Severine Kelly

“ Gloucestershire Health and Care

with you, for you
NHS Foundation Trust

lf you call or telephone, please ask for: Gordon Benson Edward Jenner Court

Pioneer Avenue
E-mail Po Gloucester Business Park
Brockworth
Gloucester
GL3 4AW
47 April 2024
Mr Roland Wooderson

Area Coroner for Gloucestershire
Gloucestershire Coroner's Court,
Corinium Avenue,

Barnwocd,

Gloucester,

GL4 3DJ

Dear Mr Wooderson

Ref: The Late Severine Kelly

| am writing on behalf 0! Chief Executive, in response to your Regulation 28 Prevention of
Future Deaths Report dated 21 February 2024 relating to this case.

On conclusion of the inquest, you established a number of concerns in regard of practice and training
regarding resuscitation, the updating of risk assessments following risk related Incidents, access to 2
portable landline telephone and the signposting of colleagues from emergency services when they arrived
onsite. The Trust has now had opportunity to reflect on its practice and | am pleased that we have been
able to identify improvements which will minimize the tisk of a similar tragic event recurring in the future.

The learning from Miss Kelly's death has focused on the 6 key issues you identified.

4. The medical training of certain “bank” staff, at the hospital on 1 October 2022, was not up
to date.

The Trust's Leaming Management System (LMS) ‘Care to Leam’ records staff training
completions, and monitors compliance of Statutory and Mandatory topics. The LMS is web-based
and can be accessed by all GHC staff and managers on any device with an internet connection.
Logging into the system requires the same details as accessing a Trust computer or laptop,
therefore, there is no additional username or password required. This also applies to Bank Staff.

Staff information including job role, team and banding is fed into Care to Learn on a daily basis
from our Electronic Staff Record (ESR), this information is used to identify and allocate the
appropriate level of training to the individual’s profile. To ensure staff remain compliant email
notifications fram the system are sent 3 months prior to the expiry date and then again 1 month
before. At this point the manager also receives an email notification. Managers and individual staff
also receive and email notification when they go out of date. In addition to the reminders, a daily
feed from Care to Learn is taken into the Trust's ‘Business Intelligence’ reporting platform Tableau,
which displays compliance at Trust, Team and Individual level and managers and individuals can
access this information.

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+ Avenue, Gloucester Business Park, Brockwortn, Gloucester; GL3 AAW

2:

Currently Clinical Bank staff have ‘Resuscitation Bank’ as an annual requirement on their training
profiles and are provided with the option to choose to undertake either Level 2 or Level 3
Resuscitation training. The reason they are not presented with just one option is because the LMS
has not previously been loaded with their location as we were not able to easily identify where
Bank staff are working. However, recent work on this issue means that information regarding their
location is now being pulled into Care to Learn, and going forward we will be able to use this to
more accurately allocate the correct level resuscitation training to their profiles. This means that in
future, Bank Staff will only be presented with one option for their training and, therefore, will not
have to choase the correct level for their role. This is a key update since Miss Kelly's death as
training can now be targeted to the requirements of the location in which bank staff work.

Additionally, the status of all Bank Staff's training compliance requirements is available on the e-
rostering Allocate System (the system we use to book staff and allocate them to a shift). Matron
and ward managers are, therefore, aware of individuals’ training compliance. This means thateven
if some individuals are out of date with specific training, the needs of the site as a whole can be
met via by ensuring that there are sufficient fully trained individuals available each shift to respond
to medical emergencies. This system was in place in 2022 but is now more robust due to the
improvements made to matching locations to bank staff training profiles.

Staff needed to be aware of the need to update risk assessments and take appropriate
action following a medical event that could be injurious to a patient. Specifically, Severine
suffered a similar choking incident.in 2021.

We have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and
have produced a practice notice to remind clinical colleagues that, following a medical emergency,
the event is reviewed by the medical team/ward Doctor. I can confirm that this has been circulated
throughout the site and discussed at team meetings. The notice mandates that following a medical
event that has the potential to harm a patient, an entry must be made in the patient record, the
medical history and any relevant risk assessment must be updated. The Practice Notice is included
as Appendix 1. We will also complete a quarterly audit to ensure that we can evidence this in the
healthcare record and the result will be shared with the Hospital Matron.

A doctor, attempting to assist Severine and speak to the 999-emergency service was
obliged to leave the patient to use a mobile phone. He did not have the facility of a
portable landline telephone which would have meant that he could have spoken to the
service without leaving the patient.

Pn, ese Matron, Wotton Lawn is currently in the process of testing Mitel DECT
phones a ospital site. Portable landlines operate from a base unit, so we need to ensure that
these have the range to function effectively at distance from the base unit. If distance proves to be
too great in some areas, we have a further option to explore Wi-Fi based phones. We envisage
that 2 permanent solution. will be in place by 1 May 2024, and | will write again after this date to

provide confirmation.

‘A paramedic attending Wotton Lawn hospital was unsure which ward he should attend
due to lack of guidance from staff at the hospital. This led toa delay in the paramedic.

attending on Severine.

As with the 2™ issue, we have shared the outcome of the hearing with all clinical staff at Wotton
Lawn Hospital and have produced a practice notice providing clarity with the actions that must be
taken when emergency services have been called to attend a medical emergency. | can confirm
that this has been circulated throughout the site and discussed at team meetings. The Practice

Notice is included as Appendix 2.

5. ‘There seemed to he uncertainty at which stage of a medical emergency a medical
professional should call the ambulance service.

We have reviewed the existing process regarding actions to be taken in the event of a medical
emergency and believe that this remains fit for purpose, | have attached a copy of the Escalation
Procedure Action Card for your information at Appendix 3. This forms part of the Care of the
Deteriorating Patient Policy and will be reinforced at all resuscitation training courses. Local
escalation procedures are also included as part of the on-site focal induction for new starters,
therefore, all staff on site should be familiar with the process. In addition, to ensure that staff have
a greater awareness of how to respond to a serious choking episode, we have developed 4
choking simulation to complement the Resuscitation Action Card 5 — Adult Choking (revised in
November 2022) which has been included as part of the Level 3 Resuscitation Training from 1
April 2024. | have attached this scenario as Appendix 4.

6. An AED used on the 1 October 2022 appeared not to have a working internal clock.

The AEDs used by the Trust are iPad SP1s supplied by Welmedical. We have liaised with
Welmedical and can confirm that the internal clocks on all devices are working but are set at the
point of manufacturing. This function cannot be changed by the end user and remains unaffected
by any local calibration and replacement battery installation. Importantly though, each time the
AED Is activated, it keeps a timed log of all events within the episode as with the event involving
Miss Kelly. This timed log forms the record of the response, but this record will not necessarily
align with Greenwich Mean Time.

| would be grateful if you could share a copy of this response with Miss Kelly's family and relay our deepest
apology for the gaps in service provision that the inquest identified. We continue to reflect on the learning
from her death and aim to improve the safety of patients through the changes made.

If can be of further assistance, please let me know.

Yours sincerely

— —_

“This practice notice is in response to Coroners hearin,

ae Gloucestershire Health and Care
NHS Foundation Trust

with you, for you

PRACTICE NOTICE — MEDICAL EMERGENCIES AT WOTTON
LAWN HOSPITAL
March 2024
z following the death of a patient at Wotton
Lawn Hospital.

All colleagues working in Wotton Lawn Hospital need to note the requirements of this notice, and
ensure their practice is compliant with immediate effect.

This notice is to clarify the role af staff members ona ward or.department where there is a medical

emergency.

When a medical emergency occurs on @ ward/department at Wotton Lawn Hospital a staff member
from the ward or department needs to be allocated the role of meeting any emergency services that
have been requested to attend. The staff member will need to be within eyesight of Mayhill Way
Road in order to be able to see the emergency services arriving, diréct to the entrance of Wotton
Lawn, Greyfriars or.Montpellier and ensure they get to the eiviergency in a timely fashion.

working together | always improving | respectful and kind| making a difference

a Gloucestershire Health and Care
NHS Foundation Trust

with you, for you

PRACTICE NOTICE — MEDICAL EMERGENCIES AT WOTTON
LAWN HOSPITAL
April:2024

This practice notice Is In response to Coroners hearing following the death of a patient at Wotton
Lawn Hospital.

All colleagues working In Wotton Lawn Hospital need to note the requirements of this notice, and
ensure their practice is compliant with immediate effect.

This notice is to clarify the role of nursing and medical on a ward where there is a medical
emergency.

Following a medical emergency for a patient at Wotton lawn Hospital including Greyfriars and
Montpellier a review with the medical team/ward doctor needs to happercat the earliest

opportunity. The review must be entered on to the medical record including the medical history.
Risk assessment will then need to be updated with:the relevant information.

working together | always improving respectful and kind | making a difference

NHS

eee Gloucestershire Health and Care

with you. for you

Escalation Procedure Action Card
Mental Health Inpatient Settings (incl Honeyborne & Laurel Hse)

NHS Foundation Trust

dl Gloucestershire Health and Care

with you, for you NHS Foundation Trust
Choking scenario (MH&LD settings)

Clinical.setting:and history

cough (ineffective), clutching throat.

Situation: Patient, appears to be in distress, attempting to
ten food on the

Background: Patient on unitfin department for assessment. Evidence of half-ea'
table.

Assessment: Increasing shoriness of breath and difficulty breathing.
Recommendation: Patient needs urgent treatment and escalation.
Decision: Commence initial treatment algorithm for choking and activate on

response procedures

-site emergency.

Clinical Course: Patient unable to talk, cough is ineffective, distressed and deteriorating.

Interventions:
Call for help, activate.on-site emergency procedures and dial (9)999

Treatment algorithm for Choking

Administer up to 5 back blows - ineffective

Administer up to 5 abdominal thrusts ~ ineffective

Repeat steps above - ineffective

Patient loses consciousness/unresponsive - lower to floor

Start CPR

Grab bag, 02 and AED available - AED 1* analysis ~ non-shockable rhythm

2 mins CPR/airway management - AED 2"? analysis — non-shockable rhythm

_ No visible chest rise/fall following attempted ventilations
lfiwhen airway checked then visible obstruction can he seen and safely removed
Patient appears to respond, movement of limbs and cough

Reassess ABCDE:
Airway - Clear
Breathing - Spontaneously breathing
Respiratory rate 11, deep, bi-lateral chest rise/fall
SpO2 92%, administer high flow O2 via NRB
Circulation - Capillary refill <2sec, radial pulse >60bpm
Blood pressure >90 systolic, appears pale.
Disability - AcVPU, Pupils dilated but responding

Blood glucose 4-7mmolll

Expasure ; ; - Temp 37°
Handover and transfer — SBARD

Discussion Points
- Escalation and on-site calling procedures 2222 /(9)999
- Treatment algorithm for choking
- Follow-up and referral for further assessment
- request medical review, update risk assessment, SALT referral
- Update patient records and complete Datix
April 2024

NHS

oe Gloucestershire Health and Care

with you, for you NHS Foundation Trust

NHS

9 a s : Gloucestershire Health and Care

with you, far you NHS Foundation Trust
Resuscitation Action Card 6 — Adult Choking

This action card cannot cover every scenario, it provides guidance for transmission-

based precautions when working in COVID-19/respiratory care pathways settings or
where clinical need indicates eg: known/suspected cluster transmission of SARS-
GoV-2.

To minimise the risk of transmission, colieagues should use their judgement to
reduce risks to themselves and others.

Version 1 November 2022
April 2024