Jodie McCann

9 June 2023 

PRIVATE & CONFIDENTIAL 
FAO: Dr E Didcock 
HM Assistant Coroner for Nottingham & 
Nottinghamshire 
The Council House 
Old Market Square 
Nottingham, NG1 2DT 

Dear Madam 

I am writing in response to the Regulation 28 Report dated 28 April 2023, following 
the Inquest relating to Ms McCann's death. 

As a Trust we fully accept that there were significant and serious issues in the care 
provided  to  Ms  McCann.  We  have  apologised  to  Ms  McCann's  family  for  these 
failings  and  taken  this  Notice  with  the  seriousness  that  they  and  yourself  would 
rightly expect. 

We know that investigating incidents that have led, or could lead to harm is a vitally 
important feature of safe organisations. UHDB is committed to continued openness 
and  transparency,  and  to  making  sure  that  we  investigate,  communicate  and  learn 
when  things go  wrong  so  that  we  can embed  improvements  that  can  support safer 
care. 

Enclosed you will find commentary that details the robust actions taken as a result of 
the learning from Ms McCann's sad case, as well as details of future planned work 
around our mortality governance processes, for assurance. 

The Trust has also retained 360  Assurance to audit the actions taken following this 
incident. 

Should you require any additional information please do not hesitate to contact me. 

Yours sincerely 

Chief Executive 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response to concerns identified in the Regulation 28 Report to Prevent Future 
Deaths issued on 20 April 2023 

1.  There is limited evidence to date for the introduction and continuing use 
of  comprehensive  airway  strategies,  with  structure  planning  and 
preparation,  when  a  difficult  airway  is  anticipated.    There  should  be 
airway plans A, B and C recorded, shared and the equipment and skills 
to carry them out must be available.  

Following  Ms  McCann's  death,  the  Intensive  Care  Unit  at  Queens  Hospital  Burton 
(QHB) has introduced a Critical Care Airway Plan for all patients on the unit. A copy 
of this care plan is attached and indicates the airway status and plan for each patient 
indicating whether the patient has a Red, Amber or Green Airway.  For patients who 
have  a  Red  or  Amber  airway,  the  clinical  teams  are  responsible  for  making  and 
documenting an airway management plan. This includes what equipment is going to 
be  required  and  whether  Consultant  assistance  will  be  required  in  the  event  of  an 
emergency.  It is the responsibility of the named Consultant to review this plan on the 
morning  and  evening  ward  round  to  ensure  that  the  plan  is  appropriate  and  up  to 
date. 

This  airway  plan  is  now  displayed  above  the  patient's  bed  and  the  airway  trolley 
containing all vital equipment is stored in each area of the Unit with clear laminated 
copies of the NAP4 algorithms displayed on the airway trolley.   

Together with the NAP4 algorithm laminated sheets, the airway trolley also contains 
an  Intubation  Checklist  which  is  to  be  used  by  the  medical  team  when  a  patient  is 
intubated.  This ensures that all the necessary equipment is available and provides a 
structure  for  how  the  intubation  is  to  be  carried  out  and  preparation  for  any  airway 
difficulties.  Once completed, these are filed into the patients notes and kept by the 
bedside.   

Patients  who  have  an  airway  plan  (patients  who  have  a  Red  or  Amber  airway)  in 
place  are  now  included  in  the  staff  handover  of  information  so  that  it  is  clearly 
handed over between shifts and patients with difficult airways are highlighted to the 
staff caring for them.  The Nurse in Charge is expected to check that all patients with 
a Red and Amber airway have an airway management plan and confirm that this is 
located above the patient’s bed.  

In  terms  of  equipment  required,  the  nursing  staff  on  the  unit  now  carry  out  daily 
checks and complete a daily sign sheet.  This is to check that all equipment required 
is  available  on  the  airway  trolley  and  that  the  NAP4  algorithm  is  attached  to  the 
airway trolley.  Evidence of compliance with this is indicated by signature sheets for 
each bed which are checked by the Nurse in Charge to ensure that these have been 
completed  daily.    If  the  airway  trolley  is  used,  the  Nurse  in  Charge  will  check  and 
restock the airway trolley and sign to confirm that this has been completed.  

 
 
 
 
 
 
 
 
 
 
 
 2.  There  is  limited  evidence  to  date  for  the  universal  use  of  the  NAP4 
algorithms  and  checklists,  which  should  be  available  on  the  difficult 
airway trolley, and be familiar to all ICU nursing and medical staff, and to 
the wider anaesthetic team. 

As  outlined  above,  the  NAP4  algorithm  and  checklists  are  available  on  the  airway 
trolley and daily checks are undertaken to ensure that these are available to staff. 

In terms of airway education, the following training events have been carried out: 

1.  The  process  surrounding  use  of  Airway  Care  Plans,  NAP4  algorithms  and 
emergency intubation checklists were circulated to all medical staff on 18 April 
2023  and  has  been  re-iterated  in  person  to  attendees  at  the  Surgical 
Divisional day on 18 May 2023; 

2.  To  complement  this,  an  Airway  Study  Day  was  carried  out  on  22  October 
2022  by 
,  Consultant  in  ICU  which  contained  theory  and  simulation 
training around airway management, airway trolley orientation and intubation 
checklist  and  management  of  a  dislodged  tracheostomy.    This  airway  study 
day is to be repeated on 21 and 28 June 2023 (this was planned for April but 
was impacted by the junior doctor strikes); 

3.  A Local practical session was carried out on 27 April 2023 for all the Band 6 

and 7 nursing teams performed by 

, Consultant in ICU; 

4.  Airway  management  is  to  be  added  to  the  junior  doctor  induction  training 
programme  which  covers  intakes  in  August  and  February.    This  is  being 
, Consultant and College 
developed for the next cohort of trainees by 
Tutor; 

5.  There is an Airway Education Board on display within the unit displaying the 
Airway Care Plan, Learning on a Page document, advice surrounding using a 
regarding 
TrachSeal  Closed  Suction  System  and 
tracheostomies.  

further  advice 

3.  There  is  limited  evidence  to  date,  for  the  robust  daily  checking  of  all 
necessary equipment on the difficult airway trolley, to ensure immediate 
replacement of all key equipment if it is broken or misplaced 

Review of processes for ensuring availability of essential equipment  

The Trust has up to date policies for 'the management of medical devices' and 'the 
competency  and  training  requirements  connected  with  medical  devices'.  The  policy 
for the management of medical devices is currently undergoing a full review. These 
policies  set  out  requirements  for  maintenance,  service,  repair,  and  replacement  of 
medical devices within the organisation. This includes all loan devices too.  

It  is  the  personal  responsibility  of  every  equipment  user  to  ensure  the  devices  are 
available and fit for purpose prior to every use. It is the additional responsibility of the 
clinical department manager/lead to ensure all equipment used in the department is 

 
 
 
 
 
 
 
 
 in  good  repair,  and  “in  service”  and  making 
maintenance.  

this  equipment  available 

for 

Currently the Engineering Department provide prompt lists on a regular basis to the 
clinical  area  based  on  information  available  from  the  Trust  information  portals. 
However,  the  Trust  are  in  the  process  of  implementing  a  new  asset  management 
database  which  will  allow  clinical  areas  to  view  their  live  equipment  data.  This 
functionality will be available by the end of 2023 and will provide greater overview for 
clinical areas as to what equipment should be in the department and when it is due 
for service.  

The Clinical Engineering Department have also recently introduced e-Quip, which is 
a medical devices training system. This system enables the Trust to have access to 
individual  and  departmental  records  of  all  medical  devices.  This  system  will  allow 
reports to be generated of department competency percentages. These records will 
be  monitored  by  departmental  leads  and  will  be  overseen  by  the  Trust  Medical 
Devices  team  to  monitor  compliance.  Department  leads  will  be  expected  to  attend 
Medical Devices Procurement User Group (MDPUG) to present their compliance of 
all medical devices going forwards.  

Each  area  is  responsible  for  reporting  through  Business  units  to  division  where 
maintenance compliance deficit action plans will be discussed before presentation at 
MDPUG, with non-compliance escalated to Medical Devices Group (MDG).  

If equipment is broken, missing or otherwise unavailable, the process for escalation 
requires the clinical areas to contact Clinical Engineering confirming:  

•  Equipment Identifier (Asset/Maintenance number) and a description of 

the equipment.  

•  A description of the fault  

•  The name and position of the person reporting the faulty equipment.  

• 

If a declaration of contamination status has been completed.  

Clinical Engineering will thereafter assume responsibility for ensuring the equipment 
is repaired  and advising  on  the  replacement  process  if  this is required.  Timescales 
will be provided where possible. Where purchase of new equipment is required, the 
Trust  has  defined  procurement  processes  in  place  for  both  revenue  and  capital 
equipment.  Replacement  of  Capital  Clinical  Equipment  (over  £5,000)  is  now  a 
centrally  managed  process.  This  will  mean  that  equipment  will  be  replaced  in  a 
timely manner than had been the case historically.  

Service and maintenance of equipment is undertaken by Clinical Engineering as per 
manufacturer's guidelines (the general rule is annually).  

 Where equipment is unavailable at any given time, Clinical Engineering will identify if 
a temporary loan is available either from the manufacturer or from elsewhere within 
the Trust, following an appropriate risk assessment with the departmental leads. If a 
loan  is  not  available,  the  clinical  area  is  required  to  escalate  through  the  Business 
Unit  to  consider  whether  procurement  of  additional  equipment  is  proportionate. 
Emergency procurement requests are made to MDPOG who will review and send on 
to the Chair of MDG for authorisation. 

The  Trust  has  recently  undertaken  a  review  of  medical  devices  governance  which 
was  presented  and  considered  at  the  Quality  Improvement  Group.  This  included  a 
review  of  roles,  responsibilities  and  the  governance  structure  related  to  the 
management  and  procurement  of  medical  devices.  In  summary,  the  current 
governance structure is as follows:  

•  Medical Device Group (MDG) receive escalations on replacement and 
new  medical  device  requests  from  the  Medical  Devices  Procurement 
Operational Group (MDPOG).  

•  Medical  Devices  Procurement  Operational  Group  (MDPOG)  provides 
the  governance  framework  of  clinical  equipment  management  and 
clinical  supplies  procurement  across  UHDB.  MDPOG  provides  MDG 
with  monthly  updates  on 
rolling 
replacement plan.  

the  Trust’s  medical  devices 

•  Medical  Devices  and  Product  User  Group  (MDPUG)  is  a  division  and 
business  unit 
linked  group,  reviewing  Training/Competency  and 
Maintenance  compliance  levels  and  action  plans.  Non-compliance  is 
an  escalation  to  MDG.  Medical  Devices  related  incident  reports  are 
reviewed monthly at this meeting.  

Availability of Equipment in ICU QHB 

At the time of Ms McCann's admission, the piece of equipment that was not available 
on ICU was an Ambuscope (bronchoscope) as the screen which the scope attaches 
to  was  broken  and  could not  be  repaired.  One  was available for  use  in  Theatre  at 
QHB but this was not obtained at the time of the airway emergency.   

Since  the  death  of  Ms  McCann,  the  ICU  at  QHB  has  purchased  a  new  intubating 
bronchoscope to replace the broken screen and has on order an additional machine 
so  that  there  are  two  options  for  clinicians  in  terms  of  use  of  bronchoscopes.    The 
unit  also  has  a  stock  of  scopes  which  can  be  used  in  conjunction  with  the  screen 
units and will be compatible with the additional unit that is on order.   

 
 
 
 4.  The  Mortality  review  policy  was  not  followed,  leading  to  a  significant 
delay in completing the serious incident review, delaying trust learning, 
and  delaying  the  family's  understanding  of  the  circumstances  of  JM's 
death.    There  is  limited  evidence  of  progress  in  implementing  the 
national Patient Safety Incident Response Framework at the Trust. 

Review  surrounding  Mortality  Governance  Processes  and  revision  of  the 
Monitoring Mortality and Learning from Review Policy 

As  a  result  of  Ms  McCann's  death,  the  Trust  is  undertaking  a  robust  review  of  its 
current  Monitoring  Mortality  and  Learning  from  Reviews  policy  which  will  be  bench 
marked against policies at neighbouring Trusts and will reflect national best practice 
and guidance.  

The revised policy will be completed by the end of June 2023 with approval by the 
Learning  from  Deaths  Group  on  the  July  2023  agenda.  This  will  be  escalated 
upwards to the Learning Review Group for approval. 

The revised mortality policy, in association with the Trust policy for incident reporting, 
management  and  learning  will  specifically  address  the  failings  identified  by  the 
coroner and will reflect the following changes that have been implemented: 

1.  The  corporate  clinical  governance  team  issued  guidance  (Actual  impact 
definitions)  in  May  2022  to  ensure  appropriate  grading  of  incidents  is 
undertaken  at  the  time  of  reporting and  through  the  incident  review process.  
The Divisions carry out a daily review of all incidents which are classed as low 
or  no  harm  in  order  to  sense  check  the  grading  is  correct.    If  there  are  any 
concerns  about  the  grading  of  an  incident,  this  will  be  escalated  and 
discussed  at  the  weekly  Virtual  Incident  Review  Group  (VIRG)  within  each 
Division, as outlined below.  

2.  Divisions  hold  a  Virtual  Incident  Review  Group  (VIRG)  to  review  incidents 
graded  as  moderate  harm  and  above  at  a  weekly  meeting.  This  includes 
clinical governance facilitators with senior nurse and medical input to discuss 
incidents  and  will  act  as  a  safety  net  to  reduce  the  risk  of  incidents  or 
unexpected  deaths  being  inappropriately downgraded.  If  they  remain  unsure 
as  to  whether  an  incident  has  been  appropriately  graded,  this  will  be 
escalated for corporate clinical governance review.   

3.  In addition to this, the Corporate Governance Team are currently undertaking 
an  audit  of  incidents  graded  as  moderate,  severe  or  death  as  the  level  of 
harm  to  validate  the  accuracy  of  grading.    The  results  of  this  audit  will  be 
reported to Quality Review Group in June 2023 for assurance.  The Corporate 
Governance Team are also completing  a data analysis on incidents reported 
as no harm, near miss and low harm in 2022/2023 which will be  received by 
the Quality Review Group in July 2023.  This is to look for themes and trends 
and to inform any quality improvement requirement moving forwards. 

4.  For incidents with an actual impact of  severe harm/unexpected death or any 
other incident of concern, these are reviewed at Divisional level and a 72-hour 

 
 report is now generated by Divisions. The 72-hour report provides assurance 
that  a  proportionate  review  of  incidents  is  completed.  The  72-report  process 
commenced  in  December  2022  and  an  audit  was  presented  to  the  Quality 
Improvement  Group  (QIG)  in April  2023.  The  audit  concluded  that  89  cases 
were  escalated  for  review.  24  required  a  PSII  or  PMRT,  44  required  a 
divisional review and the remainder were outstanding (72-hour reports not yet 
received  by  the  corporate  clinical  governance  team)  or  required  no  further 
action.  Ongoing audits are planned for ongoing assurance. 

5.  Medical Examiners (ME) review all non-coronial deaths in the Trust. The ME 
determines  if  an  SJR  is  required  and  will  activate  the  established  protocol. 
The  revised  mortality  process  will  include  an  undertaking  that  if  the  ME 
identifies an incident, which was missed by the division, they will escalate via 
the  Datix  process  to  allow  for  timely  investigation  via  VIRG  and  the  72  hour 
process. 

6.  A structured judgement review (SJR) was  requested for this patient  and was 
completed  but  this  was  not  communicated  to  the  Division  for  consideration 
under  the  patient  safety  processes.  A  monthly  report  is  prepared  by  the 
Mortality Assurance Support manager to all Assistant Clinical Directors which 
provides  an  overview  of  all  deaths  within  their  speciality  from  the  previous 
month.  This allows for oversight of mortality and allows specialities to identify 
patients who require SJRs to be completed. In addition, SJRs are completed 
via  an  electronic  platform,  CORS  and  are  graded  accordingly  which  can  be 
accessed and reviewed by the Division.  

7.  The mortality policy review will include a more detailed section regarding the 
SJR process including the criteria for SJRs, the responsibilities for allocating 
SJRs to clinicians (via Assistant Clinical Director [ACD]) and the timescale for 
completion  with  a  reporting  structure  to  include  the  divisional  mortality 
reporting  process  and  corporate  via  the  Learning  from  Deaths  Group.  If  the 
SJR  reviewer  identifies  an  incident,  which  was  missed  by  the  division,  they 
will  escalate  via  the  Datix  process.  Compliance  and  escalation  of  this  is 
monitored by the Learning from Deaths Group monthly. 

To  summarise,  any  individual  clinical  team  should  raise  a  Datix  if  they  detect  an 
incident,  but  a  safety  net  is  now  established  within  Divisions  (via  VIRG),  the  ME 
service and colleagues completing SJRs.  

The  Learning  Response  Review  Group,  which  commenced  in  January  2023,  will 
enhance  organisational  learning  from  safety  incidents  by  providing  a  corporate 
oversight  of  incidents  which  have  been  reviewed  by  the  divisional  clinical 
governance  teams.  Common  themes  and  learning  points  will  be  extracted  and 
shared throughout the organisation. 

A  communications  strategy  is  planned  to  disseminate  the  revised  Monitoring 
Mortality and Learning from Deaths Review policy which will include presentation to 
Divisions  and  discussion  at  Trust  learning  fora  including  the  Learning  from  Deaths 

 Group  and  Learning  Review  Group.  The  weekly  3.13  Senior  Leaders  forum  will 
include a presentation regarding the mortality process. 

An  audit  for  the  72-hour  report  has  been  completed  and  further  audits  will  be 
required to confirm compliance with incident reporting at VIRG, the ME service and 
SJRs.  

Implementation of Patient Safety Incident Response Framework (PSIRF) 

The aim of the project is to transition from an early adopter of the PSIRF framework 
to 'Version 1' which has been published based on the learning from the pilot sites. 

This  framework  replaces  the  Serious  Incident  Framework  and  focuses  not  on  the 
volume  of  incidents  investigated  but  the  quality  of  the  response  following  a  patient 
safety incident. Transferring importance to improvement projects to reduce the risk of 
similar  incidents  reoccurring,  demonstrating  that  reporting  an  incident  leads  to 
improved patient safety. 

We  strive  to  learn  from  all  that  we  do  and  to  share  this  learning  across  the 
organisation to make UHDB a better place to work and a safer place to be a patient. 

The  implementation  team  meets  monthly  and  comprises  of  experts  within  relevant 
given  fields  and  with  representation  from  the  Clinical  Divisions.  A  patient  safety 
partner (a lay person who works with the NHS to make care safer  for patients) has 
attended  the  PSIRF  future  state  process  mapping  event  to  reflect  the  'voice  of  the 
patient' and is invited to Trustwide future PSIRF events.   

The next key step is to agree a Trust wide process and policy for the management of 
incidents which incorporates and strengthens PSIRF within the organisation. 

The  management  of  incidents  (incorporating  PSIRF)  policy,  as  outlined  above  and 
the response plan are required to be live by the end of September 2023.  A copy of 
the Patient Safety Incident Response Plan can be made available, if required.