Beryl Holt

Joint Group Medical Directors’ Office 
Trust Headquarters 
Room 218, Cobbett House 
Oxford Road 
M13 9WL 

03 November 2022 

Mr N Meadows 
HM Senior Coroner for Manchester City Area 
HM Coroner’s Court & Office 
Exchange Floor 
The Royal Exchange Building 
Cross Street 
Manchester M2 7EF 

Dear Mr Meadows 

Beryl Holt, Regulation 28:  Report to Prevent Future Deaths (PFD) 

Thank you for your PFD report, dated 31 August 2022 addressed to 
 in 
his capacity as Medical Director for North Manchester General Hospital (NMGH).  Your report 
related to  the  death of Mrs  Beryl  Holt  on  06  July  2019  and  whose Inquest  was  held  on  11 
November 2021. 

I would like to start by extending my own personal condolences to the family of Mrs Holt.  I am 
very sorry for their loss. 

At the time of Mrs Holt’s death, North Manchester General Hospital was part of Pennine Acute 
Hospitals NHS Trust and under a management agreement with the Northern Care Alliance.  
As  you  know,  on  01  April  2021  North  Manchester  General  Hospital  was  acquired  by 
Manchester University NHS Foundation Trust (MFT). 

I  understand  that  you  concluded  Mrs  Holt  died  from  natural  causes.    In  coming  to  your 
conclusion, you noted that Mrs Holt had developed a rare but severe form of sepsis which led 
to the rapid death of tissues in the form of a severe infective process called necrotising fasciitis. 

A Root Cause Analysis investigation was undertaken by NMGH following Mrs Holt’s death and 
completed in September 2019.  This investigation was led by Pennine Acute Hospitals NHS 
Trust as it took place prior to MFT’s acquisition of NMGH.  Evidence was heard at Inquest 
around the actions and recommendations arising from this investigation and how these had 
been  implemented  at  NMGH.    It  is  acknowledged  that  there  was  a  missed  opportunity  for 
updated evidence to be provided from MFT’s perspective to assure you and Mrs Holt’s family 
that  these same  actions  and  recommendations  have  been  appropriately  embedded  across 
MFT. 

After hearing the evidence at Inquest, you raised the following matters of concern: 

1.  That MFT ensure that all their sepsis protocols and policies are up to date 
2.  That all appropriate clinical and nursing staff are familiar with them and have necessary 

training and updates as required 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 3.  That new or locum clinicians as well as agency nursing staff are made aware of the sepsis 

policies and protocols and act in accordance with them 

4.  Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made 

and appropriate treatment commenced in a timely manner 

I have sought to address each of your matters of concern in turn below: 

1.  That MFT ensure that all their sepsis protocols and policies are up to date 

MFT has a Trust wide Sepsis Policy (see attached) which was updated on 11 July 2022 
and issued to all staff across MFT in September 2022 via the Group Sepsis Committee.  
The purpose of the policy is to give guidance and define standards of care in relation to 
the recognition and treatment of patients with sepsis and septic shock in adult patients.  
The recent  updates made  were to  harmonise  the  existing MFT  policy  with the  previous 
policy  which  had  been  in  place  at  NMGH.    These  updates  also  incorporated  changes 
arising from implementation of MFT’s new Trust wide electronic patient record (HIVE, see 
below).  The policy is in line with current NICE guidance.  It will be reviewed in September 
2025 or sooner in the event of any significant recommendation to alter practice. 

In September 2022, MFT implemented a Trust wide electronic patient record (HIVE).  The 
Trust’s Policy has been amended to reflect changes to existing practice and particularly 
documentation associated with recognising, escalating, and treating patients with sepsis.  
Sepsis screening flags have also been built into the software to alert staff to patients who 
‘trigger’ for sepsis based on their clinical observations. 

2.  That  all  appropriate  clinical  and  nursing  staff  are  familiar  with  them  and  have 

necessary training and updates as required 

All clinical members of staff are required to complete Sepsis Mandatory training.  Sepsis 
training  falls  within  the  ‘Acute  Care  Management’  module.    It  is  mandatory  that  staff 
complete  this  module yearly;  medical staff  are  expected  to  include confirmation  of  their 
mandatory  training  compliance  within  their  annual  appraisal  that  supports  medical 
revalidation. 

MFT has established the Acute Care team which is made up of eight Clinical Acute Care 
Educators  (covering  adults,  maternity,  and  paediatrics)  whose  role  is  to  provide  sepsis 
education,  drive  sepsis  quality  improvement  work  and  review  the  monthly  sepsis 
compliance figures across the Trust.  This refers to compliance with sepsis screening as 
well as the ‘Sepsis Six’ treatment bundle, a set of six key tests and interventions that need 
to be applied to a patient with red flag sepsis features within 60 minutes of sepsis being 
suspected.  If a specific area/ward is under-performing the team will offer specific targeted 
sepsis education and review where improvements can be made. 

In September  2022 MFT  published new  guidelines for  acute  care  education  (attached).  
All  ward  based  registered  adult  nurses  and  nursing  associates  must  attend  the  Trust 
Nursing and Midwifery Induction programme upon commencing employment at the Trust 
and  will  receive  an  overview  on  sepsis  recognition  and  response,  early  warning  score 
protocols  and  escalation  procedures  along  with  other  topics  around  the  acutely  unwell 
patient. 

Within 12 months of any registered nurse commencing employment within the Trust, the 
Acute  Illness  Management  (AIM)  course  must  be  completed.    Sepsis  recognition  and 
management is covered within this course.  The Adult AIM course certificate is valid for 
three years (as per Greater Manchester Critical Care Skills Institute [GMCCSI]) and the 
course should be repeated once this expires.  At least one registered nurse on each shift 

 
 
 
 
 
 
 
 
 
 
 
 must  have  attended  and  passed  the  Adult  AIM  course.    All  Nursing  Associates  must 
complete the AIM course within 12 months of employment (valid for three years). 

All Foundation Year 1 doctors (FY1) starting at MFT complete an induction period which 
includes training in acute care and critical care outreach team awareness.  The Adult AIM 
course  is  also  completed  within  the  induction  period.    This  includes  training  on  the 
recognition and management of sepsis (including application of the Sepsis Six bundle).  
Regular teaching sessions in acute care are mandatory for all FY1s across the Trust.  A 
small number of doctors join MFT after their FY1 year for ‘standalone’ FY2 training; they 
too are inducted into the Foundation Programme including AIM training. 

There is also dedicated additional sepsis training provided for all Foundation Year doctors 
twice a year as part of the local Foundation Training programme. 

Secondary  and  tertiary  responders  (Foundation  Year  2,  Core  Trainee  (CT)  Year  1/2, 
Specialty  Training  (ST)  Year  1/2,  ST3+  and  other  Registrar-equivalent  grades)  in  the 
appropriate specialties all complete Trust induction which includes acute care training.  All 
must attend Resuscitation Council (UK) Advanced Life Support (ALS) training.  The Care 
of the Critically Ill Patient (CRISP) (for surgical trainees) and/or the Ill Medical Patients’ 
Acute Care and Treatment (IMPACT) course are also attended as appropriate.  Registrar 
grade doctors that carry cardiac arrest bleeps must have current ALS.  All consultant staff 
are  instructed  to  undertake  the  ‘Acute  Care  Management’  eLearning  module  that  has 
recently been updated to reflect the implementation of HIVE and now replaces the former 
‘Maintaining  Patient  Safety  in  Acute  Care’  module  as  part  of  their  clinical  mandatory 
training.  In addition, they are able to access any of the acute care courses available as 
they require. 

3.  That new or locum clinicians as well as agency nursing staff are made aware of the 

sepsis policies and protocols and act in accordance with them 

All  NHS  Professionals  staff  and  long-term  locum  doctors  will  have  a  full  induction 
programme  and  will  be  required  to  complete  any  relevant  mandatory  training  prior  to 
commencing shifts. 

It  is  not  possible  for  staff  undertaking  one-off  shifts  to  complete  all  the  Trust’s relevant 
mandatory training in advance of this however, they will receive an induction/orientation 
before.    They  will  be  shown  how  to  access  and  use  the  Trust’s  new  electronic  patient 
record system (HIVE) as well as the Trust’s policies and procedures. 

All  new  NHS  Professionals  or  agency  nursing  staff  undertaking  shifts  at  any  of  the 
hospitals across MFT will complete a local orientation/induction with the Nurse in Charge 
for the ward/area which they will be working for that shift.  This includes orientation to the 
area as well as fire and emergency situations.  Staff will also be shown where to locate 
Trust policies and guidance documents. 

All staff undertaking shifts from September 2022 will have also received training on the 
Trust’s new electronic patient record system (HIVE).  Therefore, if a patient is flagged as 
having potential sepsis based on their clinical observations (Early Warning Score of 5 or 
more), an automated alert will be issued via the system to initiate a timely clinical review 
of  appropriate  seniority  based  on  the  Early  Warning  Score.    The  HIVE  system  also 
incorporates  clinical  guidance  about  the  Sepsis  Six  bundle  of  care  including  a  timer  to 
facilitate this promptly. 

 
 
 
 
 
 
 
 
 
 
 
 
 4.  Periodic audits are undertaken to ensure appropriate recognition of sepsis has been 

made and appropriate treatment commenced in a timely manner 

In 2022 an inpatient sepsis audit was established in line with the MFT Acute Care team 
audits.    It  has  run  for  two  cycles  and  the  findings  have  been  presented  to  the  Clinical 
Effectiveness Committee.  One outcome of the audit was to establish a Sepsis Task and 
Finish Group to improve sepsis education and awareness across MFT and harness HIVE 
to access real time meaningful data on sepsis screening compliance. 

I  hope  that  the  above  provides  you  and Mrs  Holt’s  family  with  assurance  in  respect  of  the 
matters of concern you have raised.  The Trust is committed to ensuring patient safety is our 
priority.  If you require any further information, please do not hesitate to contact me. 

Yours sincerely 

Joint Group Medical Director / Responsible Officer 
GMC 3442971 

Encl.   

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services