Colin Greenway

25 September 2023 

Yvonne K Blake 
Area Coroner for Norfolk 
County Hall 
Martineau Lane 
Norwich 
NR1 2DH 

Dear Ms Blake 

The Queen Elizabeth Hospital 
Gayton Road 
Kings Lynn 
Norfolk 
PE30 4ET 

www.qehkl.nhs.uk  

Colin Greenway – Trust’s Response to Regulation 28 

We write further to the Report for the Prevention of Future Deaths made under paragraph 7, 
Schedule  5,  of  the  Coroners  and  Justice  Act  2009  and regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013, dated 18 July 2023. 

We will respond to each of Ms Blake’s areas of concern in turn and set out the actions being 
taken in response, as follows: 

1.  Junior doctors incorrect prescribing despite clear guidelines. 

We  have  reviewed  Mr  Greenway’s  medical  records  and  confirm  that  the  junior  doctor  who 
clerked him on admission prescribed the incorrect dose of thromboprophylaxis. They noted his 
kidney  function  was  impaired  and  prescribed  a  renal  dose,  which  is  lower  than  the  standard 
dose on account of this medication being potentially dangerous to patients with kidney injury 
and/or failure. The junior doctor having left the Trust and since the hearing has been in contact 
to  say  that  she  prescribed  the  renal  dose  anticipating  that  renal  function  might  deteriorate 
further.  However,  to  be  in  strict  compliance  with  the  Trust’s  Prevention  of  Venous 
Thromboembolism  (VTE)  Guidelines  in  place  at  the  time  Mr  Greenway  should  have  been 
prescribed the standard dose. Our local Guidelines relating to VTE are under review, and this is 
due to be taken to the next Drug and Therapeutics Committee Meeting for ratification on 31 
October 2023, before being referred on to our Clinical Effectiveness Executive Group for final 
approval. In the meantime, these local guidelines have been removed from the Trust’s intranet 
and replaced with a link to the appropriate NICE guidance for VTE Adults.  

We recognise the importance  of  standardising  the prescription  of thromboprophylaxis  across 
our  Integrated  Care  Service,  particularly  because  junior  doctors  regularly  complete  training 
placements  in  more  than  one  Trust  across  the  group.  We  are  therefore  consulting  with  our 
colleagues at the other acute Trusts within the Norfolk and Waveney Integrated Care System 
(ICS) and also with our Integrated Care Board to see how we can better regulate this.  

 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 26 September 2023 

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 

We  have  reiterated the  importance  of  accurate  VTE  risk  assessment  and  thromboprophylaxis 
prescription (medication to prevent clot formation) via Trust-wide communications. We are also 
reviewing our induction materials to ensure these issues are given appropriate emphasis. VTE is 
part of our mandatory training, and our Anticoagulation team have produced a booklet which 
has been distributed to our junior doctors. We are looking into making this available via a QR 
Code, to improve accessibility. 

2.  VTE  assessments  not  being  completed  on  clerking  a  patient  just  on  the  electronic 

medicines prescription which is much less detailed. 

Currently we have VTE risk assessments within our Clerking Documents, and also on ePMA, our 
Electronic Prescribing and Medicines Administration which is an electronic system designed to 
mostly replace paper drug charts. The purpose of these risk assessments is to identify potential 
risk  factors  for  patients  who  may  be  at  risk  of  VTE,  and  to  identify  any  contra-indications  to 
thromboprophylaxis. This is required because there are patients who will be at a higher risk of 
VTE, and those for whom thromboprophylaxis may not be suitable, such as those with a risk of 
bleeding.  The  ePMA  risk  assessment  must  be  completed 
to  prescribe 
thromboprophylaxis on the Trust’s ePMA system.  

in  order 

When Mr Greenway was admitted, the VTE risk assessment was completed on ePMA, but not 
on  the  paper  Clerking  Document.  As  noted  at  the  hearing,  the  risk  assessment  in  the  Trust’s 
paper  Clerking  Document  is  more  detailed  than  the  version  on  ePMA,  however  the  eMPA 
version is fully compliant with NICE guidance.  

In consequence, we are removing the VTE risk assessment within the Clerking Documents, so 
that this must be completed on ePMA only. Following feedback from our clinicians, we have 
made the decision to retain the guidance on VTE risk factors and contraindications within the 
Clerking Documents.  This is because our clinicians advised that they found this very helpful as 
a reference, and it includes more examples than the guidance on the ePMA risk assessments and 
is based on the Department of Health advice. When our Clerking Documents are revised and 
reprinted next, they  will  contain  a  check  box for  the  Consultant  to confirm  that  the  VTE  risk 
assessment  has  been  completed,  and  the  dosage  checked.  In  the  meantime,  we  have 
commissioned  stickers  to  add  these  checks  to  the  Clerking  Documents,  and  these  have  been 
circulated to the ward clerks to be added to the existing stock of Clerking Documents. 

3.  Consultants stating it is the pharmacists’ job to check for errors when there is only a 3 
day service by pharmacists to do this and it is intended as a safety net procedure only. 

Medicines Reconciliation should be carried out within 24 hours of admission to an acute Trust, 
in accordance with NICE guidance. Although this is not a service which is carried out exclusively 
by Pharmacists, was previously a daily service provided by the Trust’s pharmacists. 

Although  the  focus  of  the  Coroner’s  concern  related  to  the  Consultant’s  perceived  lack  of 
ownership,  it  is  important  to  set  out  the  wider  context  in  order  to  clarify  how  this  can  be 
resolved. Against a background of local and national Pharmacy staffing shortages, the Trust had 
reduced its ward pharmacy service including effective medicines reconciliation on admission and 
clinical medicines support for the medical teams by the Trust’s pharmacists, meaning that this 
was not taking place at weekends during Mr Greenway’s admission. The shortage of pharmacists 
has been identified as an area of risk, and is included on the Trust’s Risk Register. 

 
 
 
 
 
 
 
 
 
 26 September 2023 

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 

There  have  been  a  number  of  challenges  to  successful  recruitment  and  retention  within  the 
Trust’s  Pharmacy  team,  which  is  currently  being  mitigated  by  the  employment  of  10  agency 
Pharmacists, to ensure compliance with checking of inpatient prescriptions and medications to 
be taken with the patient on discharge. To mitigate the challenges of employment within the 
Trust’s  local  area,  the  Trust  is  looking  to  recruit  5  Pharmacists  from  inside  the  European 
Economic Area. It is hoped this  recruitment, together with the provision of opportunities for 
career growth to the EEA Pharmacists, will encourage their settlement within the King’s Lynn 
area and allow for greater security for the Trust in a mutually rewarding arrangement.  

In the longer-term, the Trust believes a focus on education is required to improve its ability to 
attract  quality  candidates  and  further  improve  retention.  The  Trust  is  looking  to  increase  its 
available trainee undergraduate placements at the earliest opportunity, as well as offering one 
or more apprenticeships in the field. The Trust is to recruit a dedicated Education team within 
the Pharmacy group, to focus on education activities and ongoing training.  

With respect to consultant responsibility for Medicines Reconciliation, we confirm that senior 
doctors  should  be  taking  responsibility  for  their  patients’  medications,  and  for  oversight  of 
prescribing and other decisions made by junior doctors working within their team, in line with 
GMC Guidance and our own Trust values. 

4.  Consultants  not  accepting  that  it  is  their  responsibility  to  monitor  what  their  junior 

doctors are doing when prescribing new medications for patients. 

As above, we confirm that is it the expectation of the Trust that consultants accept responsibility 
for the junior doctors within their team in line with GMC Guidance and Trust values. This relates 
to prescribing new medications for patients and also for other decisions made or advice given 
by the junior doctors.  

With  respect  to  the  prescription  of  thromboprophylaxis,  as  above  we  will  be  updating  our 
Clerking Documents to include a specific check box for consultants to prompt confirmation that 
they  have  checked  the  VTE  risk  assessment  has  been  completed,  and  they  have  checked  the 
dosage prescribed. 

The  Trust  is  working  to  reduce  the  level  of  locum  consultant  cover  and  foster  better  patient 
ownership with a more substantive workforce.  

The  concerns  raised in  the  Regulation  28  report  were  disseminated to  all  Consultants  by  our 
Interim Medical Director as points to note for their own practice, and that of their colleagues. 
This case was also presented at the Acute Medicine Mortality Meeting, where it was emphasised 
that lack of ownership is against our Trust values and GMC Guidance, and this is within expected 
practice for our consultants. 

5.  Three different consultants seeing the same patient over three days, no continuity of 

care. 

Although we would very much wish for every patient to be able to have the same consultant 
for  the  entirety  of  their  admission,  this  is  not  currently  within  our  ability  to  provide  due  to 
pressures  within  the  NHS  leading  to  staffing  shortages  across  all  levels  and  working  time 
requirements. A shortage of substantive consultants affects our ability to assign consultants to 
the same area for an extended period of time. However, we will focus on effective handover of 
care between consultants and improving communication.  

 
 
 
 
 
 
 
 
 
 26 September 2023 

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust 

6.  Patients at higher risk of an embolus not being monitored correctly or at all after initial 

clerking. 

We would expect that VTE risk assessments and thromboprophylaxis should be reviewed within 
24 hours of admission or whenever the clinical situation changes, in accordance with the Trust’s 
VTE guidance as included in the Clerking Document. This review is to be recorded on ePMA.  

The Coroner expressed particular concern that Mr Greenway’s fluid balance charts had not been 
fully completed, and that considering his known dehydration, this would have greatly assisted 
us in making an accurate assessment of his VTE risk. We know that completion of fluid balance 
charts  is  a  nationwide  issue,  and there  are  particular  difficulties  with  this  across  Norfolk  and 
Waveney  because  fluid  balance,  observations and prescriptions run across  multiple  electronic 
and paper systems. The Trust has recently completed a joint procurement exercise in conjunction 
with Norfolk and Norwich University Hospitals NHS Foundation Trust and James Paget University 
Hospitals  NHS  Foundation  Trust  to  agree  a  supplier  for  an  Electronic  Patient  Record  System 
which will be in place across all three Acute Trusts within the ICS. This EPR will streamline our 
processes with respect to patient monitoring, including Fluid Balance Charts, and is estimated 
to  be  in  place  by  2025.  Engaging  in  a  joint  exercise  across  the  ICS  will  mitigate  the  risk  of 
processes differing across neighbouring Trusts, and we consider that ensuring that practices are 
aligned across the region will particularly help junior doctors as they rotate through placements. 

In the meantime, we continue to audit compliance with patient monitoring and the completion 
of  documentation.  Fluid  Balance  Charts  are  included  within  Tendable©  audits  which  are 
completed on a monthly basis, together with other patient documentation. 

In  addition,  we  have  recently  designed  and  implemented  the  Trust’s  Patient  Safety  Incident 
Response Plan under the new NHS Patient Safety Incident Response Framework (PSIRF). As part 
of this Plan, we are required to identify three areas of focus which will receive multi-disciplinary 
input over the coming year to identify potential improvements which can be implemented to 
improve patient safety in this area. PSIRF provides a framework for Trusts to put in place a Plan 
tailored to patient safety issues identified within that Trust, with a view to preventing similar 
incidents  before  they  occur.  This  is  a  more  preventative  process  than  the  previous  Serious 
Incident Framework, which reacted to patient safety incidents. I confirm the Trust has identified 
VTE as one of its areas of focus for its 2023/24 Patient Safety Incident Response Plan, and we 
believe this will allow us to drive improvement in this area across the Trust. 

I would be happy to provide you with further information if required. 

Yours sincerely 

Medical Director