Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0549, written 29 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Dec 2023 |
|---|---|
| Reference | 2023-0549 |
| Deceased | Andrew Guillaume |
| Coroner | Deborah Lakin |
| Coroner area | Coventry and Warwickshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South Warwickshire University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. , Chief Medical Officer, South Warwickshire University NHS Foundation Trust , Chief Executive of South Warwickshire University NHS Foundation Trust 3. Secretary of State for Health, Department of Health 4. NHS 1 CORONER I am Deborah Rachel Lakin, assistant coroner, for the coroner area of Coventry and Warwickshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 6 July 2023 I commenced an investigation into the death of Andrew Douglas Guillaume, aged 51. The investigation concluded at the end of the inquest on 29 December 2023. The conclusion of the inquest was a narrative verdict. 4 CIRCUMSTANCES OF THE DEATH 1. Mr Guillaume was admitted to Warwick Hospital on 5 June 2023, having presented himself to his GP with shortness of breath and a cough. 2. Following a review on 7 June 2023, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team, to be followed by a multi-disciplinary meeting with UHCW. 3. No Consultant to Consultant referral was made as the Consultant was unable to get through to the switchboard at UHCW. 4. Mr Guillaume remained at Warwick Hospital. 5. Mr Guillaume’s condition worsened and on 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite the surgery required but the Consultant was unable to get through to the switchboard at UHCW. 6. Mr Guillaume was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 The MATTERS OF CONCERN are as follows. – (1) The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions. (2) A previous incident in which a similar concern had been raised, had led to provision of an emergency GP phone number, that can be used by the clinical teams at SWFT, which is manned 24 hours a day and is prioritised over other calls. The Cardiology team had not been aware of this, nor did they have the telephone number. (3) Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023, as the referral had not been completed. (4) Had the referral been completed, the team at UHCW could have prioritised the patient’s transfer. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 February 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: – brother and sister-in-law of the deceased I have also sent it to Chief Executive, University Hospital Coventry and Warwickshire, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 29 December 2023 Deborah R Lakin 2
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From the Rt Hon Andrew Stephenson CBE MP Minister of State for Health and Secondary Care Department of Health and Social Care 39 Victoria Street London SW1H 0EU HM Coroner Deborah Lakin Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL 13 May 2024 Dear Ms Lakin, Thank you for the Regulation 28 report to prevent future deaths of 29 December 2023 about the death of Andrew Douglas Guillaume. I am replying as Minister with responsibility for secondary care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Guillaume’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. The report raises concerns about communication in relation to referrals for patient transfer between the Trusts mentioned in your report, and the consequences of that poor communication in the case of Mr Guillaume. The matters of concern raised are primarily for the Trusts to address, and I note both the South Warwickshire University NHS Foundation Trust (SWFT) and the University Hospitals Coventry and Warwickshire NHS Trust (UHCW) have addressed your concerns in detail in their responses. Local collaborations and working options are being explored to develop long term technological solution and short-term measures so this does not happen again. Several recommendations and actions have also been completed by the SWFT which address your concerns directly. I also note that NHS England has replied and are sighted on the issues you raised. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE
Deborah Rachel Lakin
Assistant Coroner Coventry & Warwickshire
Warwickshire Justice Centre
Newbold Terrace
Leamington Spa
CV32 4EL
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
23 February 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Andrew Douglas
Guillaume who died on 20 June 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29
December 2023 concerning the death of Andrew Douglas Guillaume on 29 December
2023. In advance of responding to the specific concerns raised in your Report, I would
like to express my deep condolences to Andrew’s family and loved ones. NHS England
are keen to assure the family and the coroner that the concerns raised about Andrew’s
care have been listened to and reflected upon.
The matters of concern raised in your Report predominantly fall under the remit of the
relevant Trusts, South Warwickshire University NHS Foundation Trust (SWFT) and
University Hospitals Coventry and Warwickshire NHS Trust (UHCW). I note that you
have addressed your Report to SWFT, but you may also wish to address your
concerns to UHCW.
NHS England has already been sighted on SWFT’s Root Cause Analysis Investigation
Report, which we understand has been shared with the coroner and Andrew’s family.
We note that lessons have been learned around communication, documentation and
the problems encountered by SWFT in contacting UHCW. We welcome the report’s
action plan which, in addition to the joint review references above, includes a review
of UHCW referral mechanisms and circulation of a Trust-wide Safety Practice Alert
with the priority telephone number for UHCW referrals. NHS England has also asked
to be sighted on the Trust’s response to your Regulation 28 report so that we can, in
addition, give it due consideration.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are 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 for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Chief Executive
Warwick Hospital
Lakin Road
Warwick
CV34 5BW
PRIVATE AND CONFIDENTIAL
21 February 2024
Mrs Deborah R Lakin
Assistant Coroner for the Coventry and Warwickshire Area
The Coroner’s Office
Warwickshire Justice Centre
Newbold Terrace
Leamington Spa
Warwickshire
CV32 4EL
Dear Mrs Lakin
Regulation 28 report – Mr Andrew Douglas Guillaume
DoB 09/07/1971
DoD 20/06/2023
Thank you for your Regulation 28 report dated 29 December 2023 relating to the inquest of
Mr Andrew Guillaume. I was sorry to read of your outstanding concerns at the conclusion of
the inquest and hope that the following information will provide both you and Mr Guillaume’s
family with further assurance of how seriously this matter is being taken by both NHS
organisations involved in caring for Mr Guillaume.
Following receipt of your Regulation 28 Report, the Trust arranged a meeting between senior
staff and managers from UHCW and SWFT who it was felt could contribute to the points you
raised. Attendees at the meeting included SWFT’s Chief Nursing Officer, Associate Chief
Medical Officer for Governance, Consultants and General Managers for relevant specialities
and UHCW’s Group Director of Nursing, Associate Director of Nursing, Quality and Patient
Safety Lead, and Deputy Chief Medical Officers. The Group discussed a number of issues
highlighted by Mr Guillaume’s case and also carefully considered the adequacy of the actions
that had been jointly identified by the two organisations as part of the Serious Incident
investigation that was referred to at the inquest.
Details of the actions that had previously been agreed, and about which evidence was heard
at the inquest, are set out below. These have been updated where appropriate, in particular,
to reflect that the one action outstanding at the time of the inquest – that the learning be
shared at the SWFT Grand Round meeting for medical staff – was completed in January.
The Trust is committed to being environmentally friendly, therefore where possible we use 100%
recycled paper. This paper has been made using no harmful chemicals in the manufacturing
process.
In addition to the work that had been carried out in response to the Serious incident (SI)
Review, the meeting identified work streams/ themes which will be progressed by the two
organisations. These include both short and longer term work to improve communications
between SWFT and UHCW. Although many of these are still a work in progress I will,
obviously, be happy to keep you updated.
To address your concerns as they appear in your report:
1. The inability of Medical Consultants and staff to get through to the switchboard
at UHCW on two occasions
Reaching UHCW staff to request advice/transfers has been problematic for a number of years
due to infrastructure issues. Following discussions at Executive level in 2022, a telephone
number primarily intended for use by GPs to bypass UHCW’s Main Switchboard was shared
by UHCW. This was as an interim solution whilst UHCW considered a more robust permanent
solution. A solution agreed as part of the SI review was implemented in September 2023,
namely for a list of direct numbers for cardiology wards and mobile ‘phone numbers for
Cardiology Consultants to be provided to SWFT. The benefit would be that SWFT staff could
make contact directly with the ward to establish which clinician was on call and then contact
that person, thereby avoiding switchboard. In addition, the outcome of the meeting was that:
a. Long-term Technological Solutions
i. Technological solution to be developed to provide an alternative access
to clinical teams (VOIP, Consultant Connect, WhatsApp, Teams). Initial
discussion to be held with UHCW Director of IT around long term
technology solutions to improve overall communication at UCHW (for
tele
example
based
cloud
connection/messaging/email)
around
in systems for making referrals (getting a clinical
improvements
conversation/ getting a bed).
solutions,
and more
specifically
together
with
b. Short-term Communication Pathways
ii. Whilst long-term solutions are being developed, SWFT/ UHCW to
develop short term process for:
- How we do a clinical conversation better when seeking advice/ seeking beds/seeking
conversations so it does not involve multiple people;
- How we create a referral pathway backwards and forwards between the organisations; and
- How we have a safety net when those do not work so we have an ability to escalate. (This
may include: daily huddle between SWFT and UHCW to share patients needing transfer as
two way, centrally held lists of patients requiring input from the other organisation, central
oversight by site team at each organisation of patients requiring transfer to support front door,
improved links between on-call managers).
iii. SWFT to send names of staff to be involved who understand systems to
take part in discussion for action ii;
iv. Give SWFT switchboard contact details for UHCW’s site office – which
will ensure one single point of access into the organisation. The site office
is covered 24/7, should there be a need for escalation. This has now been
actioned.
v. UHCW to complete work to collate information by specialty on how to
contact teams on call into user-friendly and accessible form and share
with SWFT
The Trust is committed to being environmentally friendly, therefore where possible we use 100%
recycled paper. This paper has been made using no harmful chemicals in the manufacturing
process.
c. Relationship Building
vi. Look at how registrar level staff can build relationships across the
organisations to improve communication and team working
d. Specialty specific care pathway issues
vii. UHCW cardiothoracic/ cardiology to review contact details that can be
provided to SWFT to support response to PFD
2. A previous incident in which a similar concern had been raised, had led to
provision of an emergency GP phone number, that can be used by the clinical
teams at South Warwickshire University NHS Foundation Trust (SWFT), which is
manned 24 hours a day and is prioritised over other calls. The Cardiology team
had not been aware of this, nor did they have the telephone number.
As explained above, the sharing of the GP telephone number was only ever meant as an
interim solution. This has been superseded by provision of direct numbers to reach the
cardiology wards at UHCW and a list of Cardiology Consultant’s mobile ‘phone numbers whilst
more robust short and longer-term technological solutions are developed.
3. Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with
UHCW on 9 June 2023, as the referral had not been completed [and] 4. Had the
referral been completed, the team at UHCW could have prioritised the patient’s
transfer.
The Trust recognises that it didn't pursue efforts to ensure that a consultant-to-consultant
discussion took place between 7th and 9th June 2023. At least one attempt to call was made
to the UHCW team but, as is made clear elsewhere in this response letter, difficulties in
making contact with an appropriate clinician at UHCW hampered that communication and
further attempts were not pursued rigorously enough. In reality, although Mr Guillaume's case
was not discussed at MDT that day, an echocardiogram performed on the same day led to a
recognition that a Transcatheter Aortic Valve Implantation (TAVI) procedure was not required
and that a valve replacement would be a clinically more appropriate option. A referral for valve
replacement surgery does not involve an MDT discussion and so a referral to UHCW's
surgical team was made electronically that same evening. These points are highlighted on
page 4 of the Trust's root cause analysis investigation document.
In essence, there was a delay in making a referral for a TAVI procedure before the MDT
meeting which the Trust recognises and for which it has apologised. This was in part due to
difficulties in gaining access to UHCW colleagues and in part that an alternative temporary
solution to aid communication was unknown to the consultant team. However, a cardiac
investigation undertaken on the same day as the MDT highlighted that a different procedure
was clinically more appropriate and referral for that occurred on the same day as the MDT
meeting. It is believed that the short, and long, term plans described above to improve
communication between the UHCW and SWFT consultant teams will mean that consultant-
to-consultant discussions will be able to be more speedily and effectively achieved in future.
I hope that this provides you with the assurance that you require but if, having read this letter,
you have outstanding concerns, please do not hesitate to contact me.
The Trust is committed to being environmentally friendly, therefore where possible we use 100%
recycled paper. This paper has been made using no harmful chemicals in the manufacturing
process.
Yours sincerely
Chief Executive
Actions
Recommendation
Action to Address
Recommendation
1
2
3
4
5
To complete a joint review to
provide to the family and HM
Coroner
UHCW to review the
mechanisms of referral for
SWFT cardiology patients. To
consider similar pathway used
for neurosurgical referrals and to
include how to track patients
referred to them
Safety Practice Alert to be
circulated Trust wide with priority
telephone number for referrals
to UHCW
UHCW to prepare a response to
the family questions
Learning from the review to be
shared within cardiology
governance meeting and as part
of the cardiology specialty report
to the Emergency division audit
and operational group
By whom?
By when? Evidence of Progress
Clinicians from
Roundtable discussion to be
held with UHCW to review this SWFT & UHCW
case
UHCW to confirm a one contact UHCW cardiology
referral process for SWFT
moving forward, similar to the
pathway used for neurosurgical conjunction with
referrals and to include how to
the patient safety
track patients referred to them
team at UHCW
& cardiothoracic
team in
and Completion
31/08/2023 Action completed 6
September 2023
30/09/2023 Action complete. Direct
contact numbers of
cardiologist/cardiothoracic
surgeons from UHCW
provided for Consultant to
Consultant direct
referrals. Circulated to
SWFT cardiology
department.
Safety practice alert to be shared Patient Safety
at each handover for 2 weeks.
team SWFT
06/09/2023 Action completed 6
September 2023
UHCW
12/09/2023 Complete. Received and
included in the report
Dr Y Tan
31/10/2023 Action completed 12
January 2024
Family concerns discussed at
roundtable, UHCW agreed to
forward their response to be
included in the report
Dr Tan, Governance lead to
share learning at cardiology
governance meeting and at the
Emergency division audit and
operational group Case to be
presented by the cardiology
team at Grand Round
The Trust is committed to being environmentally friendly, therefore where possible we use 100%
recycled paper. This paper has been made using no harmful chemicals in the manufacturing
process.
,,,,:1;1 University Hospitals Coventry and Warw ickshire NHS Trust Clifford Bridge Road Walsgrave Coventry CV22DX www.uhcw.nhs.uk 22 February 2024 PRIVATE AND CONFIDENTIAL Mrs Deborah R Lakin Assistant Coroner for the Coventry and Warwicks The Coroner's Office Warwickshire Justice Centre Newbold Terrace Leamington Spa Warwickshire CV32 4EL Dear Mrs Lakin Re: Inquest into the death of Andrew Douglas Guillaume held 29th December 2023 Thank you for sharing the Regulation 28 report for the above patient. Whilst the Regulation 28 response is required from South Warwickshire University Hospitals (SWUFT) we have engaged with them by way of a tabletop review/learning event, having recognised that there were aspects of our processes that were identified in the report that required improvement. We have agreed to explore the technological options that may improve this however, in the interim we have agreed an escalation process that now provides a direct line of communication 24 hours, seven days per week. This arrangement has been confirmed with SWUFT following the tabletop review and we will also share this with the other Providers across the System. We hope this provides assurances, and I would like to assure you that we will continue to explore communication improvements as part of our digital plans. Yours sincerely Chief Executive Offjcer
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