Jane Wadsworth

Alison Mutch 
Senior Coroner  
Manchester South Coroner’s Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

10 October 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Jane Elizabeth 
Wadsworth who died on 31 December 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 July 
2023 concerning the death of Jane Wadsworth on 31 December 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Jane’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  Jane’s  care  have  been 
listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  to  Jane’s  family  or  friends.  I  realise  that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them. 

The matters of concern raised in your Report come under the remit of Tameside and 
Glossop  Integrated  Care  NHS  Foundation  Trust  (hereafter  “the  Trust”),  who  are 
therefore the appropriate organisation to respond to the concerns raised. I am however 
grateful to you for bringing these important patient safety issues to my attention. The 
concerns have been shared with my relevant regional Quality colleagues in the North 
West,  who  are  engaging  with  Greater  Manchester  Integrated  Care  Board  (the 
responsible commissioning body for Greater Manchester) about the issues raised.  

NHS England had been waiting to be sighted on the Trust’s response to you, which 
we received a copy of on 2nd October 2023. We note that the Trust’s response does 
address  each  of  the  concerns  raised  in  your  Report  and  that  they  have  been 
implementing improvement work to address missed doses of medication, together with 
new processes for clinical documentation and review.  

Your Report will also be discussed by the Regulation 28 Working Group, comprising 
Regional Medical Directors, and other clinical and quality colleagues from across the 
regions. This ensures that key learnings and insights around preventable deaths are 
shared across the NHS at both a national and regional level and helps us pay close 
attention to any emerging trends that may require further review and action.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Thank you again for bringing these issues to my attention and please do not hesitate 
to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

r.!1:b1 

Tameside and Glossop 
Integrated Care 
NHS  Foundation Trust 

Chief Executive Officer 
Tameside and  Glossop Integrated Care NHS  Foundation Trust 
· Silver Springs 
Fountain Street 
Ashton  under Lyne 
Lancashire OL6 9RW 

7 September 2023 

Strictly Private and Confidential 

FAO Ms Mutch 
HM Coroner 
Coroner's Court 
1 Mount Tabor Street 
Stockport 
Cheshire 
SK13AG 

Private and  confidential 
To be  opened by the addressee only 

Dear Ms  Mutch, 

I am  writing  further to  the  inquest touching  upon  the  death  of Mrs Jane Wadsworth, 
who died on 31 st December 2022 which concluded 12th  June 2023 and the subsequent 
Regulation 28 Notice issued to the Trust. 

You  raised  6 questions of concerns which are set out below and  I will respond  and 
answer these questions as succinctly as possible to provide you with additional 
information and  assurance. 

1.  Mrs Wadsworth missed three doses of antibiotics prescribed to treat her 
infection  according  to  the  ev~dence  given  to  the  inquest.  This  did  not 
appear  to  have  been  escalated  and  there  was  no  clear  explanation 
regarding this  occurring  other than that her cannula may not have been 
in  place and there was a delay in a doctor being available to reinsert one; 

The Trust acknowledge that in  Mrs Wadsworth's case she missed a number of doses 
of intravenous antibiotics on  26/12/2023 as her cannula  had  become dislodged. The 
medical records document the  steps taken  by the  Registered  Nurse to  attempt to  re-
site the cannula without success. This also included escalation to both the Night Nurse 
Practitioner  and  the  doctor.  The  doctor  was  eventually  successful  in  gaining 
intravenous access. 

 
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Tameside and  Glossop 
· Integrated Care 
NHS  Foundation Trust 

During  Trust  induction  all  registered  members  of  staff  undergo  clinical  induction 
training  which  includes  intravenous  (IV)  cannulation.  Registered  members of staff is 
asked to  complete an  e-learning  package and  present evidence of the completion  of 
training  by way of a certificate to the Trust Training team.  On  receipt of the certificate 
the Trust training team  support simulated  practice on an artificial arm to  illustrate and 
reinforce practice under direct su·pervision. Once completed the registered member of 
staff is  provided  with  a  competency  document which  is  taken  into  clinical  practice. 
Competency  is  completed  foll.owing  assessment  in  the  clinical  setting  by  another 
competent colleague.  This  skill is  essential  to  role  for all  Registered  Nurses working 
within Acute Care and the IV therapy Team. 

The Trust continue to focus on improvement in relation to missed doses of medication. 
There is an established program of medication audits which are reported to the Trust's 
Medication  Safety  Group.  The  Medication  Group  meet  bi-monthly  and  has  a 
multidisciplinary  membership.  At  present  the  Pharmacy  Department  perform  an 
annual  snapshot retrospective audit which focusses on  omitted/unsigned  doses. The 
audit  covers  inpatient  areas  and  looks  at  any  medication  doses  which  are  not 
administered  as  prescribed  and  the  documented  reasons  for this.  The  most  recent 
audit was presented to Trust Medicines Safety Group on 28/04/23. 

. 

The Trust recognise that there is an overall percentage of medication doses which are 
omitted  for  a  'non-valid  clinical  reason'.  This  means  that  unsigned  doses  would  be 
recorded  under this category (along with any medication doses omitted due to  lack of 
availability).  In  the  last completed  audit the  percentage of medication  doses omitted 
for a 'non-valid clinical reason' averaged 4% of all prescribed doses. This audit is part 
of the Trust's standard audit cycle and the results are fed  back to the multidisciplinary 
Medicines Safety Group.  One  of the  actions from  the  last audit was  to  issue  a new 
poster which  highlights to  all  staff how to  avoid  missions in  medication- this  includes 
information of how to access medication if unavailable within the clinical area. 

In  addition  to  the  annual  pharmacy  led  audit,  Ward  Managers  perform  their  own 
documentation  audits  and  complete  electronic  incident  reports  as  appropriate.  An 
incident  would  then  evoke  further  local  investigation  and  individual  competency 
assessment  using  the  medication  management assessment tool.  Any learning  from 
this is shared at the daily huddles within each ward setting to ensure all staff appreciate 
the importance of accurate medication management. Medication incident numbers are 
monitored through the Trust Medicines Safety Group and the Medicines Safety Officer 
also  provides a summary document of any emergent themes and trends. 

In  addition  to  documentation  audits  the  ward  managers  also  complete  a  monthly 
Quality Assurance  audit.  This  includes an  assessment of whether medications have 
been  administered  as  prescribed,  each  audit  involves  the  review  of three  patient's 
medical records which includes the medication kardex. 

The  Trust  has  an  embedded  ward  accreditation  process,  where  each  ward  is 
accredited  on  an  at least  32  weekly  basis  and  more  regularly  if required.  The  ward 
accreditation  process  includes  a  review  of  omitted· doses  of  medication.  The 

 ,.,,:f;j 

Tameside and Glossop 
Integrated Care 
NHS  Foundation Trust 

accreditation team  is  led  by a Head  of Nursing  or Midwifery and  is  supported  by four 
senior  health  professionals.  The  results  are  shared  with  the  ward  managers  and 
leadership team with  Executive oversight.  This enables areas for improvement to  be 
identified and  appropriate action to be taken. 

The Trust medication  kardex has been  redesigned to place greater emphasis on time 
critical  medications.  Pharmacy  systems  for ordering  medications  to  the  ward  have 
been  streamlined  and the Trust also  has an  emergency medication cupboard  and  an 
on-call pharmacy for obtaining medications out of hours. I attach a copy of the template 
of  the  updated  medicines  kardex  and  the  PowerPoint  slides  to  support  the  new 
medicine chart for your consideration and  information. 

To provide further support for inpatient areas each ward  has a Ward  based  Pharmacy 
Team.  Each  ward  area  has  an  allocated  ward  pharmacist and  pharmacy technician 
who evaluate individual treatment sheets on a daily basis. They form a key element of 
the  multidisciplinary team  caring  for our patients.  Pharmacy  presence  on  the  wards 
supports the accurate prescribing and  administration of medication. They also ensure 
timely ordering of medications which do not form part of the routine medication stocked 
within the ward  area. 

Out  of hours,  in  the  event  of a  medication  being  unavailable  on  the  ward,  nursing 
colleagues have access to an Emergency Drug Cupboard, a list of where medications 
are stocked across the site ("Location of Stock on Wards" list available on the Trust's 
intranet site).  This is further supported with access to  an  on-call  Pharmacist who can 
offer further support if necessary. 

The  issue  of  omitted  doses  is  covered  in  the  nursing  induction  training  that  the 
Pharmacist delivers.  Every nurse receives this training at the point of joining the Trust. 
This training can also be accessed as a refresher course. Every nurse new to the Trust 
also  receives  a  medication  management  assessment  undertaken  by  the  Ward 
Manager which evidences safer practice in  keeping with Trust policy. This is recorded 
in  the  individual's  personnel  file  and  a  copy  sent  to  the  learning  and  development 
department. 

2.  The  evidence  before  the  inquest  was  that  on  her  admission  over 
Christmas/New Year there was no effective consultant input into her care; 

The Trust operates a Consultant on-call  rota  which  includes all  weekends  and  bank 
holidays throughout the year.  The  on-call  Consultant's  remit  is  one of assisting  their 
Urgent  Care  consultant  colleagues  in  the  review  of  new  patients  who  have  been 
admitted to the Acute Medical  Unit and  also tp  perform the review and  care  planning 
of any acutely unwell medical patients located in the medical wards across the Hospital 
if required. 

This  Consultant  rota  is  planned  6  weeks  in  advance  and  managed  by  the  Trusts 
medical staffing department. The medical staffing department have confirmed that the 
Consultant on-call rota identified no deficit for the period of Mrs Wadworth's admission. 

 ,.,,:~j

Tameside and  Glossop 
. Integrated Care 
NHS  Foundation Trust 

Alongside the Consultant on call rota the Trust operate a Consultant ward  round which 
includes weekends and bank holidays, which focusses upon patients who are deemed 
medically  optimised  and  fit  for  discharge.  This  ward  round  takes  place  on  every 
medical  ward  between  the  hours  of  9am  - 1pm  and  despite  the  focus  being 
dischargeable  patients,  the  Consultant would  be  a  point of escalation  should  any of 
the ward team identify that a patient required  urgent review. 

In  terms  of staffing  areas  of the  Trust  there  is  a  robust  mechanism  of oversight  of 
staffing  both .medical  and  nursing which  takes place several times per day to ensure 
safe staffing across the organisation. This is monitored at least 5 times per day during 
the  Trust  capacity  meetings,  where  operational  /  clinical  /site  and  senior  managers 
attend.  Any  potential  shortfalls  in  medica_l  cover  are  addressed  and  actioned  by 
operational  and  clinical  colleagues  to  mitigate  risk.  Should  any  further  escalations 
relating to staffing shortfalls be  required then the onsite team  are supported  by a first 
on call  senior manager rota and  a Executive on - call rota. 

3.  The  junior  doctor  involved  in  her  care  felt  that  ICU  involvement/input 
would  be  beneficial. The  evidence was that there did  not seem to  be  any 
doctor to doctor discussion of this. The  inquest heard evidence that this 
was  one  way  a  patient  could  be  transferred  to  ICU.  It was  unclear why 
there  had  not  been  such  a  discussion  and  whether  in  periods  such  as 
Christmas/  New  Year where  there  were  fewer  consultants  available  the 
system worked effectively. This was not a situation where there had been 
a ward  based  ceiling  of care  put  in  place  and  ultimately Mrs  Wadsworth 
was  treated  by  ICU  but was  extremely  unwell  at  that  point  and  did  not 
respond to that intervention at that point; 

From a review of Mrs Wadsworth care and medical records there is evidence that she 
was reviewed  by the medical team on a daily basis.  Mrs Wadworth was also reviewed 
by a Renal  Consultant (30/12/2022) and  a Microbiology Consultant. On  28/12, 29/.12, 
30/12  and  31/12/22  Mrs_  Wadsworth  was  reviewed  by  a  Medical  Registrar.  On 
31/12/22 at 08:S0am Mrs Wadsworth was reviewed by the Medical Registrar following 
appropriate escalation by the nursing team, who contacted the Critical Care Team to 
request a higher level of care for her.  Following this Mrs Wadsworth was admitted to 
the  Critical  Care  Unit. ·Further  information  regarding  Critical  Care  and  MERIT team 
provision is provided as part of the response to point 4. 

4.  The  alternative support available ,to ward  based  staff and  possible  route 
into  ICU  according  to  the  evidence  given  at inquest was  via  the  Critical 
Care Outreach team. That team is staffed primarily by nurses and  its  key 
focus  is  on  presentation  linked  to  NEWS2  scores  according  to  the 
evidence given to the inquest. Mrs Wadsworth's case was a complex one 
involving issues  relating  to  her liver function  and  kidney function  rather 

 t.•1:kj 
Tameside and Glossop 
Integrated Care 
NHS  Foundation Trust 

4.  The  alternative support available to  ward  based  staff and  possible  route 
into  ICU  according  to  the  evidence  given  at  inquest was  via  the  Critical 
Care Outreach team. That team  is staffed primarily by  nurses and  its  key 
focus  is  on  presentation  linked  to  NEWS2  scores  according  to  thf:! 
evidence given to the inquest. Mrs Wadsworth's case was a complex one 
involving issues  relating  to  her liver function  and  kidney function  rather 
than  just  her  NEWS2  scores  and  it  was  unclear  if  the  Critical  Care 
Outreach Team were best placed to assess her need for ICU support; 

The  Trust has  an  establi§,hed  Critical  Care  Outreach  Team  which  is  cpmprised  of a 
number of highly skilled and experienced critical care nursing colleagues. The service 
is  available  on  a 24  hour,  seven  day a week  basis.  In  addition  to  this the  Trust  also 
implemented a MERIT (Medical Emergency and  Rapid  Intubation Team) team as part 
of its  response  to  the  Covid-19  pandemic.  Although  the  Trust,  like  others  nationally 
have stood  down  many of the  supportive  measures  implemented  in  response  to  the 
pandemic, the organisation has continued with the MERIT Team. The MERIT Team is 
staffed  by  senior  anaesthetic  colleagues,  including  Consultant  level  from  08:30  to 
18:00,  and  from  18:00  to  08:30  this  is  staffed  by  a  middle  grade  anaesthetist.  The 
MERIT  team  is  available  on  a  24  hour  seven  day  per week  service  and  this  is  in 
addition to the medical staff who support the Critical Care Unit who would also provide 
support ( advice and  guidance. At the time of Mrs Wadsworth's admission there were 
no deficits within the staffing of the MERIT team or the Critical care Medical team. 

The Admission and Discharge Policy for Critical Care clearly sets out referral pathways 
for those patients who may require a higher level of care including critical care due to 
their current  clinical  condition.  The  referral  pathway is  in  line  with  national  guidance 
(National Confidential  Enquiry into  Perioperative Deaths- NCEPOD,  The National  In-
stitute for Health and  Care Excellence- NICE,  National Patient Safety Agency-NPSA, 
and  Royal  College Physicians) that the optimal  referral  pathway is consultant to con-
sultant.  However the policy describes that in  more critical  instances where any delay 
may be detrimental to the patient then a referral may come from training grade doctors. 
It is expected that this be  a medical registrar (i.e. the medical middle grade either on-
call or responsible for the patient).  It is  not expected that F1/F2 trainees are to  refer 
directly to Critical Care unless directed to do so whilst the registrar is  in  attendance. 

5.  The inquest heard that on the date of one referral that team was not in any 
event available  to  the  ward  and  the  nurse  who  should  have undertaken 
the  role  had  been  redeployed  elsewhere  in  the  trust  and  there  was  no 
capacity to fill  that role; 

~he  outreach  team  at  Tameside  Hospital  are  a  team  of 7  clinical  practitioners,  the 
service  is  run  on  a 24 hour a day,  7 day per week basis and  this was first  launched 
January 2018.  On  29/12/2022 when nursing staff contacted the Outreach Practitioner 
to  review  Mrs  Wadsworth,  she  had  already  been  reviewed  and  been  seen  by  the 
medical doctor who  had  prescribed Albumin to  be given intravenously. The Outreach 
Practitioner had  advised  the  ward  nurse  that they  could  not attend  so  therefore  the 
nurse correctly re  contacted the ward  doctor to  review Mrs Wadsworth  again  and  for 

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Tameside and Glossop 
Integrated Care 
NHS  Foundation Trust 

the  appropriate  medical  plan  to  be  put  in  place.  At  the  time  of  Mrs  Wadsworth's 
admission the Outreach Practitioner had been allocated to an inpatient area to mitigate 
risk following  a short notice staff absence.  However de.spite this the ward  team  could 
have  also  considered  contacting  the  MERIT team  for  advice  and  guidance  for  Mrs 
Wadsworth. 

There is a Standard  Operating procedure to manage short notice absence from within 
the  outreach  team  which  includes  a  number of proactive  steps to  cover the  shift.  In 
terms of staffing other areas of the Trust there  is  a robust mechanism of oversight of 
staffing  which  takes  place  several  times  per day to  ensure  safe  staffing  across  the 
organisation.  This  is  monitored  at  least  5  times  per  day  during  the  Trust  capacity 
meetings, where operational/ clinical /site and  senior managers attend. 

6.  Following  her  first  admission  to  ICU  there  was  a  note  that  Mrs 
Wadsworth's  case  should  be  discussed  with  a  specialist  Liver  team. 
There  was  no  evidence  available  to  the  inquest  that  such  a  discussion 
had taken place. It was not entirely clear on the evidence precisely which 
clinician was to take ownership of the action. 

The Critical  Care Team  have regular team  huddles during  each  day to  overview and 
discuss  patient's  in  their care.  The  huddles  which  take  place  several  times  per day 
involve  Advanced  Care  Practitioners,  Medical  Staff,  Physiotherapists,  Nurses  and 
support  workers.  The  huddles  involve  diagnostic  tests,  results,  current  condition, 
specialist team involvement and can also include resuscitation status of the patient.  In 
addition to the huddles the medical team also have a formal handover of care between 
shifts, these are recorded  electronically. 

The Trust acknowledge that the clinical documentation recorded within the Critical Unit 
was not clear with regards to who and when Mrs Wadsworth was referred to the Liver 
Unit.  In  response to  this the Critical  Care  Unit have amended their daily review chart 
to  provide  additional  clarity  on  this  point  and  that  this  is  documented  in  a  more 
comprehensive way. 

Medical  Director 
On  behalf of Karen James 
Chief Executive Officer 
Tameside and Glossop Integrated Care NHS Foundation Trust