Juliet Saunders

Barking,  Havering and Redbridge  fil/:kj 

University Hospitals 
NHS Trust 

Chief Executive's Office 

Queen's Hospital 

Rom Valley Way, Romford, Essex RM7 OAG 

www.bhrhospitals.nhs.uk 

@BHR_hospitals 

Mr. Graeme Irvine 
Acting Senior Coroner 
Walthamstow Coroners Court 
Queens Road 
Walthamstow 
E17 8QP 
12th July 2021 

Dear Mr Irvine, 

Following the recent inquest touching upon the death of Ms. Juliet Saunders, please find the Trust's 
response in relation to the Regulation 28 report that was issued on the 18th May 2021. 

The following actions have been implemented in relation to the matters of concerns: 

1.  The absence of any support within the emergency department during weekends, in dealing with 

patients with a learning disability: 

•  The Learning Disability (LD) Team provides an  advisory service to support clinical teams during 

the hours of 09:00 - 17:00, Monday to Friday.  To increase the cover to include weekends would 
require an  increase in the LD establishment.  The Trust has recently attempted to recruit a Lead 
Learning Disabilities nurse,  however following three attempts; it has not been possible to find 
candidates with suitable experience to fulfil the requirements of the role.  In addition to this, 
there has been a reduction in student applications for the learning disability nursing cohorts 
nationally. However, the Trust will continue with its recruitment to the post and has again 
advertised for this position in July 2021. The Trust has also developed a learning Disability Career 
map to attract staff into the Trust. In addition, the LD team have looked at different ways in 
which support can be provided to staff within the emergency department (as well as across the 
Trust) to care for learning disability and autistic patients who attend the Trust at weekends, bank 
holidays and out of hours. These are listed below: 

•  The  Creation  of a  Safeguarding  Oncall  Manual.  Relevant  information  pertaining  to  Learning 
Disability,  Safeguarding  Children,  Safeguarding  Adults,  and  Mental  Health  Act/Deprivation  of 
Liberty Safeguards is now available for all staff who participate on the oncall rota. This manual is 
an aid memoire to assist staff. 

•  A  Learning Disability Checklist has  been created for use  in the Emergency Departments on  both 
hospital sites. The checklist was implemented on the 28th June 2021 for a trial period of 3 months. 

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 •  A  programme  of  LO  and  Autism  training  sessions  has  been  implemented  for  Bands  6  and  7 

Emergency Department Staff, to enable cascade training to all staff within the department. 

•  The  Learning Disability Team  attend all of the Departmental Keep  In Touch  Days  and  deliver a 2 
hour training  session  to  reinforce  the  key  areas  to  focus  on  when  caring  for  patients  with  a 
Learning Disability in the Acute Care Setting. 

•  KIT days were/are due to be held on the following days: 

o  27/04/2021 
o  21/05/2021 
o  08/06/2021 
o  30/06/2021 
o  20/07/2021 
o  10/09/2021 - 2 sessions 
o  11/09/2021 - 2 sessions 

•  The  Learning  Disability  Team  provides  teaching  during  induction  of  new  doctors  to  the 

department. The case  has been shared with staff within ED  at the team briefs. 

•  A  review  of  the  Learning  Disabilities  Core  Skills  Education  and  Training  Framework  (Health 

Education  England,  2016) has  been undertaken by the Lead  Nurse,  Learning Disabilities and the 

Director of Nursing, Patient Experience & Engagement and Safeguarding Director. 

•  The Trust has approved the implementation of mandatory LD  training, dependent of staffs roles 

and  responsibilities.  There  are  three  different tiers  of training,  and  staff would  complete these 

dependent  on  their  role  within  the  organisation,  for  example  non  facing  clinical  staff would 

complete a different tier to clinical staff. 

•  The  LO  Team  has  liaised with the Communications  Department to ensure that all  staff have the 
information,  tools  and  su pporting  information  available  digitally via  the Trust  intranet  site.  A 
standalone Learning Disabilities and Autism page has been created to include all of the resources 
contained within the ward LO and Autism Resource Packs. 

•  A review of the information available via the external Trust website has also taken place to ensure 

that patients, visitors and their carers/relatives have access to up to date information. 

•  A policy for People with Learning Disabilities and Autism has been approved and circulated across 

the Trust. 

•  A Learning Disability & Autism five year Strategy has been produced and was launched Trust wide 
on the 22nd June 2021.  This strategy includes seven key priorities, which are Patient centered care, 
reasonable  adjustments,  Workforce,  Decision  making,  Training,  Service  user  engagement  and 
Transition for children to adult services. 

2.  The poor standard of medical record keeping and documentation within the emergency 

department and observation unit: 

•  There are routine nursing documentation audits in place which are completed monthly and a 

peer review process has now been established between both Emergency Departments. 

•  The  department  conduct  the  following  documentation  audits  to  identify  areas  requiring 
improvement and to provide assurance that our documentation is monitored and improvements 
sustained. All of the audits are completed monthly other than two which are done weekly: 

 •  Monthly: 

o  Deteriorating patient 
o  Falls 
o  Morphine 
o  Sskin 
o  Mental Health documentation 

•  Weekly 

o  Sepsis 
o  Discharge and Transfer checklist. 

•  A weekly task and finish group was set up which was set up led and chaired by the DDON 

with all Lead  Nurses and Matrons attending. Part of its remit was to review our compliance 
on both sites.  Part of its remit has been to review our discharge and transfer compliance on 
both sites; the Matrons have completed their own weekly audits. We were keen to improve 
our compliance and tackle our underlying issues and deliver sustained care to our patients. 
•  The minimum compliance for all audits is 80%. Currently the discharge and transfer audit is 
at 85%.When the audits started the baseline level of compliance was 10%, since then there 
has been a steady improvement weekly. 

•  A Senior Sister and the Practice Development Nurse (PDN) have provided training on 

documentation. They have been speaking to staff during handovers, training sessions and 
impromptu discussions. 

•  There is a plan in place for Consultants to deliver clinical notes reviews as part of their 
supervisor meetings, with the next meeting to be held in August 2021. The Trust 
acknowledges that there has been some capacity issues which have impacted on the 
supervisors meetings, due to the impact of the Covid pandemic.  The process will be part of 
supervisor meetings and will now be officially part of the appraisal process. The ED 
Consultant Clinical Supervisors plan to review 10 records of their supervisees notes and 
providing them direct feedback about their document which is led by a dedicated ED 
Consultant. 

3.  The failure of systems within the department to allow for the supervision ofjunior doctors to 

ensure that complex cases are escalated to more experienced staff: 

•  A consultant is allocated in each area of the ED at Queen's during the day up to 21:00 at night. 
The Consultant works alongside the junior doctors and will review all patients as needed. After 
hours and if there is not enough Consultants to be physically in every area, we will allocate a tier 
one/senior middle grade Doctor to supervise the area at both sites. We have 24 hour Consultant 
cover at Queen's and 18 hour Consultant cover at KGH.  Regular board rounds are done in each 
area and Consultants are present for reviews in between. 

•  There has been reinforcement with the junior staff that there can be no handovers between FY2 
level doctors and  any handover should be to a Tier 2 doctor at a minimum. There is a dedicated 
handover Standard Operating Procedure (SOP). We have now installed a new IT system called 
Care Flow which requires Consultant sign off for specific patients such as patients with learning 
disability, cardiac chest pain and all patients that were seen by junior Doctors; i.e. FY2 and SHO. 

 •  No patient with LD  can  be discharged without Consultant sign off. The new Care flow system has 
been designed in such a way that an alert is raised and the Junior Doctor must come and consult 
a Senior Doctor before the patient can be discharged 

•  Generally complex patients fall under the following categories and all require Consultant 

presence or input before patients can  be admitted or discharged: 

o  Trauma calls in adult or children, a Consultant must be present 
o  Cardiac arrest and peri-arrest adults and children, a Consultant must be present 
o  High frequency users 
o  Cardiac chest pain 
o  Learning disability 
o  Aggressive patients 
o  All patients admitted via the resuscitation unit 
o  All patients that were seen by junior Doctors i.e. FY2 and SHO's 

•  No patients are allowed to be moved to the observation ward or the EDU without Consultant 

sign off. This has  always been in the SOP.  In this case the SOP was not followed. 

4.  Consecutive failures by medical and radiology staff to recognize abnormal findings  within an 

abdominal radiograph, impacted upon by diagnostic overshadowing: 

•  Radiology clinical leads are in discussion with ED  department to remove plain abdominal 

radiographs in assessing patients presenting with acute abdominal pain due to issues with low 
specifity and sensitivity. This would be in line with the recent GIRFT report in radiology and are 
meeting with ED to progress this. 
The ED  department will be using CT scans for acute abdominal pain and clinically obstructed 
abdomens instead as sensitivity and specificity are much higher.  The department has had 
discussio ns with the Radiology department and we need to involve general surgery to complete 
a new guideline. This should be complete by mid-August and the next meeting is scheduled for 
next week (W/C 19 July 2021). 

•  There is ongoing training and this has been added to the teaching rotation. Teaching takes place 

every Thursday and is done virtually to accommodate staff that cannot be present on site. 

5.  A lack of clinical curiosity, combined with diagnostic overshadowing meant that there was a 

reluctance to depart from a queried diagnosis of gastritis which led to the failure to diagnose an 
acute intestinal obstruction: 

•  There has been a teaching session based on this case which highlighted the need to discuss 

patients with a learning disability with a senior team due to the risk of diagnostic overshadowing. 
This was presented in the January 2021 Mortality meeting. This included reference to escalation 
and consideration of CT scan and specific reference to Cornelia de Lange syndrome. 
In July 2021 Junior Doctor teaching on mental health including learning disability has occurred. 
This has included the Lead  Nurse for LD & Autism being a speaker. This lecture included LD issues 
including diagnostic overshadowing. 

• 

•  The teaching program is in full rotation which means that all the subjects will be repeated over a 
six month period. Safeguarding and diagnostic overshadowing will be included in the induction 
pack at the end of July 2021. 

6.  A departure from established procedures to ensure the safety of transfers to ensure the safety of 

transfers out of the emergency department onto the observation unit: 

•  Queens's Hospital Observation Ward closed in April 2020. 

 •  The Observation Ward at KGH  will be closing at the end of August as soon as  building work is 

complete at KGH  at the end of August. 

•  There is a consultant sign off that is required prior to a patient being transferred to the 

Observation Ward area. 

•  There has been a review of the discharge process from the Emergency Departments and a focus 

from the Matron and Lead Nurse team to ensure that the staff within the department are 
following the correct procedure. There is an on-going audit process with PDSA cycle ensuring 
that there is compliance. 

7.  The absence of safety-netting advice to patients leaving the hospital: 
•  A discharge leaflet has been designed in partnership with patients which provides information 
on discharge. This will be launched shortly once the final approval has been signed off and the 
leaflet has returned from the printers. In addition to the leaflet, the Emergency Department are 
trialing a Discharge Helpline this is planning to launch from Monday 12th July and will provide a 
number to call if they have any queries after discharge. There is a draft SOP for the 2 month pilot 
period. 

•  The initiative is trying to provide a safety net service whereby patients who are discharged or 

leave the hospital can get in touch with us and clarify any further questions they may have. The 
leaflet contains contact numbers to assist in safety netting. 
The telephone line will be launched on Monday 12th of July by our Nursing team, the SOP is for 
the discharge helpline in place and will be audited weekly to ensure efficacy and to make 
necessary adjustments. The SOP is for internal staff to follow procedure and have a document to 
refer to ifrequired. 

8.  Ineffective identification of significant care delivery problems through the Trusts own Serious 

Incident Investigation process, leading to a finalised report of poor quality: 

•  The Trust commissioned an external thematic review in  March 2021, into Serious Incidents {Sis) 
from the period of January 2019 to December 2020. The review involved a structured review of 
SI  reports as well as a review of SI  related policies and procedures at the Trust. This was in 
conjunction with a series of semi structured interviews with staff at all levels of the Trust as well 
as  site visits during which more informal conversations with staff and patients took place. The 
final report has now been received by the Trust. This will enable the Trust to undertake a review 
of existing systems and processes, and the opportunity to plan positive actions as well as 
planning for the transition to the new national policy framework, particularly the new Patient 
Safety Incident Response Framework (PSIRF), set to be rolled out nationally from spring next 
year.  During the Covid pandemic governance arrangements, including SI  reports were placed on 
hold, to allow for clinical staff to be released to support ward areas. The pause is still in place 
(the declaration of Sis or Never Event continues) however the Trust is taking proactive steps to 
ensure reports are still being progressed in line with reporting requirements, which the Trust is 
awaiting guidance from NHSEI  and the CCG. 

Yours sincerely, 

/i"l C~ 

Chief Executive