Margaret Sales

The Queen Elizabeth Hospital 
Gayton Road 
Kings Lynn 
Norfolk 
PE30 4ET 
www.qehkl.nhs.uk 

25 January 2021 

Mrs J Lake HM Coroner for Norfolk 
Carrow House 
301 King Street 
Norwich 
NR1 2TN 

Dear Mrs Lake 

Re Mrs Margaret Lilian Sales 

I write to set out the Trusts’ response to the Regulation 28 Report dated 11th November.  With respect to your 
three concerns listed, I will respond to each using the same numbering 

1. 

Evidence was heard that Records were not always completed as required.  It is understood clinical teams have been 
notified of this and the records are being audited.  There was no evidence as to the outcome of those audits and any 
further action taken. 

I  attach  the  latest  audit  on  medical  records  carried  out  across  the  Trust’s  wards.    The  wards  involved  were 
Oxborough and Marham for the admission in question.   With medical record completion, action taken is taken 
on a regular basis and I set out the detail of this process below.  

The  findings  from  the  documentation  audit  are  taken  through  appropriate  governance  channels  such  as  the 
Harm Free Care Group, Learning from Deaths Forum, Hospital Thrombosis Committee, Divisional Governance 
Boards  to  feed  into  Clinical  Governance  Executive  Group  (Executive  level)  to  Quality  Committee  (sub-
committee) and finally to the Trust Board. Assurances provided this way help with enabling visibility and also 
focus on areas of improvement.  Whilst this is a framework and continuing process, we are aware of the areas 
requiring  improvements  and  have  created  dedicated  quality  improvement  projects  which  also  report  to  the 
Trust  Board  to  track  the  progress  on  the  work  undertaken.  For  example,  there  was  a  decline  in  the  Venous 
Thrombo-embolism (VTE) screening uptake since January 2020 until April 2020.  

The quality improvement project (QIP) led by the Medical Director reviewed and revised the existing pathways, 
improved awareness through training and inclusion in the induction programs, increasing capture of the harms 
caused through the patient safety teams (Audit and Effectiveness Group) and over 3 months of this effort the 
VTE screening rates improved back to above the nationally recommended target levels. A similar project is now 
in place with regard to improving Dementia screening rates, reduction in prescribing and administration errors 

 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
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The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 

with insulin and anticoagulants with clear milestones. There is clarity in approach and framework of reporting 
acknowledging that there is always more work to do.  

The Multidisciplinary Documentation Forum oversees all the documentation aspects of Health Records that not 
only capture medical documentation but  all multidisciplinary  input  into patient records. Equally this forum is 
planning  to  facilitate  a  seamless  transfer  to  Electronic  Patient  Records  that  will  improve  quality  of  care  for 
patients. Through this forum, improvements in documentation of clinical care that includes, medicines, fluids, 
feeds,  monitoring  of  vital  signs  are  planned  and  where  deteriorations  occur,  improved  focus  to  address 
deterioration is identified and facilitated through examples described above.  The Trust is fully committed to 
identifying  issues  which  may  occur  regarding  all  aspects  of  our  documentation  and  responding  accordingly 
when identified. 

2.  Nurses had difficulty in contacting front line on call medical staff on two occasions.  Several members were contacted 
before anyone attended.  Bleeps are now to be provided to all on call medical staff.  However, some of the team had 
bleeps and still did not respond to the requests to attend the patient.  

Firstly we have redesigned the clinical escalation pathway with providing  a compliant 7-day standard service. 
This  has  increased  the  medical  workforce  required  to  improve  cover  for  the  patients.  Access  to  medical 
personnel has improved through this. This is set to improve further with the Urgent and Emergency Pathway 
Reset  program  led  by  the  Chief  Operating  Officer  that  encompasses  system-wide  changes  to  improve  early 
access for patients and facilitate timely treatment. A dedicated Project Management team is set up to expedite 
this process looking at our medical workforce. 

The bleep tracking system and the use of smart phones with video calling facilities is in place to enable tracking 
and access to our medical work force. Inability to access doctors to escalate problems is captured through our 
incident reporting system (Datix) and actions are enabled through this. Feedback to defaulters for not accessing 
properly  is  part  of  this  and  if  there  are  avoidable  lapses  identified  then  they  are  put  through  an  internal 
process. In this way the system is strengthened significantly.  

The escalation process is also captured through  the New Early Warning Score (NEWS)  audit process that not 
only captures accuracy of scoring system but also escalations or lack thereof. Where escalations have failed to 
happen  this  is  addressed  through  feedback  to  the  individuals  involved.    Improving  awareness  within  nursing 
teams that they are empowered to access consultants where local escalation plans have failed is in place. This 
is  done  at  induction  and  monitored  through  incident  reports,  documentation  audits,  NEWS  audits  etc. 
Previously, junior staff have  not  felt  confident  to contact people higher up in the command  chain which has 
cultural origins  and will take time to address. However there  is general improvement in the process and the 
Board is committed to facilitate this via the team approach.   

3.  On a previous discharge from hospital, it was noted Mrs Sales had been referred to the Home Enteral Nutrition service 
for monitoring and follow up and that in situations such as this, requests will be place with the GP.  However, no such 
request was placed with the GP.  The Discharge Letter in fact stated: "Actions for the GP: No recommendations”.  As a 
result, the GP did not monitor Mrs Sales’ capillary blood glucose following discharge. 

For this matter, some clarification is needed.  Mrs Sales had Type 2 Diabetes Mellitus (T2DM), for which she 
was being diet-controlled when she was admitted at the end of September 2019.  On imaging a left cerebellar 
infarct was found and she was treated for a stroke.  This caused her to lose her ability to swallow so PEG tube 
feeding was initiated.  However, during the admission the diabetes remained fully controlled without the need 
for  insulin  or  any  oral  hypoglycaemic  medicine,  and  so  was  regarded  as  stable.    She  was  discharged  on  6th 
November 2019 and she had developed no additional needs with respect to her diabetes. 

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The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 

Regarding the PEG feeding itself, she was seen prior to discharge by our dietetics team and they handed care of 
the tube feeding over to the community based Fresenius Kabi nurses for training of the relatives on the feeding 
pump and general care of a PEG tube. The handover to Lincolnshire dietitians includes the fact this patient has 
T2DM  –  but  that  would  be  for  their  awareness  only.    I  attach  the  referral  forms  from  the  Dietetics  team  to 
show this.   

If  the  patient  needed  regular  blood  glucose  testing  as  an  inpatient  (and  had  not  required  this  prior  to  that 
admission) because of treatment for T2DM, then the GP would have been advised that blood glucose  testing 
was necessary.  The records show that at the point of discharge Mrs Sales did not have any additional medical 
requirements with respect to the diabetes and so this instruction would not have been given to the GP.  

We know that when Mrs Sales returned on 13th December 2019 she had become acutely unwell and had a very 
high  blood  glucose  with  condition  known  as  Hyperosmolar  Hyperglycaemic  State  (HHS)  so  treatment  with 
insulin  was  necessary  to  save  life.      She  remained  on  this  medication  from  that  point.   Antibiotics  were  also 
given for her probable acute lung infection, and it is well known that infection can precipitate an acute diabetic 
crisis.    However,  patients  with  T2DM  who  are  effectively  diet-controlled  do  not  require  blood  glucose 
monitoring at home.  In fact The National Institute for Health and Care Excellence has specific guidance on “Do 
not do” which concern treatments and investigations that should not be carried out and monitoring of blood 
glucose levels is not required1 except where: 

• 
• 
• 

• 

the person is on insulin or 
there is evidence of hypoglycaemic episodes 
or  the  person  is  on  oral  medication  that  may  increase  their  risk  of  hypoglycaemia  while  driving  or  operating 
machinery 
or the person is pregnant, or is planning to become pregnant. For more information, see the NICE guideline on 
diabetes in pregnancy.  

At this Trust our Diabetic Specialist Nurses would ensure that the GP was made aware that they had to ensure 
blood glucose monitoring was done at home if a patient had been put on either Gliclazide or Insulin during an 
admission.    It  is  true  to  say  that  if  Mrs  Sales  had  had  her  blood  glucose  monitored  at  home  between  6th 
November and 13 December 2019 her subsequent illness would have become apparent sooner, but in terms of 
current practice and guidelines there was no indication for us to make such a recommendation to the GP.   

I have heard from our consultant
 and also Legal Services Manager that we had not expected this issue 
to be raised at the inquest, if so we would have taken the opportunity to supply evidence on this point for you 
at the time from one of our Dietetics or Diabetes team members who deal regularly with referrals to Fresnuis 
and  the  General Practitioners  in  Norfolk,  Cambridgeshire  and Lincolnshire.   With  hindsight,  perhaps  our  RCA 
could have gone into more detail on that point; but presently we think that the system remains robust and with 
no discourtesy intended do not propose to take any further action on this point at the present time. 

I would be happy to provide you with any further information you require on any of these concerns. 

Yours sincerely 

1 Type 2 diabetes in adults: management 
NICE guideline [NG28]Published date: 02 December 2015 Last updated: 16 December 2020 - Para 1.6.13  

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The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 

Deputy Medical Director 

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