required by TVN to make informed clinical decision. 

4.  We  progressing  work  to  ensure  urgent  escalation  processes  if  there  are  delays  to 

requests from GPs for further information to inform triage. 

5.  We will establish clear processes to be in place to review jointly as part of an MDT all 
people  referred  who  are  know  to  multiple  teams  to  ensure  timely  joined  up 
responsiveness. 

6.  Where  referrals  for  doppler  are  made  incorrectly  to  the  TVN  team  we  will    put  the 
patient at the centre of the care and work to avoid delays in care by; liaising with the 
appropriate team to see if the required assessment can be undertaken to aid clinical 
decision making. 

7.  We will clarify to the GP information required in a referral including a detailed clinical 

assessment and indication of urgency for patient. 

8.  Further to the poor communication between TVN & DN teams. The Merton DN/TVN 
team are to make urgent contact with the Trust accredited service in Harrow, to see 
what  learning  can  be  shared  about  providing  a  seamless  service  between  these 
teams and the arrangements in place to managing joint referrals. 

9.  The  Team  will  urgently  review  how  known  medical  history  is  being  used  to  inform 

clinical decision making.  

10. We  will  urgently  review  the  caseload  prioritisation  process  for  a  doppler  in  the  DN 

service to ensure it is risk based. 

I am sorry our communication and management of referrals was below our expected  high 
standards which led to delays in care.  I am confident that the steps we are undertaking will 
ensure  that  each  patient  referred  is  reviewed  in  a  collaborative,  systematic  way  and  care 
provided  at  the  correct  level.  As  well  as  continuing  to  review  the  actions  we  have 
implemented,  we  will  also  be  sharing  learning  from  this  investigation  with  other  teams 
across the Trust.  

I hope our approach to learn from this assures you. Please do not hesitate to contact me or 
 the Divisional Director if you require any further information. 

Yours sincerely 

Director of Nursing & Therapies (Quality & Safety)  
Central London Community Healthcare NHS Trust