David Kerr

r.Jt:kj 

Stockport 
NHS Foundation Trust 

Oak House 
Stepping  Hill  Hospital 
Poplar Grove 
Stockport 
SK2  7JE 

Telephone: 01614831010 
Fax: 
01614873341 
Direct line:  0161 

stock  ort.nhs.uk 

E-mail : 

Our ref. LR/18-05-2020  letter to  HM  Asst.  Coroner- DCK 
Your ref. Case 312830 

Mr Jason Wells 
HM Assistant Coroner 
Coroner's Court 
·Mount Tabor 
Mottram Street 
Stockport 
SK13PA 

4 June 2020 

Dear Mr Wells, 

Re:  David  Craig  KERR (Deceased) 

I am  writing  further to  the  inquest of the  late  Mr David  Craig  Kerr  held  on  16  October 2019  and  the  concerns · 
you  ra ised  relating to the care provided  to  Mr Kerr by this Trust,  between  15 and  27 April 2019. 

I  am  grateful  to  you  for  highlighting  these  concerns  and  for  providing  me  with  an  opportunity .to  respond. 
Please  also  accept my  apologies for any  undue  stress and  anxiety that  has  been  caused  to  the  family  by  the 
delay in  the  information being  provided . 

I asked  the  Surgical,  Gastroenterology  &  Critical  Care  Business  Group  to  investigate  on  my  behalf.  M r_  

Associate  Medical  Director and  Mrs 

, Associate  Nurse Director have reviewed 
the  matters  of concern  which  arose  during  the  inquest.  I have  chosen  to  respond  to  each  concern  in  order, 
which  I trust is satisfactory to you . 

· 

Mr Kerr's  medical c~re on  ward  D2 was poor and  probably contributed to  his  death. 

Mr Kerr was quite an  unwell  gentleman , who  had  a fall  in  the  toilet before  being  discharged from  hospital.  The 
cause  of  his  syncope  was  felt  to  be  due  to  his  respiratory  condition.  Mr  Kerr  sustained  an  extra-capsular 
fracture  neck  of femu r from  the  fall  and  underwent  surgery  without  delay  in  less  than  24  hours.  He  was  on 
Ward  D2,  a  designated  fractured  neck  of  femur  ward  over  the  Easter  weekend  and  had  ·a  stable  post-
operative period . 

Mr Kerr did  not receive an  orthogeriatric review on  the 22 April  as  this was a bank holjday weekend . Our usual 
practice,  during weekend  and  bank holidays,  is  for the on-call  team  of doctors to  provide care  should the  need 
for  their  intervention  arise.  In  Mr  Kerr's  case,  this  happened  on  2  occasions.  Further  reviews  were  well 
detailed  and  patient-centric.  He  was  reviewed  from  the  23  April  2019,  ·by  both  the  orthopaedic  and 
orthogeriatric  teams.  The  majority  of  the  interventions  were  provided  by  the  orthogeriatric  team ,  as  being 
physicians  they  are  best  placed  to  manage  Mr  Kerr's  medical  conditions  during  his  post-operative  recovery 
and  rehabilitation . He was also reviewed daily by the Orthopaedic team . 

The  medical  team  had  noted  the  positive  fluid  balance  within  the  post  ward  round  notes.  These  were 
appropriately  recorded .  The  food  and  fluid  intake  charts  were  completed,  but  were  not  dated  for  24  and  25 
April ; the  charts  were  fully  completed  pre  and  post these  dates. From  review  of the  documentation  within  the 
medical  notes,  oral  intake  was  noted  to  be  reducing .  Mr  Kerr  was  encouraged  to  increase  his  intake  of diet 
and  fluids . Discussion of oral  and  intravenous intake was documented. 

On  26  April  2019,  Mr  Kerr  had  a  ton ic-clonic  seizure  and  this  was  managed  by  the  medical  and  nursing 
teams . Physiological  observations were  recorded  and  _scored  using  the  National  Early Warning  Score  (NEWS 
2).  Escalation  for medical  review when  required  was  detailed  in  the  medical  records. The seizure  occurred  at 

Your Health. Our Priority. 

 13:42  and  observations  are  noted  in  the  documentation  during  this  emergency  situation,  although  I  accept 
these  were  not  transcribed  electronically  on  Patientrack  as  should  have  been  done.  Vital  signs  were  not 
recorded  when  Mr Kerr went for a  CT scan  of his  head.  They  should  have  been  undertaken  on  his  return  to 
the ward  although these were not completed.  The scan  report was  noted  in  the  medical records at 16:42. The 
next set of observations was recorded as being taken at 21 :06 when a NEWS score of O was noted. 

On  Mr Kerr's  initial  presentation  in  AMU,  the cardiologist  had  advised  that  his  bisoprolol  should  be  reviewed 
and  stopped  if his  blood  pressure was low.  We acknowledge that this  adv.ice  provided  by  a specialist was not 
acted  upon  expediently.  Mr  Kerr  continued  to  be  monitored  during  this  time  and  was  being  managed  with 
fluids to  improve his BP,  as  he was within his peri-operative phase.  It is the clinical teams view that the  low BP 
was more ·likely to  be  related  to  a decrease in  intra-vascular volume;  hence improving  this with  fluids was the 
first line of treatment. 

The  clinical  team  acknowledge  that  the  food  and  fluid  intake  charts  should  have  been  dated  and  the 
physiological observations should have been recorded  on  his return  from CT. 

We have discussed his case with  consultants across all clinical business groups and agreed the following 
Trust wide actions: 

•  When speciality advice has been  given,  this should be  acted on,  or a conversation consultant to 
consultant should be undertaken, to ensure patients get the right treatment at the right time 
Improved communication for weekend/ bank holiday handovers 

• 
•  Reiterated the critical importance of reviewing and accurately documenting fluid  balance and 

alternative reasons for hypotension being  explored 

Between  24th  and  26th  April  2019,  Mr Kerr was  allowed  to  become  increasingly  dehydrated;  on  24th 
April  he  received  a  total  of 300mls  of fluid  and  the  input/output  chart  was  not  filled  in  on  25th/26th 
April, despite the fact that he was seriously unwell. 

As  noted  previously  in  this  response,  on  review of this  case,  Mr Kerr was  in  positive fluid  balance from  24 to 
26 April  2019,  although  this was  reducing  over those  3 days.  On  24  April  it was  1.6  litres,  on  25  April  it was 
398  ml  and  on  26  April  it  was  180  ml.  The  team  recognize  that  fluid  balance  charts  are  not  consistently 
completed to the standard expected. 

In  order to ensure compliance with  best practice standards in Ward  D2, the following actions are being taken: 

•  All staff involved in  this incident are being spoken to  by the Matron or Associate Nurse Director and 

reminded of the importance of accurate fluid  balance 

•  Training sessions are being delivered on  the ward to ensure that all staff involved  in this incident are 

able to complete the fluid  balance correctly and in  a timely manner 

•  The Ward are undertaking daily audits on the ward to  monitor the compliance of fluid  balance 

recording,  providing feedback to clinical teams to  promote best practice 

· 

•  To ensure objectivity of audits,  matrons outside the Business Group have been requested to 

undertake peer reviews. 

· 

•  Consistent individual failings will be addressed with the individual concerned,  recorded  in. their 

personal file and appropriate actions taken. 

In  addition,  to  ensure  that  learning  is  applied  across  the  organisation,  we  have  embarked  on  a  Quality 
Improvement  Project  focussed  on  all  aspects  of  hydration  and  nutrition.  This  will  be  supported  by  the 
transformation  team  unison  recognised  quality  improvement  methodology  to  achieve  rapid  and  sustainable 
change. 

There were few clinical observations undertaken for Mr Kerr.  On  26th  April,  clinical observations were 
performed  at 11:12 (NEWS  1)  and  21.06  (NEWS  0).  There were  no clinical  observations thereafter.  No 
protocol was produced regarding the frequency of observations in sick patients on Ward D2. 

On  26 April  2019,  Mr Kerr had observations  undertaken  at 11:12,  13:42 when the seizure occur-red  (and were 
repeated  during  that episode  but not  recorded  on  'Patientrack')  and  at 21 :06.  He was  off the  ward  at  15:03, 

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 undergoing a CT scan when  his observations were due.  These should  have been  undertaken on  his return  to 
the ward  and this was an omission. 

In  order to ensure compliance with  best practice standards in  Ward D2,  the following  actions are being taken: 

•  All  staff involved  in  this  incident are  being  spoken  to  by  the  Matron  or Associate  Nurse  Director and 

reminded  of the importance of appropriate and timely recording of observations 

•  Training  sessions  are  being  delivered  on  the  ward  to  ensure that all  staff involved  in  this  incident are 
competent and capable  in  observation  recording  and  escalation  in  accordance with  Trust policies and 
procedures 

•  EWS  daily  reports  are  produced  and  sent via  email  to  Matrons  and  Ward  Managers  with  details  for 
each area of patients who have scored on the  NEWS2 which  is  reviewed to ensure appropriate action 
has been taken. 

•  Consistent  individual  failings  will  be  addressed  with· the  individual  concerned,  recorded  in  their 

personal file and  appropriate actions taken. 

In  addition, to  ensure that learning  is applied across the organisation, we have started the roll-out of a 
fundamental care framework across the Trust which  includes common best practice standards for the 
management of nutrition and  hydration. 

Summary 

Following  the  review  of  Mr  Kerr's  care  on  Ward  D2,  it  is  acknowledged  that  documentation  requires 
improvement,  as there were  missing dates for 2 days with  regards to  nutrition and  hydration chart recordings. 
The observations  are  noted  in  the documentation  during  the emergency situation  on 26 April  2019,  but these 
were not transcribed on  Patientrack.  Mr Kerr should  have had  his observations undertaken on  his return  to the 
ward after his CT scan on  26 April 2019. 

· 

As  part  of the  governance  processes  for  the  Trust,  quality  and  care  standards  are  monitored  through  the 
completion of audits which are reviewed  at service level on  a monthly basis and reported for further assurance 
through  to  the  Trust's  Patient  Safety  and  Quality  Group  (PSQG).  These  are  quality  metrics  which  are 
completed by the senior nursing team and are discussed at ward,  business group and Trust quality meetings. 

The  audits  have  shown  that compliance  for ward  D2,  over a six  month  period  is  variable  between  82-100%. 
The  identified  areas  for  improvement  on  ward  D2  are  being  addressed  with  the  senior  nursing  team  on  the 
ward,  the  Matron  and  Associate  Nurse. Director.  An  action  plan  has  been  implemented a copy  of which  is 
attached for reference. 

Once again,  I would  like to thank you  for giving  me the opportunity to  respond  to your concerns and  trust that 
my response has  been  helpful to  you.  If there  are any areas where  I could  provide further clarification,  please 
do not hesitate to  contact me. 

Yours sincerely, 

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