Terence Hines

Office of the Chief Executive Officer  
CEO: 

Our Ref: 

8th February 2024 

D.D.W. Reid  
H M Senior Coroner 
Coroner’s Court  
Martins Way  
Stourport-on-Severn 
Worcestershire 
DY13 8UN 

Dear Sir  

Terence Hines Regulation 28 response  

Thank you for forwarding on your Regulation 28 report. I have read your report with great care 
and note the concerns that you have raised as a result of the coronial inquiry into the death of 
Terence Hines.  

In your report, you highlighted the following points of concern and I will respond to these 
concerns below, as a sequence, where appropriate. 

Concerns 

1)  Mr Hines had been admitted to the Alexandra Hospital on 26.5.23, where he was 

treated for a ruptured Baker’s cyst; 

2)  On 19.6.23 Mr Hines was moved to side room 2, on ward 2 at the hospital. This 

room had been vacated that same day by another patient who had had a known 
MRSA infection and an exfoliating skin condition which, taken together, 
represented a heightened risk of a subsequent occupant of the room developing 
an MRSA infection, and therefore ought to have triggered a Red (hydrogen 
peroxide) clean of the room before Mr Hines moved into it; 

3)  A Red clean of the room did not take place before Mr Hines moved into the room – 

instead, an Amber (Chlorine) clean was carried out in error; 

4)  The Trust’s investigation into the circumstances surrounding Mr Hine’s death was 
unable to establish why no Red clean was ordered, or why an Amber clean had 
been mistakenly ordered instead; 

The Trust accepts that the Red clean was the appropriate clean in this case, due to the risk of 
environmental contamination with MRSA, and apologises for this not being carried out. On 

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD 

 
 
 
 
 
 
 
 
 
 Office of the Chief Executive Officer  
CEO: 

further investigation of this issue, we found that the Trusts policy around the Red, Amber, Green 
(RAG) cleans was unclear and therefore there was a risk of human error. 

As a result of this, clinical staff have been reminded of their responsibilities to carry out a Green 
clean before the Amber and Red cleans are carried out. This was done through an email sent to 
Infection Prevention and Control (IPC) link nurses, Ward Managers and Matrons across the 
Trust, as part of IPC Awareness Week on 16th-21st October 2023. In addition to this, the Record 
of Terminal Cleans has been updated to prompt the team to ask the nurse in charge, whether 
the Green clean has been completed, before they undertake the Amber and Red cleans.  

The RAG poster has also been updated to include what the Red, Amber and Green cleans 
consist of, and this has been hand delivered to each ward by the IPC team. Each ward has 
signed to acknowledge receipt of these new posters, which were then discussed in the safety 
huddles and displayed on the wards. 

In relation to MRSA, the new guidance makes it clear that we will always require a Red clean 
when a known MRSA colonised patient is in a side room and not just when there is an 
accompanying exfoliating skin condition. This will remove any potential uncertainty and make 
the process clear. 

5)  On or about 24.6.23, because Mr Hines had now been an inpatient for28 days, he 
should have been screened for MRSA. That routine MRSA screen was not carried 
out. The Trusts investigation was unable to explain why that routine screen had 
not been carried out.  

The trust has now implemented both further learning and additional checks, to ensure that 
further routine screens are not missed.  

The Divisional Management Team has reminded the Ward Teams of the requirement to carry 
out routine 28-day MRSA screens. This has been done in an outbreak meeting.  

A pop-up reminder has now been set into the electronic patient record, Sunrise, which will pop 
up on day 28, to alert staff that the MRSA screen is now due.  

A report has been added to the Trusts reporting network (WREN) which lists all patients who 
are due MRSA screening. This is a live report, which identifies patients who have had a length 
of stay of 28 days plus, who do not have an MRSA screen. The IPC Team now use this report 
to monitor MRSA screening and escalate relevant cases to the ward teams when required.  

There is also a report under construction to review the Trust compliance with MRSA admission 
screening and 28-day MRSA screening that will be monitored via the Trust Infection Control 
Committee and the Divisional Governance meetings.  

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD 

 
 
 
 
 Office of the Chief Executive Officer  
CEO: 

6)  On 26.6.23 Mr Hines suffered an accidental fall in the room and was found to have 

sustained a fractured right neck of femur. As a result, he was transferred to 
Worcestershire Royal Hospital where surgery to fix the neck of femur fracture was 
carried out on 1.7.23. 

7)  As a matter of established routine, Mr Hines should again have been screened for 
MRSA prior to his surgery. Once again, that routine MRSA screen was not carried 
out. The Trusts investigation did not explore the question of why that routine 
MRSA screen had not taken place. 

The Trust has identified that although it was routine practice to screen for MRSA prior to 
surgery, the peri-operative checklist form did not include the MRSA status, or infection status of 
the patient. This therefore meant there was nothing to prompt the clinicians, leaving room for 
human error. The Trust has now updated the form so that it includes this information, to ensure 
that clinicians are routinely prompted to check the MRSA status.  

In addition to the updated checklist, the Deputy Director of Infection, Prevention and Control 
attended the Surgical Division Board meeting and have shared the report with the Team, to 
raise awareness of the requirement for MRSA status to be confirmed prior to surgery. If MRSA 
status is not known, then decolonisation treatment will be commenced to alleviate the risk. 

The IPC Team have also implemented a real time Monitoring and Surveillance process. MRSA 
results are imported into ICNET (infection control software program). IPC Nurses review the 
results and follow-up. This enables oversight and escalation of results. When a patient has been 
discharged before the results are available, IPC will send a letter to the GP, which sets out 
recommendations for decolonisation if required. The wards are informed if the patient remains 
an inpatient, and advice and guidance is given to the ward teams. Decolonisation is always 
required for inpatients with MRSA going for surgery.  

For outpatient, the pre-admission swab for elective surgery is valid for 18 weeks. Decolonisation 
is recommended for new MRSA cases and known MRSA cases.  

Prophylactic antibiotics should be risk assessed for any patients that are known MRSA or newly 
diagnosed if going for surgery.  

8)  Mr Hines was eventually screened for MRSA on 3.7.23 (after his surgery) and a 
couple of days later, the results of that screen confirmed that he had tested 
positive for MRSA. He was started on decolonisation treatment on 6.7.23. 

9)  A few days after his surgery, Mr Hines developed an infection around his surgical 
wound, and sepsis. He was returned to theatre on 12.7.23 for debridement and 
washout of the surgical wound. Analysis of swabs from the wound, and blood 
cultures, both taken during this procedure, showed the presence of MRSA, and 

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD 

 
 
 
 
 Office of the Chief Executive Officer  
CEO: 

that the MRSA matched that of the previous occupant of his side room at the 
Alexandra Hospital; 

10) Despite treatment, Mr Hines died at Worcestershire Royal Hospital on 15.7.23. The 

cause of death was: 
1a sepsis 
1b infected surgical wound (methicillin resistant staphylococcus aureus) 
2 heart failure and chronic kidney disease 

11) Had side room 2 on ward 2 at the Alexandra Hospital received the required Red 
clean before Mr Hines moved into it, he would probably not have developed the 
MRSA infection, and would probably not have died when he did.  

The Trust would like to sincerely apologise for the errors made and has reflected on its 
practices as a result of Mr Hine’s death.  

In addition to the changes set out above, the trust has updated the Isolation Policy to reflect the 
new process of a Red clean for every known case of MRSA, and a “lessons learned poster” has 

been distributed to wards to highlight all of the learning from this incident.  

I trust that the foregoing has adequately addressed the Regulation 28 report issued subsequent 
to the inquest into the death of Terence Hines.  

Should you require any further information in relation to this matter, please do not hesitate to 
ask. 

I confirm that I have not forwarded a copy of this response to any other Interested Person and 
would therefore be grateful if you could do so, as appropriate.  

I also confirm that the Trust is content for both the regulation 28 report and the response to be 
released or published should the Chief Coroner wish.   

Yours sincerely  

Chief Executive  

Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital 
Charles Hastings Way | Worcester | WR5 1DD