Michelle Whitehead

NHS]

Nottinghamshire Healthcare
NHS Foundation Trust

Chief Executive's Office

The Resource

Duncan Macmillan House

Porchester Road

Nottingham

Date: 15 March 2022 NG3 GAA

Private and Confidential

Dr Didcock

HM Assistant Coroner for Nottingham and Nottinghamshire
Nottinghamshire Coroner's Office

The Council House

Old Market Square

Nottingham

NG1 2DT

Dear Dr Didcock,

Please find below the organisational response to the recently received Preventing Future Deaths Report,
following the unfortunate death of Mrs. Whitehead.

The Matters of concem raised within the report

Unclear dose/type of sedation medication given, possible excess dose given, poor
documentation.

A medication error did occur during Mrs. Whitehead's care. This involved the incorrect dose of
administered Oral Diazepam being communicated to the Ward Manager and Duty Doctor. With
this incorrect information they agreed to administer Rapid Tranquilisation in the form of an
Intramuscular injection of Lorazepam.

When writing the above dose in the patient's medication card, the Ward Manager recognised the
error, and contacted the Duty Doctor again to assess the likely impact.

The assessment was that the dosages given were within British National Formulae guidelines, and
as such would not negatively impact on Mrs. Whitehead's physical health. This assessment has
been considered by senior medical colleagues within the Trust, who are in agreement with the
conclusion of this assessment.

Mrs. Whitehead was observed constantly following this, with a member of staff within an arm’s
length of her at all times.

The staff involved in the medication error engaged in supervision with their manager following the
incident and completed self-reflection pieces since this time. They are very aware of the error and
Delayed recognition of Mrs. Whitehead’s declining condition

Mrs. Whitehead was administered Rapid Tranquilisation with the aim of reducing her acute
presentation. Her physical observations were taken every 15 minutes after this, scored using the

National Early Waming Scale (NEWS2) and over the following hour remained stable. This was
reported to the Duty Doctor who confirmed that the physical observation checks were no longer

The investigators were unable however, to see an assessment of consciousness levels within the

As a response the Directorate has re-printed new refreshed supplies of the credit card sized
NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and
card is to be wom on a lanyard alongside individual identification badges, acting as an immediate
within Adult Mental Health Services and have been shared with the other directorates to ensure
consistency across sites.

Additionally, the Division is rolling out handheld devices that allow staff to immediately enter
physical observations into the NEWS2 electronic system (and patient record). This will
automatically calculate the NEWS2 scores and alert if interventions or emergency care is required.
Confirmation has been received that these have been made available and are in use on all Adult

Two senior staff members have been identified to work with individuals and groups from the Lucy
Wade Unit to ensure they fully understand how to undertake comprehensive NEWS2 assessments.
The key focus of the sessions is about confidence-building, particularly regarding decision-making
at the time of an urgent clinical incident. They will additionally ensure that all staff are supported to
scenarios to test knowledge and processes in a more realistic, true-life environment. We are initially
Prioritising the wards in the north of the county and intend to have this area fully compliant with the
training target in this area by mid-April 2022. Additionally, the intention is then for 80 percent
completion target in line with the Trust training compliance matrix for all Adult Mental Health
by end of May 2022. At this time, 34 staff (approximately one third of the required staff group in the
north of the county) have completed the scenario-based training and 59% of AMH inpatient nurses
have completed the enhanced NEWS2 training. A copy of the scenario-based aspect of this training
package is attached as Appendix 2.

A letter dated 27 January 2022 describing the learning from this event has been written and was
distributed throughout the Directorate’s in-patient services via formal letter and email copies the
week followings its completion. A copy is enclosed with this letter titled Appendix 3.

All direct care in-patient staff in the Trust complete Hospital Life Support training every eighteen
months, which includes the completion of NEWS2 assessments and associated escalations; plus,
recognition of Anaphylaxis and its emergency treatment using Adrenaline. Currently Adult Mental
Health services are at 84 percent compliance, which is within target for the directorate. The lesson
plan for this core training is being reviewed to confirm that sufficient time is spent on all aspects of

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the above, ensuring that staff are appropriately trained and have completed a competency
assessment to confirm this. A further update in relation to this will be available by the end of May
2022.

The Trust Resuscitation committee is convening (initially on 9 March 2022) to review the Rapid
Tranquilisation Policy and will explore, review and determine what actions should be taken should
@ patient fall asleep post rapid tranquilisation administration. At the initial meeting it has been
agreed that an external intensivist will be consulted to advise as part of this process. A clear
understanding of how staff will make the assessment to determine if the patient is sleeping or if the
patient is unconscious will be confirmed and any additional learning and development planned.

Currently the Directorate are placing patients on constant observations until they are mobile and
using a Pulse Oximeter to continuously monitor blood oxygen saturation and pulse rates. This has
been communicated to staff members via the aforementioned letter and within ward team meetings
and both group and individual supervision sessions.

No medical clerking from admission until her collapse

On the night of admission, 3 May 2021, Mrs. Whitehead was seen by the duty doctor Dr J

clerked her in and made an entry at 23:11. She also completed the core assessment
by patients and staff to console her. She did not respond _verbally to Dr to speak
to her. She was backing away and visibly frightened. Dr flllunderstood from nursing staff that
Mrs Whitehead’s behaviour had been the same since her arrival on the ward and she had not
spoken to any staff thus far. Dr [llbttempted to complete a full clerking but because of Mrs.
Whitehead’s mental state and clinical presentation, by necessity, much of this information was
taken from RIO and also the GP information from the portal, other than the objective observations
she could make. She was unable to complete a physical examination, an ECG or bloods because
Mrs. Whitehead was too frightened and disturbed. She recorded her reasons in RIO progress notes
and she recorded a plan to hand over to the day team to request a re-attempt at completing the
missing aspects of the clerking. This is in keeping with the Trust's policy on Physical Assessment
and Examination of patients (Appendix 4), which states that a physical examination should take
place within the first 24 hours but recognises that sometimes examination is not possible, such as
occasions when the patient refuses or is too disturbed, and the situation should be reviewed at
appropriate intervals. The Policy also recommends reattempting within the first 48 hours and at
regular intervals thereafter.

Dr BlEmaiied the ward doctors for the following day, Drang Or
This email was received and acknowledged by Dr|ijwho stated she would see the patient the
following day.

The handover has been reviewed by the Associate Medical Director and by the Director of Medical
Education, and they have considered that passing this work to the ward doctor rather than the next
day duty doctor was appropriate, given the presentation and physical needs would be ongoing for
detail of the handover on the morning of 4 May 2021, as Dr (Finished her shift, has been
clarified by the Associate Medical Director and did take place face to face as per advised practice.

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Trust Honesty Respect Compassion Teamwork

The daytime duty doctor for 4 May 2021 was made aware of the patient by nursing staff as Mrs.
Whitehead remained very unwell and they recognised that her prescribed PRN medication may
have contained lactose. The duty doctor undertook some liaison with pharmacy colleagues about
choice of medication given her allergies. There are no further entries in RIO progress notes about
consideration of further attempts to complete a physical examination and baseline investigations,
but there is a clear description in the notes of Mrs. Whitehead continuing to present as mentally

When interviewed by the investigators Drlfstated that on Wednesday the 5 May 2021 she
was not able to do a full examination as the patient was very agitated, therefore towards the end
of her working time she handed the case over to the on-call doctor. She informed him that Mrs
Whitehead was agitated, and he may be called to see her later in the shift.

She was examined physically by Dr [EEE duty doctor, on the evening of 5 May 2021. This
was after rapid tranquilisation had occurred. He records an entry in RIO at 17:45. He had been
asked to see Mrs. Whitehead by ward nursing staff, with concerns about her mental state including
agitation, verbal aggression and chaotic behaviour, along with physical symptoms of copious loose
stools and nausea. He physically examined the patient including her conscious level, hydration
status, most recent physical observations, chest examination, pulse, heart auscultation, capillary

have jointly emailed all junior and consultant medical staff in the division to remind them of the
intervals if unable to complete it at the point of admission, and the importance of documenting the
review of completing the physical assessment in the notes.

No Consultant involvement after admission

LUCY Va Striec by two consultants, IMME Consuitant Cinical Psychologist
and Dr Consultant Psychiatrist. Dr @ fully qualified approved clinician
under the Mental Health Act. This is a new role, known as a Non-Medical Approved Clinician or
also known as Multi Professional Approved Clinician. In order for medical aspects of inpatient care
to be fully provided Dr has a programmed activity in his job plan to support Dr IEE they
have a regular Tuesday meeting to discuss her patients, and he sees some of her patients directly
if indicated. He provides senior medical input if needed during the rest of the week. He also
supervises the clinical work and education of the junior medical staff on the ward. On the week in

uestion Dr| was on annual leave, and his annual leave was covered by a colleague, Dr
ME onsuran Psychiatrist at The Millbrook Unit.

On admission Mrs Whitehead was assigned to be under the care of Dr [J Or saw her
in Ward Round on 5 2021, accompanied by a Clinical Psychologist, Dr and a staff
nurse. At this time Dr lwas self-isolating due to testing positive for COVID 19 and was

working remotely. She led the Ward Round on MS teams. The Trust position during the pandemic
has been for clinicians to work remotely if they test positive and are well enough to work. Dr I
was due to end her period of isolation the following day, 6 May 2021. There was a full MDT
discussion, but Mrs Whitehead was unwell and unable to engage with Dr [via MS teams.

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The outcome of the Ward Round in relation to consultant involvement was that Drill would
attempt to see her again the following day when she was out of isolation. Dr [Jalso planned
to consider transfer of consultant care to Dr [J on his return to work because of continuity of
care as he had worked with Mrs Whitehead in the community.

Or Lon Dr ME could nave accessed consultant psychiatrist support at this point in time
from Dr They did not do so as, at the time, they did not think this was necessary.
Unfortunately, Mrs Whitehead had suffered the respiratory arrest and had been transferred before
the face-to-face consultant review could take place.

Clinical Directors of the service plan the balance of workforce need and annual leave, with
festivals. Annual Leave will not be agreed unless sufficient cover arrangements are in place, and
this has been communicated throughout the workforce via conversations with lead consultants and
email correspondence.

Dynamic management of unplanned absences are harder to resolve, however the medical
workforce has committed to offer flexible cover arrangement in these circumstances, led by the
local area lead consultant.

To offer Divisional resource oversight, a daily report of all Covid related absences during the Covid
spikes is collated for the Associate Medical Director.

All cover arrangements are communicated to the ward and management teams, held on a central

Inability to reach Duty Doctor for deteriorating patient

The Trust takes the difficulty experienced by the nursing team in making contact with the duty
doctor for a deteriorating patient extremely seriously. The nursing team describe ‘Tinging
continually but the doctor did not answer the phone” from about 20:45 on 5 May 2021 and report
inability to leave a message.

From investigation of this issue, it is known that the duty doctor had one registered missed call,
which he noticed at 21:10 that had been made at 20:55 and no message had been left. He had
been seeing another patient, and he had taken blood samples across to the laboratory at Kingsmill
Hospital and noticed the missed call as he was walking back. We have explored this further and
concluded that the most likely explanation is that he lost mobile signal. In response, this has been
reviewed with the Trust Chief Digital Information Officer and the Head of ICT Operations. It has
been recognised previously that a number of our sites lack a mobile phone signal, and the solution
in place for some years is to ensure all junior doctor smart phones are enabled for Wi-Fi calling. It
is highly probable that connection with Wi-Fi calling was lost when he went to the laboratory at
Kingsmill Hospital, and he also had no mobile phone signal.

The recommendation from the SI report was to have a “crash bleep”. This was considered but
discounted as the duty doctor covers a number of geographical sites and cannot provide an
immediate response. Therefore, the response to a medical emergency needs to remain as 999.

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The option of a “back up bleep” to be an alternative contact method if the mobile phone fails was
then considered. Advice from IT was that there is a national target to remove bleeps from the NHS,
which was to be achieved by the end of 2021. Alternative options include various apps, but they
all require a smartphone and a reliable signal or Wi-Fi calling. We have therefore reviewed all first
on call rotas to establish all locations where the junior doctor may need to visit as part of their
duties. For the duty doctor at Millbrook, in addition to Millbrook itself, this consists of all of Kingsmill
Bracken House and the road in between. ICT have now developed a solution using Wi-Fi calling
via a specific NHIS wireless network. Staff will need to select this network when inside Kings Mill
and there is a requirement for them to register using first name, last name and Trust email address.
This is a one-off registration per mobile phone device allowing auto-connect to occur at each
should be able to initiate and receive calls when there is no cellular mobile phone signal. This
solution is available with immediate effect and extends onto a non-Trust site. The Head of ICT
Operations has communicated with medical education to ensure all junior doctors are informed
and have the user guide (Appendix 5).

Additionally, Millbrook Mental Health Unit is co-located within the grounds of the Kings Mill Acute
Hospital. As such, Trust leads have liaised with acute colleagues at Sherwood Forest Hospital
Trust to assess whether this proximity is sufficient to allow the Acute Emergency Response “Crash*
team to attend medical emergencies. This would offer the quickest and highest level of response
to medical emergencies in the future. In February 2022 they agreed that this cover is possible.
However, before fully operational we have to ensure appropriate additional equipment is in place
and develop a list of practical issues to cover off, which is currently being managed by the Head of
Development Unit. Throughout March 2022 the operational challenges will be worked through with
the aim to implement this process as soon as it is deemed safe to do so. In the interim period the
primary action remains to call for an ambulance via 999. Further updates can be provided to the
Coroner's office once we can give assurance that this system is fully operational.

Delay in calling paramedics

As detailed above, colleagues made attempts to contact the Duty Doctor when they recognised
that a medical emergency was unfolding.

The primary message to staff, is that they must call for immediate support from the Ambulance
service when they recognise that someone's physical health is rapidly deteriorating, and a medical
emergency is or is likely to occur. This has been included clearly within the notification of learning
letter already referred to within this response (Appendix 3).

Summoning a local medical response to support their life support interventions is a secondary
action.

Additionally, senior leads, including the AMH General Manager has liaised with the East Midlands
Ambulance Service to ensure they are aware of the nature of our Mental Health Units, the
limitations of the life support interventions that can be made, and off site working of medical
colleagues. Between them they have agreed that when an emergency response is requested, it

‘The Resource, Duncan Macmillan House,
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becomes a priority one call, initiating an immediate response. This remains the case until the
emergency crash process with Sherwood Forest Hospital Trust is in place and safely operational.

Delay in Paramedics gaining access to the ward

Once the ambulance response was confirmed, staff focused on carrying out hospital life support

No one was allocated to go to the main reception to greet and hurriedly escort the ambulance team
through to Mrs. Whitehead. This led to a delay in the ambulance team accessing the site.

The Directorate has reviewed the formation and functioning of the Incident Response Team and
now added the allocation of an Emergency Services Liaison Responder for each ward. This role is
allocated on each ward by the nurse in charge as part of every handover at the start of each new
shift. This individual functions within the team during normal incident scenarios, however, when a
medical emergency is identified, they will immediately go to the main reception, wait for the
emergency services to attend, and will escort them immediately to the casualty. This role will also
be used in the event of Police or Fire Service support being required and will be allocated to a

This process has been agreed with inpatient staff members and is identified as requiring allocation
on the ward handover sheets (Appendix 6). This will be audited on the inpatient units bi-monthly to
ensure compliance, and the outcome of the audit fed back to the senior management team. A copy
of initial audit will be made available to share with the coroner's office by end of May 2022.

The management team is committed to learn from these mistakes and have met with the authors to
review each recommendation, their thinking behind them, and to clarify all the details that lie behind the
report.

By doing this, we have ensured that the actions identified in our Quality Improvement Plan (QIP)
effectively respond to the learning identified in the report and are agreed by the investigators, local team
based at Millbrook Mental Health Unit and the Directorate leadership team.

Some of the themes are out of the Directorate’s sphere of influence and will require Divisional and Trust
| —_ ee eee

We have made efforts to engage with the family and express our sincere apologies. They have asked
not to be approached at this point, but as the QIP develops efforts will be made again to share our
leaming and changes with them.

| hope the information above provides the assurance that we have and continue to consider your
recommendations seriously, that we are actively seeking to improve the services we provide by
implementing the actions outlined, on which, if you are in agreement, a full update will be made available
to you by the end of May 2022.

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Yours sincerely

Dr,
Chief Executive

Enc Appendix 1- NEWS2 Quick Reference Guide
Appendix 2— NEWS2 Scenario Training Package
Appendix 3 — Letter detailing learning to inpatient staff members dated 27 January 2022.
Appendix 4 — Trust's policy on Physical Assessment and Examination of patients
Appendix 5— NHIS wireless network staff user guide
Appendix 6 — Ward handover sheet

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Making a The Resource, Duncan Macmillan House,

. Porchester Road, Nottingham NG3 6AA
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