Douglas Owens

INHS

Blackpool Teaching

Hospitals
NHS Foundation Trust

Trust Headquarters
Blackpool Victoria Hospital
Whinney Heys Road
Blackpool

Lancashire

FY3 8NR

11 December 2020

Mr Tim Holloway

Assistant Coroner Blackpool & Fylde
- PO Box 1066

Corporation Street

Blackpool ©

FY11GB

Your reference: , | - Prevention of future deaths Reg 28-1

Dear Mr Holloway

Re: Douglas Owen (deceased) — Inquest concluded Tuesday 7 October 2020

Further to my letter dated 4 November, in which | confirmed receipt of your Regulation 28 Report to
Prevent Future Deaths, dated 19 October 2020, in relation to the death of Douglas Owen, who sadly
passed away on the intensive care unit of Blackpool Victoria Hospital on 7 July 2018.

In my letter, | explained that we would take actions to prevent a similar event from occurring.

1 have below outlined my responses to the matters of concern you have raised with us and what action
we have taken:

1. That Blackpool Victoria Hospital has not yet finalised an agreement with Spire Fylde
Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool
Victoria Hospital when appropriate. Unless arrangements are formalised, the lives of
patients may be put at risk.

The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the
Ophthalmic Unit at Blackpoo! Victoria Hospital has been considered and discussed at length with
relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde

‘ Coast Hospital. may not be sufficient to prevent similar incidents from occurring and thus the focus was
directed to the development of more responsive and effective protocols in our existing services, to
ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then
ophthalmology would be performed quickly and comprehensively.

To that effect, the Clinical Director of Ophthalmology, who is a Consultant Ophthalmic Surgeon, has
developed a protocol that details a number of elements (please see attached) that ensures the safe
care and treatment of ophthalmology patients:

Chairman: F | Chief Executive: | |

. RESEARCH MATTERS AND SAVES LIVES - TODAY'S RESEARCH IS TOMORROW'S CARE
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to
improve treatment of our patients. A member of the healthcare team may discuss current clinical rials with you.

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NHS

Blackpool Teaching
Hospitals
NHS5 Foundation Trust

e Handover Document (Ophthalmic Emergency Patients)

e In-house pathway (Ophthalmic Emergency Patients)

e Securing of a room in ED for ophthalmic Casualties in the new Emergency Village. This
will primarily be the new ED room for ED Ophthalmological patients to be seen and part of our
new ED Minors area. It will also be used specifically as a room for Ophthalmology to see
Ophthalmotogy patients who have been transferred from. Spire Fylde Coast Hospital with
post-operative complications. For clarity, Ophthalmology patients within the ED have always
been able to be seen by Ophthalmology in the department, but this dedicated room will
enhance the services we provide.

To further develop the safety of services we provide, the Clinical Director of Ophthalmology has also
drafted a number of recommendations for Spire Fylde Coast Hospital to bring out essential in-house
changes to their Ophthalmic Services. Spire Fylde Coast Hospital will then be able to evidence to
yourself the changes they have brought to ensure the safe care and treatment of ophthalmology
patients at their hospital.

2. That the Deceased was not seen by a speciality doctor in the Emergency Department
notwithstanding the need for him to be seen. Unless action is taken there may be a
continuing risk that patients in the Emergency Department will not be seen by on call
doctors in speciality disciplines, in particular, ophthalmology, even when the need
arises in that Department.

Following on from the previous concern, the protocol developed by the Clinical Director of
Ophthalmology details the mechanism in which the ophthalmology specialty doctor attends the
Emergency Department (ED) to assess and treat patients when the need arises.

In addition, the Medical Leadership Forum has agreed a policy for Internal Professional Standards for
Blackpool Teaching Hospitals NHS Foundation Trust. The purpose of agreeing a set of professional
standards, is to provide a clear reference point against which the organisation can function and to
which medical colleagues can be accountable. They are commonly used by Emergency Departments
to clarify patient flow though the front end of a hospitai, but can be used across an entire organisation.

To support the implementation of the Internal Professional Standards, the Trust is currently recruiting
to a Director of Professional Standards / Deputy Medical Director post. One of the main responsibilities
of the postholder will be to work with colleagues to support the Trust's plans for quality improvement
in clinical safety, mortality, clinical efficiency and effectiveness, by providing day.to day responsibility
for delivery of safe, personal and effective care.

3. That the evidence disclosed omissions in the taking of vital signs observations and in
the recording of observations in the vital signs observation chart (incorporating the
National Early Warning Score). Unless action is taken, there is a risk that any
deterioration in the condition of patients which might put their lives at risk will not be
‘identified at the earliest opportunity.

See below

4. That the evidence disclosed that the review process was not followed upon the
Deceased’s blood pressure dropping by more than 40mmHg, notwithstanding the fact
that that observation had been recorded. Unless action is taken, there is a risk that any
deterioration in the condition of patients which might put their lives at sk will not be
reviewed at the earliest opportunity.

INHS|

Blackpool Teaching
Hospitals
NHS Foundation Trust

See below

5. That the evidence disclosed the fact that, whilst fluids had been prescribed, no
prescription chart or fluid balance chart had been completed. Unless action is taken to
ensure the completion of applicable documentation, the lives of patients may be put at
risk.

| have taken the liberty to answer your concerns 3, 4 and 5 in a combined response, that addresses
all three concerns.

We sincerely apologise for omissions in the taking of Mr Owen's vital signs observations and in the
recording of observations in the vital signs observation chart, that Mr Owen's drop in blood pressure
was not followed up and that Mr Owen’s prescription chart or fluid balance chart had not been
completed.

Over recent months, the Trust and the Emergency Department (ED) have committed to major
improvement projects ‘and programmes to improve the ‘recognise and act’ element in the care and
treatment of a deterioriating patient. The ED currently are 92.91% compliant with the Trust's Recognise
and Act Mandatory Training (120 staff are compliant, nine staff are waiting to attend, three of which
are new staff and two are paediatric nurses). We have a plan for all outstanding staff to attend the
training, although limited places are available due to social distancing. Our two Advanced Clinical
Practitioner's (ACPs) are running simulation training sessions for all staff to attend, following the Trust
Pathways of the recognition of the the deteriorating patient. Both ACPs are Advanced Life Support
(ALS) trainers and follow the ALS algorythms and the NEWS 2 Escalator.

Furthermore, the Trust monitors completion of the NEWS2 charts through spot audits.undertaken by
the Matrons and Ward Managers, with any gaps identified. managed immediately at ward level and
key themes are discussed at Nursing Quality Governance Meetings, with actions created for shared
learning.

At an organisational level, the Quality Improvement Strategy describes a new Deteriorating Patient
Collaborative, to test ways of working that will help teams to recognise and respond to the clinical
deterioration of patients and reduce preventable’ deaths. A Project Initiation Document has been
prepared and a Senior Responsible Officer and Improvement Programme Manager have been
identified to support the work. The Board of Directors support commencement of the Deteriorating
Patient Collaborative and agreed to receive regular updates on-progress as part of the Quality
Improvement Strategy reporting mechanism.

In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff
will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score
recorded correctly, that any changes in score are acted upon promptly and that fluid charts are
completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily,
where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this
includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and
manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round,
where.all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC
(Emergency Physician in Charge) to ensure that appropriate plans of care are in place. The nursing
team undertake two-hourly care huddles, where the nurse management of the patients’ care is
reviewed, to ensure that the coordinating nurse has a robust overview.

6. That the evidence disclosed the fact that the Once-only and Pre-medication Chart does
not make provision for the dose of medication actually given to be recorded in the event
that the dose prescribed has been specified as falling within a range (for example, as
here, morphine 1-10mg) and that, in any event, the actual dose given was not recorded
in that chart. Unless the giving of medication is recorded fully the lives of patients may
be put at risk.

INHS

Blackpool Teaching
Hospitals
NHS Foundation Trust

We sincerely apologise thatthe actual dose given was not recorded in once only and pre-medication
chart.

The once only and pre-medication sections of the chart are to be used for STAT doses only where the
exact dose to be given is clearly indicated. Variable doses are written on the PRN section of the chart
-with the person administering. the medication completing the dose given. This is standard practice
throughout the hospital and the ED have been reminded of this. The ED pharmacist will monitor to
ensure this happens.

From November 2018 morphine elixir has been treated as a restricted drug within the Trust and all
doses given are recorded in the restricted drugs register and are therefore traceable.

| hope that the above responses provide you with the assurance that we have taken your concerns
extremely seriously and that we have taken appropriate actions as a Trust, to prevent a similar event
from occurring.

Dr|
Executive Medical Director