Nicholas Rousseau

eMKWay NHS

CARE. COMMUNICATE. Milton Keynes
COMARORETE CONTRGUTE University Hospital
NHS Foundation Trust

Our ref:
Date: 29 April 2021

Private and Confidential

Dr Séan Cummings

Assistant Coroner for Milton Keynes
The Coroner's Office

Civic Offices

1 Saxon Gate East

Central Milton Keynes

MK9 3EJ

Dear Dr Cummings
Regulation 28: Report to Prevent Future Deaths

| am writing to you following receipt of a Regulation 28 report dated 28 March,
subsequent to the Inquest held by you on 02 February into the death of Mr Nicholas
Rousseau who died in October 2019. Mr Rousseau died from acute bowel ischaemia.
He had attended the Emergency Department at the hospital on two occasions in the
week prior to his death.

On the first attendance, a venous blood gas had been taken which demonstrated that
Mr Rousseau had a blood lactate level of 3.9 mmol/L. The Regulation 28 report
highlights conflicting accounts given by two senior members of the medical staff in
relation to the importance that should have been placed upon this result and the
actions, if any, that it should have prompted. Specifically, you assert that an elevated
blood lactate level on presentation should have been repeated (referencing NICE
Sepsis Risk Stratification Tools).

Before coming to the substantive matter of blood lactate levels, | would like to take this
opportunity to extend my condolences and sympathies to Mr Rousseau’s family. | am
conscious that any sense of divergence in view, at Inquest, between HM Coroner and
attending physicians will have added to the family’s distress. | am not clear from the
Regulation 28 report whether you consider that an alternative course of action
regarding the measurement of blood lactate might have afforded an opportunity to alter
the subsequent clinical course and Mr Rousseau’s untimely death. For avoidance of
doubt, we do not consider this likely.

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patients. During your visit students may be involved in your care, or you may be asked fo
participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns.

TheMKWa INHS

CARE COMMUNICATE Milton Keynes
ia University Hospital
NHS Foundation Trust

There are several pertinent points in relation to the issues that you raise:

e Ultimately it has been determined that Mr Rousseau died from ischaemic bowel and
therefore it might be postulated that his presentations on 03 and 05 October were
related. Mr Rousseau did not have risk factors for either acute or chronic mesenteric
ischaemia. The predominant symptom on 03 October was vomiting and on 05 October,
it was vomiting and diarrhoea with abdominal pain. Had his blood lactate level been
rechecked on 03 October, it seems likely (given the normal levels on 05 October) that it
would have been improving. In the absence of abdominal pain, it is very unlikely that
the attending physician would have considered that a CT scan of the abdomen would
have been indicated, still less a mesenteric angiogram.

e Whilst it is taught that ischaemic bowel can be a cause of elevated blood lactate levels,
this is a non-specific marker. Elevations in blood lactate level may also occur in
association with dehydration.

e It is important to note that Mr Rousseau did not have sepsis at the time of either of his
presentations to the Emergency Department. Whilst | was not present at the Inquest
and have not been privy to a detailed account of discussions, | wonder if clinical
colleagues were surprised by a granular discussion on ‘blood lactate and sepsis
guidelines’ in relation to the case of a patient who was not thought to have had sepsis
and who subsequently died from bowel ischaemia.

e The NICE guideline Sepsis: recognition, diagnosis, and early management (NG51,
13 September 2017) defines several markers of high risk in those presenting with
suspected sepsis (‘high risk criteria’). These include: altered mental state; respiratory
rate >25 per minute; systolic BP <90mmbHg; and, HR > 130bpm. There are paired risk
stratification tools (flowcharts) accompanying this guidance, to which you refer.

The guideline notes that an elevated blood lactate level can be a marker of the severity
of sepsis and is associated with poor outcome. It is therefore an important test to be
undertaken on patients presenting with suspected sepsis and can influence subsequent
assessment, treatment, and monitoring. The NICE guideline describes a lactate over
Ammol/L as being of heightened concern in a patient presenting with suspected sepsis.
A lactate of between 2 and 4mmol/L is regarded as an intermediate ievei. The NICE
guideline does not make any specific reference to repeated or serial measurements
other than implicitly — if a person with suspected sepsis and any high-risk criteria fails to
respond within an hour of initial treatment, it is recommended that a consultant is

As a teaching hospital, we conduct education and research to improve healthcare for our
patients, During your visit students may be involved in your care, or you moy be asked to
ines clinical trial. Please speak to vour doctor or nurse if you have any concerns.

TheMKWas INHS

CARE. COMMUNICATE. Milton Keynes

COLLABORATE. CONTRIBUTE. University Hospital
NHS Foundation Trust

alerted. A failure of the blood lactate to fall by >20% from the initial value over the first
hour is specified as a marker of failure to respond.

Mr Rousseau presented on 03 October with a history of diarrhoea and vomiting. The
clinical impression was one of mild gastroenteritis associated with a slight tachycardia.
Mr Rousseau was not suspected of having sepsis on this attendance. His blood tests
formed part of a baseline assessment of a patient presenting through the ‘majors’
pathway (as opposed to the ambulatory / ‘minors’ pathway) with undifferentiated illness.
They were not triggered by a specific suspicion of sepsis.

Even if sepsis had been suspected, Mr Rousseau would have been presenting without
any high-risk criteria, meeting just one ‘moderate to high risk’ criterion (tachycardia — 91
to 130 beats per minute). In these circumstances, blood tests are not mandated by
guidelines. In the absence of high-risk criteria, the reference to a 20% reduction in an
initial blood lactate does not arise. Mr Rousseau was given intravenous fluids and
monitored. His vital signs were checked on two further occasions and were normal
aside from persistence of tachycardia (improved from 114 to 103 bpm). He was then
discharged.

Approach to the identification and management of sepsis in the Emergency
Department

As above, it was not considered that Mr Rousseau was presenting with sepsis at the
time of his attendances and therefore the relevance of compliance with sepsis
guidelines is perhaps limited. However, we fully agree that the early recognition,
assessment, and management of sepsis is a core function of an Emergency
Department.

in this regard, the Emergency Department:

e Maintains a local MKUH policy that is consistent with national guidance (including
NG51). The current policy is due for scheduled review in November 2021.

e Operates an induction and weekly teaching programme, led by consultants, to
ensure that each cohort of junior and middle grade medical staff is fully aware of the
importance of this topic and the local management guidelines.

e Makes full use of the National Early Warning Score (NEWS) as part of the triage /
monitoring process in patients attending the department. Heavy investment in our IT
infrastructure (Cerner eCare) means that measurement, calculation, and display is
automated.

As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to
Participate in a clinical rial, Please speak to your doctor or nurse if you have any concerns,

TheMK INHS|
CARE. COMMUNICATE Milton Keynes
LABORER: CONTRIOAITE. University Hospital

NHS Foundation Trust
e Uses a model of Rapid Assessment and Triage (RAT) whereby ‘majors’ patients are
seen by a more senior clinician at the outset of their time in the department, and
appropriate investigations are ordered (and the results reviewed) promptly. Near
patient testing (with its shorter turnaround time) is available and used.
e Participates in Royal College of Emergency Medicine (RCEM) national audits,
including the audit on sepsis in 2016-17. This audit examined performance in
relation to 8 standards and the Trust performed at / above the peer median.

The profile of sepsis is also high across the wider Trust.
Proposed Actions

Whilst these actions are not specifically prompted by Mr Rousseau’s case, the Trust will
continue with existing measures as described above and:

1. Ensure that the MKUH sepsis policy is updated for November 2021

2. Repeat an audit locally of the management of patients with suspected sepsis
against the eight RCEM standards.

3. Consider the case for the designation of a sepsis lead within the department with
specific responsibilities for ensuring that the profile of sepsis remains high.

We shall also ensure that the Regulation 28 report, this response and a summary of Mr
Rousseau’s case are discussed at an appropriate departmental forum in order to
ensure that there is a wide understanding of the issues raised and that clinicians are
reminded of the particular challenges in making a positive diagnosis of bowel
ischaemia.

| hope that this response is helpful.

Yours sincerely

Chief Executive Officer

As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to
participate in a clinical trial. Please speak to your docior or nurse ifyou have any concems.

ThemMkw\ INHS.

CARE COMMUNICATE. Milton Keynes

CALABRO University Hospital
NHS Foundation Trust

Copies

(parents of the late Mr Nicholas Rousseau)
Clinical Director, Emergency Department, MKUH
es Viedical Director, MKUH
Clinical Chair, BLMK Clinical Commissioning Group
ES Inspector, CQC
MKUH Quality and Clinical Risk Committee (sub-Committee of Trust Board)

‘Asa teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you May be asked to
participate in a clinical trial. Piease speak to your doctor or nurse if you have any concerns.