Susan Roberts

via Email 

12 July 2021 

Dear Dr Howard, 

Chief Executive Officer 
Trust Headquarters 
Chestnut House 
Bradford Royal Infirmary 
Duckworth Lane 
Bradford 
BD9 6RJ 

www.bradfordhospitals.nhs.uk 

I am writing with respect to the outcome of the inquest relating to the circumstances surrounding the 
death of Susan Roberts, which concluded on the 11 March 2021.  

I am now in receipt of your Report to Prevent Further Deaths (Paragraph 7, Schedule 5 of the Coroners 
and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulation 2013) 
dated 9 June 2021 where you identify the following matters of concern:  

1.  There has been lack of timely and effective hand over between the different surgical specialties, 

with an absence of formal protocol. 

2.  That when asked for help at the time and during the investigation, there seems to have been a 
lack of engagement from the Plastic Surgeons. They failed to join the Orthopaedic  Registrar in 
theatre at the time of the incident and then failed to attend the round table analysis as part of  the 
SI investigation. 

I would like to take this opportunity to confirm that we take opportunities for reflection and learning to 
help us improve the quality of care that we provide to our patients very seriously. I welcome the 
opportunity to respond to your concerns and outline the actions the Trust has taken in respect of these 
directions. 

1.  There has been lack of timely and effective hand over between the different surgical specialties, 

with an absence of formal protocol. 

The  Bradford  Teaching  Hospitals  NHS  Foundation  Trust  hosts  an Electronic Patient Record (EPR). 
Routine referrals to specialities and individual consultants are made through this system. For time critical 
medical  conditions  it  is  the  Trust’s  well  established  practice for a referral to be made directly to the 
specialty/consultant via telephone. As part of the recommendations following the investigation into this 
case a protocol for cases of Necrotising Fasciitis has been issued. The protocol clearly stipulates which 
speciality needs to be contacted and involved and at what point in the treatment dependant on the are a 
of the body that is affected. 

Chief  Executive Officer 

Chairman 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 Page 2 

The protocol has been issued to consultants and is also available on the Bradford Teaching Hospitals 
NHS Foundation Trust’s intranet pages. 

2.  That when asked for help at the time and during the investigation, there seems to have been a 
lack of engagement from the Plastic Surgeons. They failed to join the Orthopaedic Registrar in 
theatre at the time of the incident and then failed to attend the round table analysis as part of  the 
SI investigation. 

It is not acceptable for a team to fail to attend when requested to participate in a formal invest igation of  a 
patient safety incident. The Trust has an Incident Reporting and Investigation Policy which makes clear 
its  commitment  to  patient  safety  and  improving  the quality of care that it provides, developing a just 
culture and encouraging staff to be willing to admit mistakes without fear of punitive measures. Staf f are 
therefore actively encouraged and are supported to be open and honest about events and issues that 
have or could pose a risk to patient safety. It is the Trust’s expectation that all st aff participate in and 
support the investigation into a patient safety incident that they were either directly involved in or could 
provide  insight  into  why  such  an  event  has  occurred.  The  round  table  discussion  approach  to  this 
investigation was a new methodology that was being tested with the intention to explore together as a 
multi-disciplinary team the events surrounding this case. The round table discussion for this incident took 
place early in the investigation and at that time it was not clear what t he contribution the plastics team 
would provide. Subsequently statements were obtained from the relevant clinicians which were used to 
inform  the  investigation  process,  subsequent  recommendations  and  actions.  As  the    ‘Round Table’ 
approach  to  investigating  incidents  has  matured  as  well  as  in  response  to  the  new  national  Patient 
Safety  Incident  Response  Framework  we  are  currently  revising  our Serious Incident Reporting and 
Investigating  policy  to  make  it  explicit  that  all  crucial  staff  attend  the  ‘Round  Tabl e’  discussion  to 
establish the facts of the incident and identify key learning and areas for improvement not only for the 
local team but also organisational wide. 

To address the point regarding attendance in theatre, we refer back to the earlier statement  that it is 
standard practice that the plastics team will become involved once primary management of abscesses 
are complete and reconstruction is required. We intend to revise the referral protocol to make it explicit 
that the leading speciality is responsible for clearly documenting in the patient record the agreed plan 
with  the  secondary  speciality  at  the  point  in  the  procedure they become involved and who this was 
agreed with. It must noted that the orthopaedic specialist registrar and the plastics specialist registrar in 
this case were in direct telephone consultation regarding the treatment of the surgical debridement and 
further treatment. 

I trust that the information provided assures you that the Trust has taken appropriate actions to meet the 
requirements of your Report to Prevent Future Deaths. 

Yours sincerely 

Chief Executive Officer