Christine Dickinson

25th August 2023 

Private and Confidential 
Mr C Morris 
HM Area Coroner 
1 Mount Tabor Street 
Stockport 
Greater Manchester 
SK1 3AG 

Chief Executive 
Oak House  
Stepping Hill Hospital 
Poplar Grove 
Hazel Grove 
Stockport 
SK2 7JE 

Dear Mr Morris 

Re: Inquest into the death of Christine Mary DICKINSON 

Thank  you  for  giving  the  Trust  the  opportunity  to  respond  further  to  the  concerns  you  raised 
regarding documentation practices for staff working in the Laurel Suite. 

I have asked the Division of Medicine & Urgent Care to provide further information.  

You have raised two issues for our consideration which I will respond to in turn. 

1)  During the course on the inquest, the court heard evidence that staff on the Laurel Unit 
previously  used  a  variety  of  systems  (including  one  system  not  routinely  accessible 
by staff elsewhere in the hospital) to record the administration of Chemotherapy.  

As 
  gave  evidence  to  you  during  the  inquest,  documentation  was  previously  solely  on 
paper  which  was  then  scanned  in  to  our  electronic  storage  system,  called  Evolve.  This  process 
changed in 2018 when the team used digital documentation in Advantis CDS. 

The Trust has a range of digital systems to support the delivery of patient care, this is to remove 
the  reliance  of  paper  and  make  patient  data  more  accessible  to  users  (who  all  have  the 
appropriate  access).  Some  clinical  systems  have  a  Trust  wide  use,  and  some  are  specialist 
systems for specific areas of care.  

Within the Laurel Suite, the team currently input clinical details for haematology patients into two 
digital systems. These are AdvantisCDS and iQemo. The team also have access to a range of 
other Trust systems to view additional information regarding their patients.  

The detail of the three systems is noted below: 

The  Advantis  Clinical  Document  System  (AdvantisCDS)  is  the  Trust’s  central  document 
management  system.  Information  is  inputted,  created,  shared  or  viewed  in  this  system  and 
include  the  following  examples  (all  information  created  within  the  system  is  based  on  self-
populated templates for hospital staff to complete): 
-  Real  time  clinical  data  recording  (this  is  used  by  the  Laurel  Suite  as  stated  in  this  particular 
case)  –  At  the  time  Mrs  Dickinson  was  attending,  when  a  patient  attended  Laurel  Suite, the 
nursing  staff  accessed  AdvantisCDS  and  added  in  information  throughout  the  patient’s 
attendance  on  an  open templated  document. When  the  day’s  treatment was  completed,  the 
document was then finalised, closed and published on the day which enabled the information 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to  be  available  to  anyone  with  AdvantisCDS  access.  Laurel  Suite  medical  staff  and 
pharmacists  can  also  add  to  AdvantisCDS  directly.  Toxicity  assessments  are  documented 
within the AdvantisCDS document. 

Other AdvantisCDS documents include: 
-  Clinic outcome letters which are dictated by the medical staff and typed by the secretarial staff 
which are sent to General Practitioners (GPs) and the patient. These letters would include any 
information regarding a patient’s planned treatment and / or any changes in the chemotherapy 
to be delivered. 

-  Referral  letters  which  include  letters  generated  by  Trust  clinicians  for  referral  of  patients  to 
other  Trusts,  scanned  copies  of  GP  referral  letters  and  scanned  copies  from  external 
consultant referrals.   

-  Discharge letters following a patient’s episodes of care.  

iQemo  is  a  specialist  e-prescribing  system  which  provides  an  end-to-end  solution  including 
storage  of  predefined  chemotherapy  regimes,  prescribing,  scheduling  of  drugs,  dispensing,  and 
administration recording. Only a small number of relevant staff have access to this system which 
includes the haematology medical team, Laurel Suite nurses, pharmacists and aseptics staff (staff 
who  make  and  dispense  the  chemotherapy  treatments).  It  should  be  noted  that  it  is  a  national 
requirement,  as  per  the  2013/2014  NHS  standard  Contract  for  Cancer:  Chemotherapy  (Adult) 
Service  specification, 
including  chemotherapy  are 
prescribed using an electronic prescribing system. 
-  The  process  for  managing  patient  care  using  iQemo  is  that  the  doctor  prescribes  the 
necessary regime on iQemo, it is then reviewed by the pharmacist and the aseptics member 
of staff (who will be making up the chemotherapy). The medic then uses the ‘go ahead’ button 
to approve the administration of medication. iQemo is then used by two of the nursing staff to 
electronically ‘sign’ to say that medication has been administered. 

that  Systemic  Anti-Cancer  Therapies 

As  referenced  by 
,  the  staff  in  Laurel  Suite  also  view  patient  information  in  Evolve. 
Evolve is the Trust’s patient record scanning solution which is used to scan any paper records a 
patient  may  have.  In  the  absence  of  an  Electronic  Patient  Record  (EPR)  system,  clinical 
information  written  on  paper  notes  during  an  inpatient  stay  or  outpatient  appointment  is  then 
scanned into Evolve. This information can be viewed by all hospital staff (subject to appropriate 
access).  Additionally,  some  key  documents  from  AdvantisCDS  are  also  sent  into  Evolve  for 
example  a  patient’s  Emergency  Department  attendance,  test  results  or  patient  monitoring 
information. Laurel Suite staff used to record on paper a patient daily care record which was then 
scanned into Evolve. As stated above, this practice ceased in 2018, when the staff move to direct 
electronic recording into Advantis CDS. 

In summary, Laurel Suite staff use two key digital systems to input data for patient care (Evolve is 
a  record  viewing  only  solution).  However,  the  fact  that  a  patient  is  on  chemotherapy,  details  of 
what  treatment  they  have  received  in  the  Laurel  Suite  and  information  with  regards  to  the 
chemotherapy  regime  is  available  in  AdvantisCDS  within  clinic  letters  and  Laurel  Suite 
attendance  records.  This  means  that  should  an  emergency  occur,  the  Emergency  Department 
medical staff or ward staff if a patient was admitted, would be able to access the information they 
would  need  to  make  decision  on  care  and  /  or  be  prompted  to  contact  a  haematologist  on  call 
should that be required for specialist input before a treatment decision would be made.  

2)  Whilst  the  Consultant  Haematologist  told  the  court  the  requirement  to  use  a  single 
method  of  recording  administration  of  Chemotherapy  has  been  reinforced,  in  view  of 
the  above  together  with  the  fact  that  details  pertaining  to  another  patient  entirely 
appear to have been entered into Mrs Dickinson’s record from September 2022, it is a 
matter  of  concern  that  no  recent  audit  has  been  undertaken  in  respect  of  record-
keeping on the Laurel Unit. 

With regards to Mrs Dickinson's record being incorrect on 29/09/2023; this was incident reported 
on 17/04/2023 by Bethany Harrison (Laurel Suite Ward Manager) whilst staff were reviewing Mrs 
Dickinson’s  records  as  part the Morbidity  & Mortality  process.  This  is  our  Datix  incident form ID 
96391. The incident description is: “On reviewing documentation for this patient it was noted on 

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 29/09/2022  the  documentation  on  Advantis  written  by  the  staff  nurse  treating  the  patient  had 
included an entry incorrectly about another patient attending the same day for treatment.” And the 
immediate  action  taken:  “The  importance  of  documentation  and  ensuring  the  right  patient  is 
written  for  in  the  right  notes  has  been  reiterated  to  the  nursing  staff  within  the  team  on  Laurel 
Suite.”  

As 
  informed  you  during  her  evidence  for  your  enquiry,  this  incident  happened  with  a 
member  of  staff  who  was  new  to  the  role  at  that  time  (29/09/2022).  The  team  was  spoken  to 
regarding the recognised error some seven months earlier to which all have reflected upon. The 
Laurel  Suite  Ward  Manager  has  confirmed  that  she  is  not  aware  that  such  an  error  has  been 
identified at any other time and we can confirm that this has been confirmed by searching through 
the Datix incident system. 

Matron 
  has  completed  a  documentation  audit  following  Mrs  Dickinson’s 
inquest. Twenty Laurel Suite patients’ records were randomly selected between March 2023 and 
August  2023.  For  all  twenty  records  there  was:  relevant  documentation  on  AdvantisCDS 
regarding the attendance, no incorrect patient details present and relevant information on iQemo 
relevant to the AdvantisCDS record.  

To further assure you the following actions have also been taken: 
-  A  monthly  record  keeping  audit  will  be  completed  for  Laurel  Suite  documentation  and  the 

results will be reviewed quarterly at the Division of Medicine’s Quality Group meeting. 

-  The  team  will  be  implementing  a  day  case  nursing  admission  documentation  booklet  for 
consistent documentation. This will be a proforma ‘live’ in AdvantisCDS for the nursing staff to 
add  their  information  to  which  includes  a  question  relating  to  any  recent  new  diagnosis  or 
hospital  admission  that  may  influence  the  decision  to  administer  chemotherapy.  This  is 
currently in a pilot phase on paper with the intention to go electronic in the future. Whilst being 
piloted,  at  the  end  of  each  day  the  paper  information  is  scanned  in  to  AdvantisCDS  so  it  is 
available  on  the  day  of administration.  A  copy  of  this template  is  included  with  this  letter for 
your information. 

-  The  team  have  purchased  three  additional  computers  on  wheels  (rather  than  desk  based 
computers) so nurses are able to complete their documentation at the side of a patient rather 
than leaving them to work elsewhere. This allows for more timely contemporaneous recording, 
especially when patients require close observation. 

-  The  Trust  has  established  an  electronic  patient  record  (EPR)  programme  with  the  aim  to 
procure  and  implement  a  single  electronic  patient  solution  to  replace  the  majority  of  the 
Trust’s  clinical  systems. This  programme  is  part of  a  national  NHS digital  initiative to ensure 
all Trusts have implemented such a solution by 2026 and associated funding has been made 
available  to  support  Trusts.  The  Trust  is  working  with  Tameside  Integrated  Care  NHS  Trust 
and the Joint Outline Business Case is currently in the external approval process.  Once final 
approval  has  been  received,  a  formal  joint  procurement  exercise  will  be  launched.  This  is 
anticipated  in  Autumn  2023.  It  should  be  noted  that  the  utilisation  of  iQemo  will  not  be 
replaced under this procurement exercise due to its specialist nature. The consolidation of all 
other core Trust data into one solution will however deliver increased clinical safety benefits. 

Once  again,  I  would  like  to  thank  you  for  providing  me  with  the  opportunity  to  respond  to  your 
queries and provide this additional information. I trust that my response has been helpful to you. If 
there  are  any  areas  where I  could  provide further  clarification,  please  do  not  hesitate  to  contact 
me. 

Yours sincerely 

Chief Executive 

Enc 

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