Geoffrey Brooks

Philip Spinney 
HM Coroner 
County Hall 
Topsham Road 
Exeter 
EX24QD 

26 November 2023 

Dear Mr Spinney 

Regulation 28 response  . 

f1•1:k1 

Royal Devon 
University Healthcare 
NHS Foundation ll'Ust

Royal Devon and Exeter 
Hospital (Wonford) 
Barrack Road 
Exeter 
EX25DW

CHIEF EXECUTIVE'S OFFICE 

I am writing as Interim Chief Executive of Royal Devon University Healthcare NHS Foundation Trust 
in response to your recently issued Regulation 28 Report following the Inquest.touching the death of 
Mr Geoffrey Brooks.  You  asked  me  to  consider reviewing  the  process of discharging  patients  to 
ensure that all  discharge documentation includes an accurate summary of the ongoing care needs 
of the patient. 

Please find my response below and  I .hope that will satisfy you that we have taken steps to prevent 
future deaths of patients.  However,  if you need any further information then please do· not hesitate 
to contact me. 

Current situation 

The Royal Devon University Healthcare NHS Foundation Trust (RDUH) is an organisation focused 
on  providing  patients with  safe,  high  quality medical  care.  One  of the  key aspects  of a  patient's 
hospital journey is their discharge summary and timely transfer of information to primary care and 
other healthcare providers. 

The case leading to this paper was complex and involved a rare medical condition requiring specific 
and closely monitored fluid  balance management. Although there are clear areas for improvement 
and learning, it is also recognised to be a rare set of circumstances that led to this incident. 

The  RDUH  switched  to an  electronic  patient record  (Epic) across  its  Eastern  services  in  October 
2020,  which.  was  after  the  date  of  this  incidE;mt.  This  has  led  to  significant  improvements  in 
documentation  across  inpatient  and  outpatient  encounters.  Epic  has  several  features  that  help 
improve documentation specifically around discharge: 

1.  Hospital course function 

Epic has a section in the sidebar referred to as the Hospital Course. Doctors are encouraged 
to  summarise  a  patient's  admission  in  "real-time"  and  add  to  this.  document during  their 
inpatient stay. This means  at the point of discharge there  is  a summary written  by doctors 
who  have been  involved  with the patient (rather than the traditional  process of reading  the 
notes and compiling a summary). Historically discharge letters have sometimes been written 
by doctors who  have  not  met the  patient which  carries  risk  around  factual  accuracy and 
follow-up instructions. The Hospital Course function mitigates this to a degree. 

 
 
 
 
 The hospital course is automatically pulled into discharge letters when they are generated on 
Epic.  There remains a  separate section  on the discharge  letter for ongoing  primary  care 
instructions ("Suggested Primary care Actions~). 

·  · 

2.  Bespoke templated discharge summaries 

Some areas (e.g. Stroke, Acute Care of the Elderly) have specific templates fo·r completing 
discharge letters which ensures pertinent information and ongoing instructions are as clear 
as possible. This  is important for more cdmplex patient groups who · need to have· specific 
asses.sments and follow-up. 

3.  After Visit Summary 

Epic ha~  introduced the ability to  generate a  patient focused  document for  inpatient and 
outpatient attendances - the After Visit Summary (AVS} which can be given to, patients at the 
point of hospital discharge. To date, the AVS has not been widely·rolled out. particularly after 
inpatient stays. 

A working group, has been established and will shortly begin meeting to review the use of the 
AVS across inpatient and outpatient areas across the Trust.  Once completed, the group will 
produce new guidance and Standard Operating Procedures (SOPs)forward teams, meaning 
the· AVS would be given to the patient and the discharge summary sent electronically to the 
GP as a  matter of routine.  It clearly lays out medication changes, foUowaup  arrangements 
and  can  be  used  to  provide  patient's  with  specific  instructions.  In  this  case,  clear 
documentation of fluid intake requirements could have been flagged in this document. 

4.  Education around discharge 

Junior doctors receive induction and complete training in Epic which includes the discharge 
process and completion of discharge letters. Departmental induction also e11COmpasses local 
information on discharge letter fonnulation. 

5 

Enhanced ward staffing consistency 
Within Medicine, our staffing model was changed  recently so that junior doctors in training 
have switched to a  4-day working week.  Previously.  compensatory rest meant that juniors 
were ofte_n moved from their base wards to cover rota gaps; this led to a loss of consistency 
in  medical staffing which is a  risk to discharge  letter writing as discussed above.. The new 
rota pattern means the need for cross cover is greatly reduced. 

Other considerations 
The Trust  has considered whether every discharge letter should be reviewed  by a  consultant.  On 
balance, this would not seem feasible due to: 

•  Volume and time requirement (to go through a long admission takes a significant amount of 

time resource) 

•  Difficult to define who should review (multiple consultants may have looked after a  patient 

during a  long inpatient stay} 

•  Potential additional time delay in sending out discharge summary information to primary care 
(or alternatively sending  out addendums which would  mean different discharge  letters  in 
circulation for the same admission which carries risk) 
•  Risk of mistakes due to a false sense of reassurance 

Certain  areas  have bespoke arrangements in  place.  Fm example, all generated  discharge letters 
from the stroke unit (Clyst ward) are flagged to a stroke consultant for review to ensure all relevant 
follow-up is actioned. This is noted to be a very time-consuming process. 
Epic allows a  clinician to keep a  list of patients for follow-up so offers individuals an option to keep 
track of patients which  is useful in complicated cases where a  consultant may want to ensure  a 
dis.charge letter contains specific inforrriation or instructions. 

 Future developments 

We are currently reviewing the staffing model of our community hospitals which we hope will lead to 
a  more robust,  consistent medical  team  with  specialty  doctor and  Advanced  Clinical  Practitioner 
oversight. This win provide an additional safety-net around discharge and again letters will be more 
likely to be written and checked by individuals who have reliably been involved in a patient's care. 

The Trust wide  discharge summary working group will  be shortly relaunched  with  a  plan  to  have 
primary care representation  to try and further refine discharge processes and  communication with 
primary  care.  There  is  potential  to  develop  more  discharge. summary  templates  for  specific 
specialties or conditions.  We are continually working on improving the completion rates of discharge 
summaries and ensuring they are sent in accordance with the NHS Standard Contract agreement of 
within 24 hours following inpatient, day case or ED attendance. 

The Trust is currently transitioning  to the  Patient Safety Incident Response  Framework which will 
guide future investigations into patient safety incidents. This process involved detailed retrospective 
analysis  of  117,000  events  which  were  thematically  reviewed  to  identify  key  areas  for  future 
investigations.  One of the thr~e main themes was discharge from  hospital;  this will  be a focus for 
future investigations due to the significant potential for systemic learning and improvement.  Future 
learning will help guide further refinement of our discharge processes. Learning will be disseminated 
through relevant forums, teaching sessions and training packages. 

At a system level, there is a wider piece of work looking at the expected standards of communication 
between primary and secondary care (One Devon Primary and Secondary Care Interface document 
- in draft currently). When launched, there is a plan for engagement and regular dialogue between 
services to ensure adherence and to target areas for improvement. 

I  hope that the above  information  is  helpful  and  do  let  me know if I can assist you  with  anything 
further. 

Yours sincerely 

CHIEF EXECUTIVE OFFICER (Interim) 

.