Carole McQuinn

Date:       29th September 2023  

Ms Catherine Cundy 
Area Coroner for North Yorkshire and York 

By e-mail only to: 

Trust Headquarters 
St James’s University Hospital 
Beckett Street 
LEEDS  
LS9 7TF 

Dear Ms Cundy 

I write in response to the Report to Prevent Future Deaths dated 19th July 2023 sent by you to 
Leeds  Teaching  Hospitals  NHS  Trust  following  your  investigation  into  the  death  of  Carole 
McQuinn and the inquest that concluded on 11th July 2023. 

The  Regulation  28  Report  has  been  shared  with  relevant  staff  in  the  Trust  and  this  response 
provides details of action taken by the organisation in relation to the concerns set out in it.  

In your report the matters of concern are set out as follows: 

1.  The  deceased  was  discharged  from  hospital  on  the  evening  of  20th  April  2022  with  no 
discharge  note,  medications  or  follow-up  appointment.  There  was  evidence  that  evening 
discharges are a cause for concern for the Trust and that while consideration is being given 
to ensuring follow-up appointments are set on discharge, this is not yet in place.  Trust staff 
were falsely reassured in this case that the deceased had this safety net in place when she 
did not.  

2.  Trust  staff  interacting  with  the  deceased  and  her  daughter  regarding  infection  concerns 
arising  in  the  post-discharge  period  between  21/4/22  and  3/5/22  made  no  records  of  the 
same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma 
bags and a swab to her daughter for suspected infection, but did not flag this development to 
the  treating  team  or  make  arrangements  for  the  results  of  the  swab  to  be  reviewed.  No 
clinical  observations  of  the  deceased  were  recorded  when  she  attended  the  hospital  on 
3/5/22.  The  swab  result  did  not  come  to  anyone's  attention  or  get  reviewed  until  the 
deceased's  daughter  flagged  the  issue  to  staff  on  3/5/22.  These  omissions  led  to  missed 
opportunities for earlier assessment and treatment of the deceased.  

3.  The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-
abdominal  sepsis.  A  York  doctor  was  verbally  tasked  with  communicating  with the  surgical 
team at Leeds to report back on a comparison of CT scans from both hospitals. No record of 
this contact - which was verbally reported in positive terms - was made by either hospital and 
no evidence could be provided as to who had spoken to whom and in what terms. Further, 
despite the lengthy and complex treatment the deceased had undergone in Leeds, and her 

The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre 

 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 attendance  there  the  day  prior  to  admission  to  York,  no  contact  was  made  by  the  treating 
team at York with the treating team at Leeds, to allow for additional specialist input into the 
deceased's management and consideration of possible transfer of care. 

Having considered your concerns carefully our response is set out below. 

1.  The Trust regrets the deceased’s discharge from hospital on 20th April 2022 in the evening 
and without a copy of her discharge note, the medication that had been prescribed for her 
and a date for her outpatient follow-up.  

The  process  for  discharging  patients  from  in-patient  wards  is  complex.    Planning  for 
discharge starts before the in-patient admission and usually involves a number of different 
teams,  including  pharmacy  who  will  only  dispense  medication  on  the  day  of  discharge  to 
ensure  that  accurate  and  up  to  date  information  about  the  patient’s  requirements  is 
available.    There  may  also  be  a  need to liaise  with  community  services  such  as  the  local 
district nursing team in addition to the GP, to confirm that support is in place for the patient 
at home.  Even though that was not part of the discharge process in this case, the workload 
for the discharge coordinator on any given day may be considerable and it can impact on 
the timing of patients being ready to leave the ward.  

In  this  case,  as  was  clear  from  the  written  evidence  provided  by  the  Trust,  a  nurse  had 
discussed the discharge plan with the deceased before she left hospital.  In accordance with 
her  usual  practice  the  nurse  would  have  explained  steps  the  deceased  should  take  if  she 
became  unwell  or  had  concerns  about  her  progress,  and  what  to  do  if  her  drain  site  or 
surgical  wound  leaked  fluid.  The  nurse  would  also  have  explained  that  the  deceased’s 
medication would be available for collection from the ward the following day.    

Following  the  death  and  in the  course  of  preparations  for  the  inquest  the  circumstances  of 
the deceased’s discharge and usual discharging practice within the Abdominal Medicine and 
Surgery  Clinical  Service  Unit  (AMS  CSU)  were  reviewed.    As  explained  at  the  hearing  the 
review highlighted the need for improvements.  The pancreatic team acknowledged that all 
patients should have booked outpatient appointments on leaving the ward and that those in 
the  deceased’s  position  should  receive  specific  written  guidance  on  wound  care,  including 
management  of  drain  sites  where  abdominal  drains  have  been  removed  recently.    In 
addition, the team accepted that patients should be provided with more specific information 
about  support  available  to  them  after  discharge,  including  explanation  of  the  role  of  the 
Clinical Nurse Specialists.  They should also be given contact details for those members of 
staff. 

Since  this  review  all  staff  involved  in  the  discharge  process  have  been  informed  of  the 
team’s  requirements,  including  providing  patients  with  (a)  a  paper  copy  of  their  discharge 
note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of 
outpatient  follow-up  appointments,  (c)  wound  care  plans,  (d)  supplies  of  medication, 
dressings  etc.    They  have  been  reminded  of  their  responsibility  for  making  appropriate 
arrangements  for  community  resources  such  as  district  nursing  and  the  need  for  clear 
instructions  about  repeat  prescriptions  in the  discharge  summary.    The  document  template 
for the electronic discharge note (EDAN) has also been amended to ensure that all relevant 
information and advice is included and can be reviewed by patients, their relatives and their 
GPs.  

The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre 

 
 
    
 
 
  
 
 
 
 
 I can confirm that all patients discharged from inpatient treatment in the AMS CSU now go 
home  with  an  EDAN  and  details  of  booked  outpatient  appointments.    There  will  be  regular 
audit  of  records  by  the  CSU’s  quality  team  to  ensure  that  this  is  being  done  consistently.  
Patients  with  drains  and  those  whose  drains  have  been  removed  recently  now  receive 
written guidance on management of any appliances, associated drain sites and their surgical 
wounds.  A document summarising the process to be followed by staff is attached for your 
reference  (attachment  1).    Use  of  this  drain  pathway  will  be  audited  quarterly  to  ensure 
compliance. 

Following the hearing and in response to your report the CSU has reviewed the steps taken 
to  improve  discharging  practice  and  it  has  drafted  Good  Practice  Guidance  for  the 
completion  of  discharge  advice  notes  by  registered  nurses  (please  see  attachment  2).  
Dissemination of this guidance, with training for staff, will be complete by the end of October 
2023.  Support to embed good practice will also be provided by the CSU quality practitioners 
and  the  clinical  education  team  by  the  end  of  November  2023.    The  guidance  has  already 
been discussed with the nursing staff at the CSU Perfect Ward meeting (where all matrons 
and  ward  sisters  meet  each  month  to  review  all  quality  indicators  and  incidents  within  the 
CSU) and ward sisters are now sharing it with their staff in each ward area.   

The  Trust  recognises the  difficulties that  can  arise when  patients  leave hospital  late  on  the 
day  of  discharge  and  it  is  committed  to  improving  discharging  practice  throughout  the 
organisation.    A  Quality  Improvement  collaborative  led  by  a  specialist  quality  improvement 
practitioner is in place to support wards to achieve the majority of discharges before 3pm. By 
using  data  and  metrics  the  Trust  can  track  all  wards’  progress  towards  this  target  each 
month  and  it  can  also  check  that  EDANs  have  been  sent  with  patients  at  the  point  of 
discharge.  AMS CSU is part of this collaborative and it will continue to work to improve its 
practice. 

2.  Deficiencies  in  the  recording  of  contacts  with  the  deceased  and  her  daughter  after  her 
discharge  are  acknowledged.    The  Trust  also  accepts  that  action  taken  in  response  to 
concerns  raised  by  the  deceased’s  daughter  was  inadequate  and  that  this  led  to  missed 
opportunities for earlier assessment and treatment.  

The  problems  that  arose  in  this  case  have  been  discussed  at  ward  meetings.    Staff  have 
been instructed that all contact with recently discharged patients and their relatives must be 
recorded  on  the  Trust’s  electronic  case  record  system  PPM+  for  the  first  7  days  after 
discharge  at  least.  Notes  made  must  include  details  of  advice  given,  any  investigations 
undertaken  or  arranged  and  the  clinicians  involved.    Staff  have  also  been  informed  that 
requests  for  advice  or  review  should  be  forwarded  to the  outpatient  team  to  facilitate  early 
face  to  face  assessment,  coordination  of  any  additional  investigations,  formal  review  of 
results  and  appropriate  communication  with  the  patient  and  family  members  afterwards.  It 
has been made clear that swabs should not be given to relatives for patients to use at home 
and  that  there  should  be  a  low  threshold  for  requesting  face  to  face  review  of  patients 
reporting problems. 

3.  As  explained  in  the  evidence  for  the  inquest  the  Trust  has  no  record  of  contact  made  by 
clinicians from York Hospital about the deceased’s admission there on Wednesday 4/5/22 or 
on  Thursday  5/5/22  and  no  member  of  the  surgical  team  recalls  a  discussion  about  the 
deceased with anyone in York on either day.   

The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre 

 
 
    
 
 
 
 
 
  
 
 It  is  accepted  that  communication  between  York  Hospital  and the  Trust  should  have  taken 
place.   Clinical staff within the AMS CSU should have been informed of the admission and 
details  of  the  deceased’s  condition  should  have  been  given  to  the  pancreatic  team, 
preferably  by  way  of  discussion  between  consultants.    Recent  imaging  should  also  have 
been  transferred  to  the  Trust.      If  contact  was  made  with  a  junior  member  of  the  surgical 
team, there should have been senior review of the information provided and comparison of 
the recent imaging with that obtained previously in Leeds.   Details should have been noted 
in the deceased’s electronic patient record. 

Since this death the AMS CSU has started to use new IT software (Patient Pass) to improve 
coordination and recording of requests for information and advice.  Patient Pass is a two-way 
messaging  tool  that  is  used  to  facilitate  referrals  and  improve  communication  between 
hospitals and specialist departments. It is relied on by a number of specialist teams in LTHT 
to speed up referrals and support clinical process reliability.  It improves record keeping as 
details of referrals and responses are automatically saved onto patients’ PPM+ records and 
it also provides the organisation with a full audit trail for information governance purposes. 

As  the  Trust  provides  a  regional  referral,  advice  and  guidance  service  for  patients  with 
pancreatic  problems,  requests  for  information  and  advice  from  neighbouring  trusts  are 
common.  Awareness  of  referral  pathways  is  generally  good,  including  the  option  of 
telephone  access  to  the  consultant  on  duty  during  working  hours  and  more  recently  the 
CSU’s  use  of  the  online  referral  tool  Patient  Pass,  described  above.    All  members  of  the 
pancreatic  team  are  used  to  receiving  telephone  calls  and/or  written  referrals  to  the  Multi-
Disciplinary  Team  and  they  understand  the  need  to  ensure  that  the  pancreas-specific 
Advanced  Care  Practitioners  and/or  the  consultant  on  duty  on  any  given  day  are  notified 
promptly.   

As explained by the witnesses at the hearing, if contact had been made with any member of 
the  Trust’s  pancreatic  surgery  team  about  the  deceased,  senior  review  would  have  been 
expected, leading to specialist input into her management thereafter and consideration of the 
need for her transfer to Leeds.  

Since  the  death,  and  in  response  to  your  report,  senior  members  of  the  team  have  made 
contact with colleagues in the surgical team in York to explain the arrangements in place and 
to  discuss  the  issues  raised  by  this  case  so  that  both  trusts  can  work  together  to  avoid 
similar problems arising in the future. 

Thank you for bringing these issues to my attention. I hope that this response provides 
confidence that the Trust has considered and addressed them appropriately. 

If I can be of any further assistance, please do not hesitate to contact me. 

Yours sincerely 

Chief Medical Officer 

The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre 

 
 
    
 
 
 
 
 
 
 
 
 Encs: 
AMS - Best Practice Guidance - Think Drains 
Good Practice Guidance for the completion of discharge advice notes by registered nurses 

The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre

Medical Governance 
The York Hospital 
Wigginton Road 
YORK 
YO31 8HE 

6 September 2023 

Catherine Cundy 
Area Coroner for North Yorkshire & York  

Dear Ms Cundy 

Regulation 28 Report to Prevent Future Deaths – Carole McQUINN 

Further to your report dated 19 July 2023 I note that, in respect of this Trust, your concerns 
relate to the lack of documented evidence for discussions between the clinical team at this 
Trust and colleagues at St James’ University Hospital Leeds when Ms McQuinn was admitted 
to York Hospital on 4 May 2022.   

I can confirm that this matter has been discussed at length within our Quality & Safety 
meeting where attendees include senior medical, nursing and operational leaders.  We share 
your concerns and would like to firstly reassure you that we fully recognise the importance of 
clear and accurate contemporaneous record keeping which is a fundamental element of good 
patient care.  

On review of this matter it became apparent that the Trust’s clinical record-keeping guidance 
was out of date.  This was already on the work plan to be updated and will now be expedited. 
Once the guidance is finalised it will be shared with all clinical staff.  

The following action plan has therefore been initiated: 

 
 
 
 
 
 
 
                                                                                                      
 
                                                                                                               
 
 
 
 
 
 
 
 
 
 
 
 
 
 Number  Recommendation 

Action 

Lead 

1 

2 

3 

Raise awareness 
amongst all clinicians of 
the need to document 
discussions and 
communications between 
clinicians within and 
external to the Trust 
Ensure Trust policy and 
guidance is clear on 
requirements for clinical 
record keeping 

Raise awareness of this 
case amongst surgical 
colleagues to stress the 
importance of recording 
communications  

Patient Safety 
Briefing to be 
drafted and sent 
to all staff 

Patient 
Safety Lead 

Review and 
update of Trust 
guidance on 
clinical record 
keeping 
Case is presented 
at Surgical Clinical 
Governance 
meeting 

Head of 
Information 
Governance 

Consultant 
Surgeon 

Completion 
Date 
September 
2023 

Evidence 
Required 

Copy of briefing 

February 2024 

Policy/guidance 
published and 
awareness raised 

October 2023 

Minutes of meeting 

We would be happy to share further information and evidence of implementation of the action 
plan in due course, if this would assist.  

I do hope that this letter reassures you that we have given this matter serious consideration 
and that the steps proposed are adequate to reduce the risk of any similar incidents.  

Yours sincerely 

Medical Director & Responsible Officer 

2