Linda Doherty

Surrey and Sussex
Heafthcare NHS Trust

Headquarters
East Surrey Hospital
Canada Avenue
Redhill
RH1 5RH

Tel:
www.sash.nhs.uk

Please reply to:

Chief Nurse

Fax: 01737 231769
Email:

Our ref:

H M Assistant Coroner Anna Crawford
H M Coroner for Surrey
Station Approach
Woking, Surrey
GU22 7AP

23 February 2021

By recorded delivery

Dear Ms Crawford

I write in response to the Preventing Future Deaths Report addressed to Michael
Wilson, Chief Executive, and received on 6 November 2020, following the Inquest into
the death of Mrs Linda Doherty.

Please find attached the Trust’s response to the Matters of Concern addressed in your
report dated 5 November 2020. I am aware from from earlier communications with the
family of Mrs Doherty that they do not wish to receive direct correspondences from the
Trust, and I would therefore appreciate it if you could ensure a copy of the enclosed
report is sent to them, via their legal representatives. A copy of the report has been sent
to the CQC.

I am grateful to you for the additional time you have afforded the Trust to respond, and
and I also appreciate the family’s patience.

Yours sincerely

Chief Nurse

Putting people first
Delivering excellent, accessible healthcare

An Associated University Hospital of
Brighton and Sussex Medical School

 CONFIDENTIAL

Serious Incident Report

V1817.2.21 postmeeting

Surrey and Sussex Ti!lLi

Healthcare NH Tru5t

Incident Number

Date of Incident

Date reported on Steis

Grade

7th August 2017
3rd November 2020

1

Date submitted to CCG for closure

Closure due date

31st January 2021

Please confirm that the following detail is included in the report

Root Cause identified

Being Open policy followed

Lessons Learned

Recommendations

Mechanism for shared learning

Report anonym ised

Action Plan states accountability and date for completion of actions

Was a SVA alert raised? (if appropriate)

If applicable, was a SAAR taken forward? If not, please state
reason why?

SAAR Outcome and Allegation

Any actions resulting from the SAAR process relating to SASH are
included in the RCA Action Plan
Recommendations/Further information requested have been
updated

Report prepared by

Associate Medical Director

Yes

Yes

Yes

Yes

Yes

Yes

Yes

N/A

N/A

N/A

N/A

Contact details

Report reviewed by SIRG

Serious Incident Review Group
(Chair signature)

Scrutiny_Group_Use Only

Full RCA provided

Robust Root Causes

Robust Action Plan

RCA 2020-20811

Page 1 of 23

 Surrey and Sussex
Halthc.are tJHS Twst

Root Cause Analysis Investigation Report

Incident Reference:

Incident Description:

The patient, a 69 year old lady, died in August 2017 at the end of a 3 month stay in hospital
following emergency surgery for recurrent bowel obstruction due to adhesions and
subsequently-diagnosed Crohn’s disease. An inquest reported that for the last month of her
it was not recognised that she was suffering from malnutrition, weight loss and intestinal
life,
failure.

Following the inquest a Regulation 28 Preventing Future Deaths report was issued and an SI
investigation was opened at SASH to review the matters of concern raised by the Coroner
and to provide the Trust’s response.

Incident Date:

Date Incident Reported:

Incident Type:

Datix Reference Number:

7th August 2017

4th November 2020

Care implementation

Speciality:

General surgery

Actual Effect on Patient:

Patient experienced malnutrition on the ward and
subsequently died.

Actual severity of the incident:

Severe

Level of Investigation:

Serious incident investigation

Involvement and support of
patient and relatives (application
of Duty of Candour legislation):

The chief nurse wrote to patient’s husband
following the inquest on 20th November 2020.

In an email received from the family’s solicitor,
further direct contact was requested via the
solicitor’s office.

Detection of Incident:

Coroner’s inquest conclusion

Immediate Actions Taken:

Review of dietitian provision in the Surgical division

Pre-investigation Risk Assessment:

A
Potential Severity
(1-5)
5

B
Likelihood of Recurrence at
that Severity (1-5)
2

C
Risk Rating
(C = Ax B)
10

RCA 2020-208 1 1

Page 2o123

 ______

_______ _________

________________

Terms of reference:
Purpose of investigation:

To consider the matters of concern raised by the Coroner in a Regulation 28 Preventing
Future Deaths report following the inquest, and to use this information to ensure that future
harm to patients has been significantly reduced since this patient’s care, and to identify any
further issues arising which the Trust needs to address.

Key issues to be addressed:

Extracted from the Coroner’s Regulation 28 Preventing Future Deaths report:

1

To ensure that the appropriate procedures are in place for recommendations
stemming from MDT meetings to be actioned appropriately.

2. To ensure that staff are sufficiently trained in how to score MUST charts.

3. To ensure that procedures are in place to:

(i)
(ii)

Identify those patients who require food charts
To ensure that they are properly completed.

4. To review whether any additional measures or training are required to prevent delays

in acting on a patient’s significant weight loss in the future.

5. To ensure that appropriate end of life policies and procedures are in place and that

staff are sufficiently aware of them.

In addition to the concerns raised in the Regulation 28 report, the investigation also
considered the following issues that had been highlighted during the inquest:

• The missed opportunity to commence TPN feeding.

• A review of the current dietetics provision in the Trust in 2020.

Background and context:

returning home she developed a DVT and had ongoing abdominal pain.

The patient, a 69 year old lady suffered an acute colonic perforation whilst on a cruise near
Honduras in September 2016. She underwent an emergency laparotomy and Hartmann’s
procedure at a local hospital. She was repatriated back to the UK for ongoing rehabilitation,
In
and after
November 2016, an ultrasound scan by her GP identified a suspicious abnormality in her
gallbladder for which she was referred to the upper Gl MDT, and after further investigation
with CT and repeat ultrasound, she underwent a cholecystectomy and partial liver resection
at the Royal Surrey hospital in February 2017. The final histology was benign. At around the
same time, she had already been referred to the colorectal surgical team for consideration of
stoma reversal, and was seen in the colorectal clinic in January 2017, when a colonoscopy
was planned for May 2017, with a view to possible stoma reversal later in the year.
Following the cholecystectomy, the patient continued to experience episodes of abdominal
in March with presumed adhesional small bowel
pain, and was admitted to hospital

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 In April, a colonoscopy was performed which was normal apart
obstruction, confirmed on CT.
from diverticular disease, then on 8 May 2017, she was re-admitted to East Surrey hospital
complaining of abdominal pain and poor stoma output. A diagnosis of subacute adhesional
bowel obstruction was made and she underwent a
the
Hartmann’s procedure with formation of loop ileostomy on 11 May 2017. At operation, she
was noted to have dense adhesions throughout the abdomen, and a small bowel mass
involving the terminal ileum, which was also resected. Her initial recovery was slow, with a
prolonged ileus, and she was briefly discharged to the ward on 2 June, before returning to
ITU on 3 June with urosepsis. On 9 June 2017, the histology report from her operation was
treatment with steroids was
released which diagnosed Crohn’s disease, and medical
commenced immediately.

laparotomy and reversal of

By 23 June 2017, the patient was improving and was transferred to Copthorne Ward and in
early July 2017 the various teams involved in her care were planning her discharge home.
There were fluctuating signs of progress, but by 1 August 2017, she had begun to deteriorate
again and there was inflammation in her small bowel, due to the Crohn’s disease.

On 4 August 2017, she was diagnosed with intestinal failure due to Crohns disease and by 5
August 2017 an end of life pathway was commenced and she sadly died on 7 August 2017.

The inquest was opened on 10 August 2017 and took place on 21-22 May 2019 but did not
conclude. The hearing resumed on 22—23 October 2020 and the conclusion from the
Coroner was received on 27 October 2020.

Medical cause of death

The Coroner returned a medical cause of death as:

la sepsis and acute kidney injury

lb malnutrition

ic Intestinal
nutritional intake from 23 June to 2 August 2017

failure secondary to Crohn’s disease and ileac resection, and inadequate

The Coroner returned the following narrative conclusion:-

the patient underwent a CT scan in relation to a suspected mass in
“On 2 December 2016,
her bowel. On 20th December 2076 the results of a CT scan were discussed at an upper GI
MDT meeting at East Surrey Hospital and it was agreed she would be referred to colorectal
surgeons for follow up. On 8 May 2017 the patient was admitted with bowel adhesions and
underwent a laparotomy. Thereafter the patient remaThed an inpatient.

On 9 June she was diagnosed with Crohn’s disease for which she was begun on steroid. On
4 August there was a diagnosis of Intestinal Failure. On 5 August she was placed on end of
life care.

There was no follow up which led to a delay with diagnosis and treatment for Crohn’s disease

From 10 July to 23 July there was an omission to recognise she was receiving inadequate
nutrition.

From 11 July to the beginning of August there was a failure on the part of the clinical team to
realise she was suffering malnutrition, weight loss, and intestinal failure.

As a result they failed to feed her by TPN, but for which failure she would have survived.
relation to the failure to feed by TPN, her death was contributed to by neglect.”

In

Following the inquest, the Coroner issued a Regulation 28 report — Action to Prevent Future
Deaths which was sent to the Chief Executive at Surrey and Sussex Healthcare Trust.

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 The Coroner’s matter of concerns raised are as follows:

1. There was no colorectal follow up in relation to the findings of the CT scan carried out
on 2 December 2016 despite it being recommended by the Upper Gastro-Intestinal
Multi-Disciplinary Team (MDT) meeting at East Surrey Hospital on 20 December
2016.

Consideration should be given as to whether the appropriate procedures are in place
to ensure that recommendations stemming from MDT meetings ate actioned
appropriately.

2. The Malnutrition Universal Scoring Tool (MUST) charts for the patient were

inaccurately scored during the period from 3 to 23 July 2017.

Consideration should be given as to whether staff are sufficiently trained in how to
score MUST charts.

3. The food charts for the patient were not completed from 23 June to 12 July 2017 and

again from 18 to 23 July 2017, despite the patient being at risk of malnutrition.

Consideration should be given as to whether appropriate procedures ate in place to:
(I)
(ii) To ensure that they are properly completed.

Identify those patients who require food charts

4. The MUST charts recorded that the patient’s weight was 65kg in early June 2017 and
had reduced to 57kg by 11 July 2017, yet the multi-disciplinary team caring for her did
not recognize that she had lost a significant amount of weight until 1 August 2017.

Consideration should be given as to whether any additional measures or training are
required to prevent similar delays in the future.

5. The patient was placed on end of life care on 5 August 2017 by a Senior House

Officer (SHO) following consultation with his Consultant, both of whom had had only
limited prior involvement with her. The decision to place her on end of life care was
made without any consultation with the Intensive Care team, to ascertain whether she
would be suitable for intensive care, and without any consultation with the clinicians
who had been treating her over the course of the preceding three months.

Consideration should be given as to whether appropriate end of life policies and
procedures are in place and whether staff are sufficiently aware of them.

In addition to the Regulation 28 report, the investigation also considered the following issues
that were highlighted during the inquest:

• The missed opportunity to commence TPN feeding.

• A review of nutrition documentation.

• A review of the current dietitian provision in the Trust in 2020.

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 Information and evidence gathered:

The patient’s clinical records

Statements provided for the Coroner’s inquest

Discussions

ICU Dietitian - 10.11.20
Consultant Gastroenterologist — 17.1 1.20
Chief of Surgery and Consultant General Surgeon — 24.11.20
Ward manager and sister — 25.11.20
Head of Therapies — 2.12.20
Registered Dietitian — 8.12.20
Critical Care Outreach Lead Nurse — 10.12.20
Consultant Surgeons x 2

Policies and guidelines

SASH policy for oral nutrition and hydration (ratified July 2019)
SASH policy adult enteral feeding (ratified Sept 2020)
SASH policy for fluid balance monitoring in adults (reviewed Oct 2019)
SASH clinical guideline for risk feeding (ratified Aug 2018)
SASH clinical guideline for management of hydration and nutrition at the end of life (ratified
Feb 2020)
SASH End of Life Care Strategy 2019-2023 (ratified December 2018)
SOP for Hospital Palliative Care Team Referral and Triage

Documentation

Patient Bedside Safety Booklet: Risk assessments and care plans (relevant pages appendix)
Escalation of Treatment form (appendix

Terms of reference
Oral nutrition and hydration group
Deteriorating patient group
End of Life Steering group

Training Presentations

SASH Intranet — MaST Clinical topics renewed by staff annually:-
Nutrition and Malnutrition
End of Life Care at SASH

PowerPoint presentations to doctors:
Palliative and End of Life Care FY2 — Sept 2020
Palliative Care — symptom management - medical registrars — Dec 2020
Palliative Medicine — internal medical trainees - Nov 2020
End of Life Care — year 5 medical students — Dec 2020

RCA 2020-208 1 1

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 Findings:

The events leading up to the death of the patient have already been comprehensively
covered by the statements from staff for the inquest and the report prepared by the Coroner’s
expert witness. The purpose of this investigation was to consider the matters of concern
raised by the Coroner following the inquest and other issues arising that were a cause of
concern for the Trust.

MDT meeting follow up review

The first consideration was to examine if the appropriate procedures were in place to ensure
that the recommendations stemming from MDI meetings were actioned appropriately. The
investigation focused on the Upper GI MDT meeting, which was the area of concern in
December 2016.

The investigation found that following the December 2016 MDT meeting, the patient was
seen by a colorectal surgeon five weeks later to explore the possibility of re-joining her bowel.
The consultant explained that whilst he felt that a colostomy was possible, he did not want to
do it so soon after her original surgery, so she was booked for a colonoscopy in May 2017
with a view to the reversal taking place in Autumn 2017. The colorectal consultant was not
aware of the concerns raised by the Upper GI MDT regarding a possible thickening in her
small bowel, and had not seen the CT report from December 2016.

After further investigation of the patient’s suspicious gallbladder mass with a repeat
ultrasound, she was admitted for a cholecystectomy and partial liver resection at Royal
Surrey hospital in February 2017. The gallbladder histology showed chronic cholecystitis,
with no malignancy.

The patient was admitted in March 2017 with small bowel obstruction, and a CT scan at that
time did not report any intrinsic small bowel pathology. A colonoscopy was performed in April
2017 which identified diverticular disease and follow up in the clinic was scheduled, but the
patient was readmitted to East Surrey hospital in May 2017 and underwent laparotomy for
adhesiolysis, small bowel resection and reversal of Hartmann’s with formation of loop
ileostomy and remained in hospital until her death in August 2017.

The current arrangements for the follow up of the recommendations made at the Upper GI
MDI meeting were reviewed. The outcome for all patients discussed at the MDT meeting,
whether cancer patients or not, are recorded on the Somerset database (a digital platform
designed for healthcare professionals to manage cancer patient care). This is monitored by
cancer services trackers who are then able to escalate to the most appropriate person any
concerns i.e. tests not being requested and will chase dates as needed.

The cancer nurse specialists (CNS) who attend the MDI meeting, action the meeting
outcomes, where possible, such as requesting for any diagnostic tests or appointments and
referring to specialist teams to prevent delays. The CNS will monitor the actions using their
own spreadsheet management tool, as a backup to the Somerset database, and ensure
comprehensive notes are kept in both places.

A letter is generated by the consultant who chairs the MDT meeting which is forwarded to the
patient’s GP within 24 hours detailing the outcome and plan. Patients are not copied into this
letter at this point due to the nature/sensitivity of the information. The CNS ensures that the
team who have referred the patient for MDT discussion are made aware of the outcome and
plan on the same day as the meeting. The CNS will arrange for patients to be seen in clinic
or contact them regarding the outcome and any recommendations. Where the CNS has
been in contact with the patient, they ensure the patient has been given the CNS details as a
point of contact.

RCA 2020-2081 1

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 Nutritional management

The inquest also raised concerns regarding the nutritional management of patients, in
particular the use, accurate completion and training in relation to food charts and weight loss
management whilst on the ward.

At the time of the patient’s admission in 2017, the recording of food charts took place on
loose sheets of paper.
assessments and care plans’ was introduced and is now used for all in-patients. This booklet
includes all the documentation for nursing assessments, for example falls management, skin
integrity and cannula care.

In August 2018 the ‘Patient Bedside Safety Booklet: Risk

Nutrition assessment and monitoring has now been combined into one section which
includes a malnutrition universal screening tool (MUST) assessment, nutrition care plan and
BMI score, fluid and nutrition chart (appendix 1).

The MUST screening tool documentation includes BMI chart and ‘percent weight loss’ table
for ease of BMI and percentage weight loss calculation, improving the accuracy of recording.
The ‘Nutrition Care Pathway’ directs staff on how to proceed with the MUST score identified
(from surveillance to dietitian referral) and requires a nursing signature. A food record chart
allows staff to accurately record type and quantity of food or nutritional supplements offered
using a simple tick box record which has proved effective at assessing global nutritional
intake.

Dietitians had identified deficiencies in ward based nutrition screening and in early 2018
reviewed the knowledge and understanding of ward based staff. Following this review, a new
training package was developed based on its findings, which has now become a clinical core
topic of the Mandatory and Statutory training (MaST) at SASH which staff complete annually.
Compliance is monitored via the on-line Electronic Staff Record (e-ESR) and reminders are
sent to staff 3 months in advance of expiry.

In the first 6 months of roll-out, over 1000 staff members were trained on the MUST tool,
nutrition screening and assessment. This initial training provided by dietitians has now
moved online along with other MaST training since the outbreak of COVID-19 in 2020. This
online version is available at all times via the SASH Intranet. Live webinar sessions are also
available to book, for those who prefer this format and includes the opportunity for questions
and answers. On the ward refresher training is still given by ward dietitians to staff where a
need is identified.

The training package was developed to coincide with the nutritional documentation in the
‘Patient Bedside Safety Booklet: Risk assessments and care plans’. This presentation
delivered by a dietitian is 37 minutes long. The PowerPoint slides describe in detail how to
assess and calculate MUST scores giving examples. The management of a patient’s weight
includes how to measure arm circumference for those who are difficult to weigh.

An audit to assess the impact of this training and use of the documentation is due but has
been delayed due to the pressures of the COVID-19 pandemic.

The incomplete food charts presented at the inquest hearing, reflect the omission by ward
based staff to document nil oral intake whilst artificial feeding was being delivered. On review
of the feeding routes given to the patient by a dietitian, it appears that the absence of food
recording on most dates reflected periods of enteral, parenteral or combined feeding. This
would not be expected for a patient managed with parenteral nutrition to have any food
record charted as they would be made ‘nil by mouth’ or sips of fluid for oral comfort only.

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 It was clearly documented where the patient declined nutritional input, both on the food chart
and in the patient’s clinical notes where conversations with the patient and her family were
recorded. The dietitians who reviewed the case felt that the weight loss experienced by the
patient related not only to the disease process but also a fragmented nutrition delivery.
There were episodes where parental nutrition was halted for suspected or proven line sepsis
or improvements in oral/naso gastric (NC) tolerance. There were times when enteral feeding
was halted or abandoned due to patient refusal, delayed NG placement and frequent
removal of the NC tube. On occasions the surgical team stopped enteral feeding to allow for
oral intake.

There were references in the nursing notes to the family bringing in food but this was not
entered on the food charts so the amount consumed was unknown. The patient had a
reported dislike of the oral nutritional supplement drinks and the additional food choices
available from the hospital kitchen and she had the capacity to refuse these when they were
offered, which made further input difficult.

All the wards now have “daily huddles”, where the ward team come together to discuss
nursing issues and MUST is part of the daily checks. Any problems or concerns are
escalated to the nurse in charge.

There is a nutrition nurse specialist available at SASH 4 days a week but she also works in
the community and only tends to get involved when there is a problem or complex issue.
This is unusual as there is usually at least one full time separate community and hospital
nutrition nurse available for inpatient nutritional support planning.

A need for a specialist multi professional Nutrition Support team was identified for the
oversight of the provision of nutrition for patients with complex artificial feeding needs. This
group is a national recommendation and aims to optimise the metabolic care of the sickest
patients in hospital, by performing regular nutrition ward rounds with supporting members
e.g. surgeons and feeding into the proposed complex nutrition MDT meeting. The team
consists of a gastroenterology consultant, nutrition nurse specialist, senior nutrition support
dietitian and a pharmacist.
Gastroenterologist with a special interest in nutrition who has reviewed the current nutrition
policies, procedures and service at SASH. Twice weekly nutritional ward rounds are now
taking place, led by this Consultant Castroenterologist, and a monthly complex nutrition MDT
meeting will be operational by April 2021. This will be a forum for surgeons and dietitians to
meet monthly to review nutritional needs of specific patients, any refusal of treatment and the
use of parental nutrition.

In October 2020, the Trust appointed a Consultant

An additional specialist dietitian and nutrition nurse specialist would allow more prompt
assessment of parental nutrition and better support for the Nutrition Support team and wards
to be able to see all patients referred for parental nutrition, monitor line care on the wards,
provide training to wards and provide monitoring for patients.

The Trust Nutrition Steering Group, based on another national recommendation, was
meeting every 2 months but was put on hold in 2019 when the previous lead consultant left
the Trust.
It was reinstated within SASH by the new consultant gastroenterologist.
purpose is to set and audit standards, review education and training, agree equipment used
and co-ordinate other governance issues, for example infection control and risk
management. This group is responsible for its own sub-committees of Oral Nutrition and
Hydration group, Complex Nutrition Group and Eating Disorders group and will report to the
Trust’s Clinical Effectiveness committee, chaired by the Medical Director.

Its

The Oral Nutrition and Hydration group launched in October 2020 currently meet monthly,
and was formed to contribute to the SASH food and drink strategy through ensuring the
delivery of best practice nutrition standards in relation to the accessibility of appropriate food
and drink 24/7 for all patients, taking into account individual medical requirements.

It also

RCA 2020-208 1 1

Page 9 of 23

 has oversight of the actions being taken to improve food and drink provision and to develop
and monitor related audit programmes.

The Complex Nutrition group also meets monthly to discuss and evaluate complex nutrition
needs and support which includes consultants and senior dietitians.

Nutrition was included as part of foundation training for FYi and FY2 junior doctors from
2018 and continues to be provided on an annual basis by a specialist dietitian. The talks
address the nutrition training needs of junior doctors relevant to the Foundation training
curriculum 2016. Feedback has been overwhelmingly positive.

As part of the Trust’s commitment to providing a more efficient nutrition service, it was
identified that one potential delay to instituting total parental nutrition (TPN) was in having a
P1CC (intravenous) line inserted. Prior to April 2019, the service was completed on an ad-hoc
basis and managed by Radiology with some PICC’s being completed in Radiology and some
on the CEPOD list. The service was reliant on skill mix availability on the day, and as a
responsive organisation it was recognised that this service was not wholly conducive to
patient care.

So with effect from April 2019, Theatres began the structured service provision for the P1CC
Line Service. This service is available Monday — Friday with the majority of PICC’s being
completed on a daily basis. There is also the capability to provide a P1CC service on some
Saturdays and Sundays dependant on skill mix, although primarily focused on a weekday
service. The service is run by a small named team, standard operating procedures, a
dedicated room set up, and bookings taken through a live database.

End of life policies and procedures

The patient was placed on end of life care on 5 August 2017 by a Senior House Officer
(SHO) following consultation with his Consultant, both of whom had had only limited prior
involvement with her. The decision to place her on end of life care was made without any
consultation with the Intensive Care team, to ascertain whether she would be suitable for
intensive care, and without any consultation with the clinicians who had been treating her
over the course of the preceding three months.

It is acknowledged that the decision to put the patient on end of life care could have been
more widely consulted upon; however this was unusual as processes are in place to facilitate
the process.

The Coroner asked for consideration to be given to whether appropriate end of life policies
and procedures were in place at SASH and whether staff were sufficiently aware of them.
There are a number of policies and information to support patients and staff available on the
SASH Intranet on the Policies and Palliative Care Workspaces (see information and evidence
gathered).

A SASH End of Life Care Strategy 2019 — 2023 is available based on the Ambitions for
Palliative and End of Life Care:- A national framework for local action 2015-2020 which was
produced by the National Palliative and End of Life Care Partnership. This document
identifies six ambitions for end of life care in the UK, and the eight foundations which are
necessary to support their implementation and success, and which form the basis of the
SASH strategy. This includes personalised care planning and education and training and
identifies the current situation at SASH and next steps required for improvements.

An Escalation of Treatment form to aid clinical decision-making for patients with a DNACPR
in place or who are at risk of deterioration is in place and was revised in 2020.
(Appendix 2)

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 SASH has an End of Life Care Steering group who meet quarterly to facilitate improvements
in the quality of end of life care for patients, and in the support provided to their relatives and
carers. The group is multi-professional and has representation within SASH and the wider
local health care economy.

The Deteriorating Patient group meets monthly to oversee aspects of care and treatment
related to the acutely deteriorating patient at SASH. They promote collaboration between the
Critical Care Service and other Speciality Services within the Trust, provide support to
promote and advance expert clinical resuscitation practice whilst ensuring cleat leadership of
the resuscitation service. They are also responsible for the implementation of operational
policies governing pen arrest, prevention and or management of cardiopulmonary
resuscitation, practice and training.

End of Life Care is a clinical topic on the MaST programme and is available online in an 11
minute PowerPoint presentation that includes an introduction to the team and contact details
for the 7 days a week 9am — 5pm service. The role of the team and the referral process is
outlined, together with hydration and nutrition needs and planning with the patient and their
family/caret.

There is also a training programme for palliative care which is delivered to foundation year 2,
IMT (internal medicine trainees), registrars and medical students (see information and
evidence gathered) and adapted accordingly to the group, but generally covers:

• Recognising the patient with limited reversibility of their medical condition and the

dying patient.

• Understanding palliative care service provision.
•

Increasing confidence in managing physical symptoms in patients and psychosocial
distress in patients and families.
Increasing confidence in developing appropriate advance care plans, including
DNA!CPR decisions.

•

• Managing patients in the last days of life.
• The doctor’s role in supporting a rapid discharge home.

Dietetic provision at SASH

The investigation also included a review of the dietetic service within SASH. The
management of the therapies service moved to SASH from the community provider in 2010.
There have been problems identified with the resourcing of the dietetic service which has
been on the risk register since June 2020 in the Surgical division for ‘lack of adequate adult
dietetic staffing to manage levels of referrals for both in and outpatient dietetic services’.

The current therapy structure is historical and the Head of Therapies would like this to
change and it has previously been a part of business planning but has yet to be fulfilled. The
proposal to appoint a lead dietitian was not approved, leaving no one in overall charge of the
dietetics service. Funding is available for clinical but not management posts; it was felt that
dietetics needed its own lead. There is currently a team leader who is a speech and
language therapist who manages the dietitian’s annual leave and vacancies.

To provide a flexible service within the resources of the dietetic team, it is not possible to
always assign a dietitian to each ward, However, Cl surgery, gastroenterology and critical
care do have specialist named dietitians assigned to their areas.

There is presently no dietetic support available at weekends; the Trust has acknowledged
that this needs to be part of the gastroenterologist review of policies and procedures and
service provision. At present there are hospital agreed protocols for the clinical teams to be
able to manage patients nutritionally at weekends in the SASH policy for adult enteral feeding

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 (ratified Sept 2020).

There has been an increase in the dietetic service and in comparison to four years ago the
establishment has increased by 4 whole time equivalents and this does support the
specialties of ITU, medicine and surgery teams.

There is a robust process for continuous professional development (CPD) in place. All the
teams have a direct supervisor who they meet with monthly. The meetings are formal and
notes are kept by the supervisee which may be audited as part of Health and Care
Professions Council registration and forms the evidence for their fit to practice.

They also use audit afternoons for regular professional CPD teaching sessions and internal
CPD sessions to build on what they want as a team. They attend regular staff meetings and
specific band 7 meetings and overall therapy meetings. They have recently started a What’s
App’ group to aid communication.

The outcome of the discussions was that everyone would like to have a closer working
relationship and better communication between dietitians, gastroenterologists and surgeons.
A dietitian being present at ward rounds would be welcome but it would mean taking them
away from their duties and with current staffing levels, this was not considered to be practical.

The ‘Early Recovery After Surgery’ (ERAS) programme addresses nutrition in the pre- and
post-op period. Moving forward, it would benefit surgical patients to have a more robust
approach to their post-operative nutritional care, with dietetic concerns and recommendations
noted and considered by the surgical team as part of the overall patient care process.

This serious incident investigation arose from a Regulation 28 prevention of future deaths
notice issued by HMC after recording the death of a patient in whom malnutrition significantly
contributed to the death. In conducting this investigation, the findings have made it possible
to answer the specific concerns that the Coroner raised, in a positive way.

The investigation has also been an opportunity, to provide a general and detailed review of
the nutritional service at East Surrey Hospital. The findings demonstrate that a step change
in the nutritional service is underway, for example the introduction of a complex nutritional
MDT meeting, a twice weekly consultant delivered nutritional ward round and resuming the
nutritional steering group. Where deficiencies have been identified, recommendations have
been made, for example a clinical lead post for dietetics.

Overall, the investigation has offered reassurance to the Trust that improvements are
continually being made to the nutritional service and that it is in a better place than in 2017,
but it has also highlighted that action still needs to be taken to implement further planned
improvements to achieve the optimum service that it endeavours to provide.

RCA 2020-20811

Page 12of23

 Care Delivery Problems:

Patient lost a significant amount of weight during her 3 month post-operative stay at ESH that
was not progressed.

Nursing food charts were not accurately completed.

Enteral feeding was not consistent.

Contributory Factors:

Task Factors

Nutritional decisions based on normal weight of 65kg.

MUST score was not always accurate.

Provision of nutritional care was fragmented due to parental nutrition being halted for
suspected or proven line sepsis or improvements in oral/naso gastric (NG) tolerance.

Input from different healthcare professionals was not cohesive due to lack of dedicated time
to discuss nutrition issues.

Team Factors

Dietitians not present at MDT meetings.

No nutritional specialist input on the ward rounds.

No professional lead for dietetics to provide clinical leadership and management of dietetic
service.

No lead dietitian for complex nutrition at SASH.

Nutritional nurse specialist not on site full time.

Communication

Nutrition documentation was on separate pieces of A4 sheets in 2017.

No nutritional dedicated MDT meeting.

Work Environment

Provision of the dietitian service is challenging due to limited resources.

High dependency on agency and temporary staff to cover dietetics.

There is no means of electronic referral to the dietitians; however, there is a dedicated
extension number for all referrals to the service with voicemail for 24 hour referrals.

Education and Training

Training for MUST tool was ad hoc prior to 2018

No monitoring of training results via audit.

RCA 2020-20811

Page 13of23

 Patient Factors

Patient unable to take in enough from an oral diet, and on occasions declined the
supplements offered to her.

Patient was non-compliant with NG feeding.

Patient had capacity to make her own decisions.

Patient had episodes of sepsis so unable to put on weight.

Diagnosis of small bowel Crohn’s disease, refractory to medical therapy.

Family anxious to get patient home, so emphasis was on her discharge.

Patient needed high salt diet

Organisational Factors

The dietitian service had evolved over the years and at the time of the incident required
further design and resources to reflect what at that time were the needs of the service.

Root Causes:

In 2017, the provision of nutritional care was fragmented and input from the various
healthcare professionals was not cohesive as there was no opportunity for staff to come
together at a dedicated nutrition multi-disciplinary team meeting.

Lessons Learned:

The investigation has found that whilst the provision of nutritional care at SASH has been
consistently improving since the patient’s care in 2017, it still requires some additional
support and funding to be a totally comprehensive service.

The dietetic service has good governance structures in place. The service has recruited 4
whole time equivalents since 2017, and we are now focusing on the leadership needs of the
service.

The appointment of two new consultant gastroenterologists has allowed the formation of a
dedicated nutrition MDT meeting and specialist nutrition groups.

Post-investigation Risk Assessment

A
Potential Severity
(1-5)
5

B
Likelihood of Recurrence at
that Severity (1-5)
1

C
Risk Rating
(C =Ax B)
5

RCA 2020-20811

Page 14 of 23

 Conclusions

Recommendations:

1. Review the current nutritional policies and procedures in operation at SASH to ensure

that they reflect the needs of the service - complete

2.

Introduce a formal complex nutrition MDT meeting and ensure that surgeons are
active members - complete

3. Reinstate the Nutrition Steering Group and establish the reporting structure of the sub

groups - complete

4. Undertake an audit to assess the impact of the MaST nutrition training on the

completion of the MUST documentation.

5. Appoint a professional lead for dietetics to provide clinical leadership and

management of dietetic service.

6. Appoint a lead dietitian for complex nutritional needs.

7. Secure the funding for an additional nutritional nurse specialist.

Arrangements for shared learning:

1. The investigation and its findings have been discussed at the divisional incident
review group before internal closure to ensure that the investigation has been
thorough and that the learning is shared within and across the Trust divisions.

2. Share investigation report and action plan at the Surgical Governance weekly

meeting.

3. Share investigation report and action plan at the Patient Safety and Clinical Risk

Committee.

4. Share investigation report and action plan at the Gastroenterology Governance forum.

5. Share investigation report and action plan at the Dietitian Governance forum.

6. Share investigation report and action plan at the End of Life Governance forum.

Distribution list:

1. The patient’s family will receive a finalised copy of this report via their solicitor as

requested.

2. All staff who contributed to this investigation will receive a copy of the report and

action plan.

3. HM Coroner.

Author and Job Title:

Dr
Associate Medical Director

RCA 2020-2081 1

Page 15of23

 CD
a
x

CD

0

0

CD

0)
D

0)

-,

N)
C
N)

MALNUTRITION UNIVERSAL SCREENING TOOL (MUST)

FOR ADULTS

This toot should be completed for all patients wfthln 26 hotrs of admission and
repeated weekly
Itis designed to identify patients at risk from malriuthtion.

Reported Usu& Welit

Kg

Heigtit

ros

SM! (kg1m)
>20
18.5—20
< 18.5

SCORE
0
i
2

N,B. Consdor ocdema &

[dohYdfatlcn

[_1
Unplanned vmight loss in past

+ 3-Bmonths:

+

< 5%
5—0
10%

._.___

SCORE
0
I
z 2

If the patent a acutely it p there has beon or is likely to
bcnoot0enuonhtako>5days,
Fcrexarnple:
• Nd by rroum >24tvs NC) PEG? Prcrier neacn
• Aajor sur9ey I se’,erc
• Ga

lntetnel ctseese I dudrig severe darn,oew
orpeon

ctiorV sepsIs

rng

=

Drnpenssted hvgr ersease) acute pencreatta

• E4darce of pressure ukers

poc nutñtmuI intake

SCORE 2

0

1)
C
f\J

P
N)
C
0)

0)
Ca
CD

-k
0)

0
-4,

()

1

Ward

2

3

Da o

Current

weight
(kg)’

4

5

6

7

8

9

10

11

12

Gedema?
ascites

It unable to
weigh calculate
MUACfcmr and present?
state reascai tor
no weight

SM! (Kg
M9hi

Sf4! Score Unplanned
(0. I or 2) weight loss

(%) ‘

t.%erght loss Acute
score (0.1
or 2)

Disease
efact’

Total

D,sea
effect score MUST
Score
(0 or 2)

——.———•-

—...—.—.———

j

13

14

Print name

$ gnsturs

Weight conversion ctrotts and Sf4! charts ovaablc in ward Nutrition foldor andior attached to weighing scales. Tool also available onleie on NtIS Choices, Tools.
2ff patient cannot be weighed we sitting standing or hoist scales ploase state reason
‘A MUAC of lees than 23.5cm indIcates BUT less than 2Okgtr& and greater than 32cm indicates a BUT greater than SOkglm’
‘Please see over for percentage weight loss calculation chart

record Mid Upper Arm Circumference (MUAC) instead.

Please state reason for Acute Disease efect score

5Add columns 7.9 and 11. Document MUST scare in column 12.
See ovar for notettional care plans based on total MUST Scare; If MUST >2 sign & dat. care plan overleatwhen referred to dletician.

 NUTRITION CARE PATHWAY

MUSTO
No action required +
rescreen weekly

MUST?1
To improve nutritional status
at ward level

MUST2
To improve nutritional status
at ward level -t- consider irst
line supplements

Could they be constipated,
nauseous or having loose stools?

Medical team to consider
prescribinci Complan CD

PaCkS available:

Medical team to consider
- Anti-emetics
- Laxatives
- Anti-diarrhoeals

Consider a RED tray

Could friends or family provide
assistance?

Encourage hot puddings with meals
and higher calorie ice-cream

Offer biscuits with AM and PM
drink rounds

Couidthey benefitftm encouragement,
observation or assistance?

Encourage high calorie choices

Order a dementia finger food box

Are they confused or have dementia
and have poor oral intake?

Pick up a snack box from the kitchen

Have they missed a meal?

Nourishing Drinks:

Full fat milk

• Malted drink (Horlicks)
• Hot chocolate
• Complan souplComplan shake
• Fortified milk (7tsps milk powder

with 200m1 full fat milk

Encourage nourishing drinks

Ambrosia rice pudding pots
Ambrosia custard pots
Higher calorie ice-cream
Madeira Cake
Biscuits
Cereal
Slice of bread and butter Ijam

Offer the patient the snack Hst

Refer to dietitian
(extension 6134)

Providing the following:

Ward
• Name
• Dale of Birth
• Hospital Number
• MUST Score

Diagnosis I relevant medical
conditions

Signature:

Date:

>
N)
Q
o
N)
o
0)

-

-U

Co
CD

o

—‘

N)
CA)

 % WEGHT LOSS SCORE

•1

score E
tioss

Sc/aG 2
WI use

t59hf loss In last 3.6 months
Sotwoen
(kg)

More than
(kg)

30

1.0-3.3

16-14

12 -3.6

12-17

I.E 3M

LB-3M

1.9-4.8

1.9-4.1

2.0-4.2

2,0-6,3

2.1 -4,4

2.2- 4.6

2.2-42

2.3-4,8

2.3-4.8

2.4 - SM

2.4-5.1

2.5-5.2

2.5- 5.3

2.6-54

2.6 -5.6

2.1-5.7

2.7- SM

2.8-5.9

2.8-EM

2.9-8.1

2.9 -6.2

3.0 -6.3

3.1-54

3,1-6.6

32-87

3.2-6.8

3.3-6,9

3.3 .7,0

3.4-7.1

3.3

3.4

3.8

32

3M

3,9

4.8

4.1

4.2

4.3

4.4

4.6

42

4.6

tO

SM

Si

5.3

5,4

5.6

52

5.9

SM

6.1

62

6.3

8.4

6.6

6.7

6.8

(5,9

7.0

71

___-j

ScotG
.Wtt4

Score I
WI loss

.1-.

Score 2
Wttosj

>0

“—-- s’—

lNeiuW lass in lastS- B months
Between
(kg)

‘

More than

3.4-7.2

3,5-7.3

3.5-74

3.6 -7.6

3.6-Li

3.7-7.8

3.7.7.9

3.8 - 8.0

3.8

6.1

32-82

32-6.3

42-BA

4.1 -8.6

4.I6Y

42-8.8

4.2 62

4.3- 9.0

43-9,1

4.4-92

4.4-9,3

4.5 -9,4

4.5-9.6

46-9.7

4.6- 9.8

4.7-9.9

4.7-10.0

4,5- 10.1

46 - 10.2

4,9-10.3

4,9 - 10.4

5.0- 10.6

5.1 -102

51-10.6

5.2- 10.0

52-11.0

72

7.3

7,4

7.6

7.7

7.6

7.8

8.0

8.1

8.2

5,3

BA

8.6

6.7

8,8

52

SM

9.1

9.2

9.3

9.4

9.6

0.7

9.8

9.9

10.0

10.1

102

10.3

10.4

102

102

10,8

10.9

11.0

ExcepI when nu;dtionsupporlwill beolno benefit to Ike patienleg. Patient on bnd of Life care fran
Aspects of ‘The )Aainulrftiun Uni’iersal Se’eon roof (MUST) are reproduced hero ith the kind permission of
DAPEN ([lilieS Assodokiri for Porentfdral and Enteral Nutrition). For further tiforrriallon err ‘MUSt’ see www.hapen.org.uk

RCA 2020-20811

Page 18 of 23

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RCA 2020-20811

Page 19of23

 i00w00L

4xc

L

A
p
p
e
n
d
i
x

2

R
C
A

2
0
2
0
-
2
0
8

1

1

P
a
g
e

2
0

o
f

2
3

 _____

_____________________

rzrz

Escalation of Treatment form

[

Surrey and Sussex
Healthcare NHS Trust

Please complete for afl patients with a DNACPR at risk of deterioration

Name:
Date of birth:

NHS number:

Hospital:

Do not
photocopy

This is a guide to aid clinical decisionmakIng
In the event of deterioration, this patient should be:

For referral to Critical Care (bleep 830)

YES 1 NO

For referral to Critical Care Outreach Team (bleep 766) for ward based
Nan4nvasivc Ventilation
for AECCPD / obesIty hypoventition / n

irornnselr syndromes only

,.,... YES I NO

For ward-based ceiling of treatment

YES I NO

Should this patient be for MET calls?
It not for MET coils ond cItnica concern, centactward team or on-call doctor for review

YES I NO

Summary of reasons for above and discussions with patient and/or relatives:

For ftwther information, see patient notes dated

If this escalation status Is changed please clearly mark this form as
cancelled sign and date, and complete a new Escalation of Treatment form

Name/grade of doctor completing this form:

Signature:______________________________________

Date:

Consultant endorsement of above decisions (within 24 hours)

Signature:__________________ Date:

Putting people first %

,•-I1

ii’trr

L

l fl
- Oct 0

RCA 2020-2081 1

Page 21 of23

 =

Acti on Plan

No:

1.

2.

3.

4.

.

Recommendation
I Issue to be
addressed.

Review the current
nutritional policies
and procedures in
operation at SASH
to ensure that they
reflect the needs
of the service.

Introduce a formal
complex nutrition
MDT meeting and
ensure that
surgeons are
active members.

Reinstate the
Nutrition Steering
Group and
establish the
reporting structure
of the sub groups.

Undertake an
audit to assess the
impact of the
MaST nutrition
training on the
completion of the

Reference:

Datix number:

Surrey and Sussex i/i1

Ffealthcare NHS Trust

Action Plan Lead:

, Consultant Gastroenterologist

Action
Category

Preventative

Action(s) to be taken:

Action
(SMART)

.

Action owner:
0Db title)

.

Review the current nutritional
policies and procedures in
operation at SASH to ensure that
they reflect the needs of the
service,

Consultant
Gastroenterologist

I

Deadline
for Action:

.

31.8.2021

Test of Effectiveness:

.

Monitoring
committee:

Clinical Effectiveness
committee

Current nutritional
policies and
procedures in
operation reviewed and
updated for efficacy at
CEC.

Corrective

Implement a formal complex
nutrition MDT meeting and ensure Consultant
that surgeons are active
members.

Gastroenterologist

30.4.2021

Regular complex
nutrition MDT meetings
in operation.

Clinical Effectiveness
committee

Corrective

Reinstate the Nutrition Steering
Group and establish the reporting
structure of the sub groups.

Consultant
Gastroenterologist

31.3.2021

Nutrition steering group Clinical Effectiveness
meet monthly and
minuted.

committee

Detective

Nutrition Steering group to
oversee an audit to assess the
impact of the MaST nutrition
training on the completion of the
MUST documentation, when the

31.7.2021

Consultant
Gastroenterologist

Clinical Effectiveness
committee

Results of audit to
provide assurance that
current training
programme is sufficient
or deficiencies
identified and

RCA 2020-208 1 1

Page 22 of 23

 5.

6.

7.

MUST
documentation,

Appoint a
professional lead
for dietetics to
provide clinical
leadership and
management of
dietetic service.

Appoint a lead
dietitian for
complex nutritional
needs.

Agree the funding
for an additional
nutritional nurse
specialist with the
surgical division.

No:

.

Recommendation
I Issue to be
addressed:

MCtIOfl
Category

Action(s) to be taken:

.

Action
(SMART)

limitations of COVID-19 allow,

.Action owner:
&ob title]

Deadline
. for Action:

Test of Effectiveness:

.

Monitoring
committee:

Corrective

Appoint a professional lead for
dietetics to provide clinical
leadership and management of
dietetic service.

Medical Director

30.6.2021

addressed with further
training.

Clinical lead for the
dietetics service
appointed SASH.

Clinical Effectiveness
committee

Corrective

Appoint a lead dietitian for
complex nutritional needs.

Corrective

Agree the funding for an
additional nutritional nurse
specialist with the surgical
division.

Head of
Therapies

Chief Nurse

30.6.202 1

30.6.2021

Lead dietitian for
complex nutritional
needs appointed at
SASH.

Sufficient nutritional
nurse specialist
support in place.

Clinical Effectiveness
committee

Clinical Effectiveness
committee

RCA 2020-20811

Page 23 of 23