Alexander Blewitt

TheMK  a 

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Dr Sean Cummings 
HM Assistant Coroner 
Milton Keynes Council 

20 June 2023 

Dear Dr Cummings 

,~1:;1 

Milton Keynes 
University Hospital 
NHS  Foundation Trust 

Regulation 28 Report following an Inquest into the death of Mr Alexander Blewitt 

I am writing following receipt of a Regulation 28 Report dated 06 June, subsequent to 
the Inquest which you concluded on 21  March 2023. 

Mr Blewitt attended the hospital for the first time on 09 July 2022, having been referred 
from the Urgent Care Centre (UCC, the out of hours service for primary care in  MK). 
He  was discharged  home with  a working  diagnosis (ongoing  urinary tract  infection) 
which was incorrect.  Mr Blewitt then returned to the Emergency Department (ED)  on 
11  July 2022 and  once a diagnosis was made,  went to theatre for a laparotomy.  Mr 
Blewitt suffered a cardiac arrest at the induction of anaesthesia and  sadly died post-
operatively  on  the  ICU.  He  had  been  found  to  have  pus  in  all  four  quadrants  on 
laparotomy, following  a bowel perforation. 

You  raise  several specific  issues  in  your Regulation  28  Report.  I summarise these 
issues as follows: 

•  Lack of attention to the referral note from the UCC - inaccurate transcription by 

the triage nurse and failure of the doctor to seek out the original. 

•  A  failure  on  the part of the  assessing  doctor on  09  July to  record  change  in 
bowel  habit  as  a  prominent  presenting  symptom  in  his  contemporaneous 
record,  leading to an  implied concern about the accuracy of the record and his 
subsequent evidence. 

•  Lack of reliable recording of IV fluid administration in the ED - you note that the 
author of the internal Serious Incident Report had been unable to demonstrate 
any remedy to this issue since the incident. 

•  A  potential  contributory  factor  (fluid  prescriptions  'disappearing'  from  the 
electronic  prescription  chart)  had  not  been  raised  to  hospital  authorities 
between the date of the incident and the date of the Inquest. 

 
 
 
 
 
 
 
 
 
 T  eMK 

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COU. 

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r,•t:kj 

Milton Keynes 
University Hospital 
NHS Foundation Trust 

•  A Serious Incident Report which you felt to be of an unacceptable standard (in 
part as it noted the poor documentation of fluid  prescription but did not explore 
further). 

Prescription of Fluids in  the Emergency Department and documentation of the 
same 

The  narrative  around  the  prescription  of  intravenous  fluids  in  the  Serious  Incident 
Report,  Inquest statements  and  verbal  evidence  seems to have been  complex  and 
nuanced at best, contradictory at worst. 

Intravenous fluids should be managed as any medicine in the hospital, prescribed (by 
a doctor I non-medical prescriber) and administered (typically by a nurse, occasionally 
by  a  doctor  or  operating  department  practitioner).  Since  we  have  been  using  our 
electronic patient record  (an  Oracle Gerner product,  branded  locally as  eCare),  both 
of these  steps  should  take  place within  eCare.  eCare  has  been  the  primary  record 
system in the Emergency Department since May 2018. It has been the primary record 
system in the theatre environment since September 2021. 

As with paper records,  it remains possible for medicines to be given by verbal order. 
This should occur only rarely when urgency is paramount, and it should subsequently 
/ retrospectively be recorded very clearly in the record. As a rule of thumb, I would not 
expect the doctor (in the context of the Emergency Department) to leave the vicinity 
of the patient without completing the prescription. It may be that intravenous fluids may 
be more prone to administration without prescription than other medicines as a series 
of fluids  may be  administered  in  quick succession  in  a  dynamic environment and  -
perhaps - on  account of an  erroneous view that fluids  have  less  potential  for harm 
than other medicines. 

During  the  course  of  Mr  Blewitt's  Inquest,  views  were  offered  in  relation  to  the 
prescribing  of intravenous fluids within eCare. It seems that there  may have been  a 
lack of understanding, and perhaps some misunderstanding , of the technical position 
and the impact that this might have had on practice and record  keeping. 

Several years ago,  we became aware that prescriptions for intravenous fluids would 
'expire'  if they  had  not been  administered  (commenced) prior to the  time  at which  a 
prescription should have been completed . For example, if a 1000ml bag of intravenous 
saline was prescribed at 16:03 to run over 12 hours, the prescription would expire (and 

As a teaching hospital. we conduct education and research to improve healthcare for our 
patients. During your visit students may be involved in your core. or you may be asked to 
participate in a clinical trial. Please speak ta your doctor or nurse if you hove ony concerns. 

 
 
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CJ. 
CC 

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r,•1:k1 

Milton Keynes 
University Hospital 
NHS Foundation Trust 

disappear from view as a medicine awaiting administration) at 04:02 the next morning. 
It would  still  be visible  in  the  record  ('greyed  out'),  with  details  of the  prescriber and 
the time  of prescription  but  it will  be  marked  as  'completed  but not given'.  This  is  a 
feature  of  the  Oracle  Gerner  product  internationally  and  has  some  benefits  / 
advantages. Ordinarily, this issue does not have a negative impact on workflows and 
clinical  care.  However,  it  is  more  likely to  be problematic  in  a  fast-moving  dynamic 
environment such  as  the  Emergency  Department where  fluid  prescriptions  may  be 
administered over relatively short periods of time (i.e. , over one hour rather than over 
12  hours).  Of  note,  fluid  prescribing  is  undertaken  differently  in  the  USA  (Oracle 
Gerner's base)  and  in the  UK: in the  USA fluids are ordered at a rate (e.g.,  100ml/h) 
to run  indefinitely/ until stopped, whilst in the UK fluids are ordered as a fixed volume 
to run over a defined and discrete period (e.g., 1000ml over 8 hours, then stop). 

This issue was raised with Oracle Gerner and we developed a distinct 'short infusion' 
order. In this scenario, the prescription remains a planned administration and does not 
'grey out'  on  the chart at the expected time of completion  The  'short  infusion'  order 
remains visible as due until it is administered, or when the patient is discharged from 
the  clinical  encounter.  It  does  not  expire  at  a  timepoint  related  to  the  time  of 
prescription  and/or the  calculated  time  of completion  of administration.  It  has  been 
specifically designed for use when prescribing fluids for infusion over a short duration 
(i.e., an hour or less). 

If doctors in  ED  prescribe fluids where there is a risk that they may not be started  in 
an  appropriate  timeframe,  or  where  a  number  of  fluid  options  are  laid  out  (e.g., 
depending  upon  an  awaited  laboratory  result) ,  these  short  infusions  will  be  more 
suitable. They have also  been  included  in  a  sepsis 'PowerPlan'  (an  electronic  'care 
bundle')  intended  to  guide  practitioners  through  the  required  orders  for  managing 
sepsis. 

The  orders  look  as  shown  overleaf.  A  training  video  was  also  developed  for  staff 
around the short infusion workflow. 

In Mr Blewitt's case, documentation around fluid administration is poor but it does not 
seem  that  this  specific  eGare  related  issue  - which  I  think  was  introduced  into 
evidence at the Inquest - was relevant. 

At  21 :28  on  11  July,  a  4-hourly  bag  of  fluid  was  prescribed  although  it was  never 
recorded on eGare as started (the prescription 'timed out' at 01 :37 the next day, so it 

As a teaching hospital, we conduct education and research to improve healthcare for our 
patients. During your visit students may be involved in your core, or you may be asked to 
participate in a clinical trial. Please speak lo your doctor or nurse if you hove any concerns. 

 
 
 TheMK 

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CC 

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r~1:kj 

Milton Keynes 
University Hospital 
NHS Foundation Trust 

remained on the chart available to be given until well after the patient left ED). Of note, 
antibiotics had  been given at 18:55. 

Following  the  cardiac  arrest,  a  retrospective  entry  was  made  by  the  anaesthetist 
describing the  5 litres of fluid  given  in  the anaesthetic room.  One entry that evening 
(by surgical staff) stated that the patient had received 2 litres of fluids in the ED. 

It  remains possible, although it clearly cannot be demonstrated in the record , that Mr 
Blewitt did indeed have two litres of intravenous fluid in the ED. Indeed, he could have 
received more or less (which is clearly not a satisfactory position). It seems likely that 
members of staff visiting  ED and  reviewing  Mr Blewitt (for example the two surgeons 
and  the  anaesthetist  between  21 :39  and  22:15)  would  have  commented  had 
intravenous fluids not been in progress at the time of review, given the clinical scenario 
which had by that point emerged. 

Quality of Incident Investigation Report 

It appears that the specific issue of the intricacies of electronic prescribing surprised 
witnesses at the  Inquest and  in  their efforts to  provide  answers for you,  a  confused 
picture emerged. At its core,  all ED clinicians should be aware that: 

As a teaching hospital. we conduct education and research to improve healthcare for our 
patients. During your visit students may be involved in your care, or you may be asked to 
participate in a clinical trial. Please speak lo your doctor or nurse if you have any concerns. 

 
 
 TheM 

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,~1:bj 

Milton Keynes 
University Hospital 
NHS Foundation Trust 

1.  Upon  suspicion  of sepsis,  time-critical  treatment  (including  fluids)  should  be 
commenced as soon as possible. The Royal College of Emergency Medicine's 
standard is that 75% of patients should be in receipt of fluids within 1 h of arrival, 
100% within 4h. 

2.  High quality record  keeping  is key to  the delivery of effective clinical care and 
is  a  professional  responsibility  for  regulated  healthcare  professionals.  This 
includes accurate documentation of patient history,  examination,  investigation 
and  plan.  Accurate  prescribing,  and  documentation  of  administration  of 
medicines, is essential. 

Incident  Investigation  Reports  are  reviewed  through  a  weekly  meeting  (Serious 
is  some  consistency  of  senior 
Incident  Review  Group,  SIRG)  where  there 
membership. This report was signed off by that group. The two key deficiencies which 
you  infer  were:  acceptance  of  the  diagnostic  approach  taken  on  09  July;  and 
identification of the issue of poor documentation on 11  July without further exploration 
of root causes or learning. Whilst I would  accept both criticisms to a degree, I do not 
think  they  are  as  clear  cut  as  your  Regulation  28  Report  implies.  The  09  July 
presentation was not typical for peritonitis, although there were also several elements 
which cast some doubt over the putative diagnosis of urinary tract infection. I note that 
the episode was  subsequently considered - and  not criticised  - through  a morbidity 
and mortality meeting which  aims to facilitate an objective and arms-length review for 
learning. 

The role of clinicians involved in  Mr Blewitt's presentation on 09 July 

You  criticise  the  failure  of the triage  nurse  and  the  assessing  doctor to take  proper 
account of the written notes from the UCC. 

It is not now possible to establish with certainty whether Mr Blewitt tried unsuccessfully 
to bring the note to the attention of the assessing doctor, or whether he assumed (quite 
reasonably) that all important elements would  have been entered into eCare at triage 
and  be  available  to  the  doctor.  I  agree  that  it  is  important for  a  doctor to make  all 
appropriate efforts to understand the views of other professionals who have assessed 
a patient and referred them on. The fact of onward referral from the UCC should have 
made  the  doctor  ask  himself  what  it  was  about  Mr  Blewitt's  presentation  which 
rendered  him  outside the scope of the UCC to manage: the doctor should have been 

As a teaching hospital, we conduct education ond research to improve healthcare for our 
patients. During your visit students may be involved in your care, or yoo may be asked to 
participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns. 

 
 
 TheM 

CJ 
CC 

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CONTRIBUTE. 

r~t:kj 

Milton Keynes 
University Hospital 
NHS Foundation Trust 

curious as to whether the UCC felt further tests were necessary, or whether there was 
such diagnostic uncertainty that a second opinion was effectively being sought. 

You suggest in your Regulation 28 Report that the doctor's contemporaneous record 
was  not  entirely  satisfactory,  particularly  given  his  view  at  Inquest  that  bowel 
symptoms were not present. 

The contemporaneous record by the doctor on  eCare states: 

Lower abdominal pain  associated  with  urinary  frequency ...  exacerbation  of supra 
public pain. 

There is no comment in relation to bowel habit in either this document or the discharge 
summary. The ED triage note on eCare had also focused on  sudden  abdominal pain 
in the suprapubic area and stated, 'sent to ED due to level ofpain with no clear cause', 
without reference to bowel habit. 

On  review  (in  the  writing  of this  letter)  of the  records  from  the  urgent  care  centre, 
reference to bowel  habit was  as follows:  'Abx have given  him diarrhoea  - stool was 
loose prior'.  The UCC record very much focuses on pain rather than bowel habit. 

The  statement  prepared  for the  Inquest,  finalised  approximately  5  weeks  after the 
clinical contact,  states: 

On  further questioning,  Mr Blewitt did not have  any nausea,  vomiting  or change  in 
bowel habit. 

As  shown  above, there  is no  contemporaneous  reference to  bowel  habit within  the 
notes  against  which  to  reference  his  comment  in  relation  to  responses  to  further 
questioning. The doctor may have been  basing this on his usual practice when taking 
a history from a patient with abdominal pain. 

I shall meet with the doctor in question to further understand  his perspective on  both 
elements.  Clearly,  a  distinction  may emerge  between  having  inaccurately  recorded 
the  history  given  and  having  been  insufficiently  thorough  in  eliciting  an  accurate 
history. There are I am sure other potential explanations. From reviewing entries from 
three  clinicians  (UCC  and  MKUH  ED)  on  09  July  2022,  it  is  not  clear to  me  that 

As a teaching hospital. we conduct education and research ta Improve healthcare for our 
patients. During your visit students may be involved in your care, or you may be asked to 
participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns. 

 
 
 TheM 

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CC 

CONTRIBUTE. 

r.!1:kj 

Milton Keynes 
University Hospital 
NHS  Foundation Trust 

changes in bowel habit were felt to be particularly prominent at that time: pain was the 
over-riding symptom . 

I am sure - given that you have shared your Regulation 28 Report with colleagues at 
the  General  Medical  Council  (GMC)  -
that  I  will  discuss  the  case  with  the  GMC 
Employer Liaison  Adviser in  due course.  Indeed, the doctor will  likely seek to  report 
himself formally to the GMC on the basis of paragraph 75 of Good Medical Practice:  I 
would  ask you to reflect on  how this criticism could have been shared  in  parallel with 
your Regulation 28 Report - potentially in writing to me  as  Responsible Officer. The 
doctor now finds himself in  a rather grey position in relation to paragraph 75 some ten 
weeks after the Inquest (and  having not himself been a recipient of the Regulation 28 
Report). 

We have made advances over the last year or so in relation to the visibility of electronic 
patient  records  between  different  providers  and  IT  systems  involved  in  a  patient's 
pathway.  Specifically,  through  use  of the  Health  Information  Exchange  (HIE),  it  is 
possible for clinicians at MKUH to see selected content from the primary care record 
in  SystmOne. This content includes read-only access to clinical notes from the UCC. 
By the same token, selected eCare content is available to colleagues using SystmOne. 

Sepsis work more broadly 

You will be aware that the Trust is transitioning from the reactive 'root cause analysis' 
investigation of clinical incidents to the new national Patient Safety Incident Response 
Framework (PSIRF).  PSIRF will afford  us more discretion going forward  in  targeting 
our governance  efforts  to  those  areas  where they  have  the  greatest  opportunity to 
make a positive impact for future patient care. In reviewing our historic incident profile, 
we have determined that we should focus our efforts on  a couple of areas relevant to 
this Regulation 28 Report,  namely: 

Robust clinical triage on presentation to the ED  including timely management 
of sepsis where indicated. 
Recognition of, and response to, deteriorating patients - including escalation -
in  the  inpatient  environment  (where  sepsis  may  well  be  the  driver  of  that 
deterioration). 

As a teaching hospital, we conduct education and research to improve healthcare for our 
patients. During your visit students may be involved in your care, or you may be asked to 
participate in a clinical trial. Please speak to your doctor or nurse iiyou have any concerns. 

 
 
 TheMK 

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COt 

CONTRIBUTE. 

,~1:kj 

M ilton Keynes 
University Hospital 
NHS Foundation Trust 

Notwithstanding this planned  focus,  it is noteworthy that our in-hospital mortality rate 
for patients with a coded  diagnosis of sepsis across 2022/23 was 15.9% (lower than 
both the prior year and the national average). 

Sepsis is included as a priority within our 2023 Quality Account (due to be laid before 
Parliament  in  June 2023)  and  we  have  set  up  a  'Sepsis  Quality  Improvement  (QI) 
Group' under the chairmanship of an Associate Medical Director who also happens to 
work as a Consultant within ED. 

The  Sepsis  QI  Group  will  use  quality  improvement  methodologies  to  provide 
assurance  on  current  performance  and  to  drive  further  improvement  in  areas 
contained within the relevant NICE quality statements, including: 

Use of standardised physiological monitoring  (NEWS2) 
Senior review and timely antibiotics for patients screening positive for sepsis 
Appropriate and timely fluid management 
Escalation of care to  a high dependency environment where appropriate 
Effective antimicrobial stewardship 

We are also working to  improve the way in which we capture  learning from  the work 
of  our  Medical  Examiners  and  t he  Structured  Judgement  Review  (SJR)  process, 
including in relation to deaths involving sepsis. 

Other Actions 

The  Chief Nurse and  I will  be writing to all  registered  staff in the  ED to  highlight the 
key elements of Mr Blewitt's case, and to remind them of the issues referenced in this 
letter: 

Importance  of  reviewing  notes  I  letters  from  referring  colleagues  (where 
applicable),  and  the  HIE  functionality  within  eCare  in  respect  of  patients 
referred on by UCC. 
Requirement for all  medicines,  including  intravenous fluids, to  be  prescribed 
correctly  in  eCare and for their administration to be documented.  Only in very 
rare  circumstances  should  documentation  occur  in  parallel  with  /  after 
administration, and this too must be recorded clearly within the record. 
The specific issue of the 'short infusion' order for fluids in ED, with signposting 
of the available video resources and an emphasis on the sepsis PowerPlan. 

As a teaching hospital, we conduct education and research to improve healthcare for our 
patients. During your visit students may be involved in your care, or you may be asked to 
participate in a clinical trial. Please speak to your doctor or nurse if you hove any concerns. 

 
 
 TheMK 

CA,,  COMMUNICATt. 
CC 

CONTRIBUTt. 

t~1:kj 

Milton Keynes 
University Hospital 
NHS Foundation Trust 

Value of the 'sepsis 6' interventions, with  a particular emphasis on timeliness 
of antibiotics and intravenous fluids. 

I trust that this response is helpful. 

rely, 

Medical Director / Deputy Chief Executive 

Copies 

,  Chief Executive, Milton Keynes University Hospital 

, Medical  Director, BLMK Integrated Care Board 

Relationship Manager, CQC 
Employer Liaison Officer, GMC 

As a teaching hospital, we conduct education and research to improve healthcare for our 
patients. During your visit students may be involved in your core, or you may be asked to 
participate in a clinical trial. Please speak to your doctor or nurse if you hove any concerns.