Kim Stroud

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The Queen  Elizabeth 
Hospital  King's. Lynn 
NHS  Foundation Trust 

The Queen  Elizabeth  Hospital
Gayton Road 
Kings  Lynn 
Norfolk 
PE30 4ET 

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17 April  2024 

Yvonne  K Blake 
Area  Coroner for Norfolk 
County Hall 
Martineau Lane 
Norwich 
NR12DH 

Dear Ms  Blake 

Kim  Stroud - Trust's Response to Regulation 28 

We write further to the Report for the Prevention of Future Deaths made under paragraph 7, Schedule 
5,  of the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of the .Coroners  (Investigations) 
Regulations 2013,  dated 22  February 2024." 

We will respond to Ms  Blake's areas of concern  as  set out below, and explain the actions being taken · 
in response,  as  follows: 

"Mrs Stroud's  care  appears  to  have  been  non-compliant with  both  hospital policies and  the 
Nursing and Midwifery Council regulations for the administration of medication.  Mrs Stroud's 
relatives found pots with tablets in on several occasions just left on their mother's bedside table. 
These  had been signed for as given.  On  one·.occasion Mrs Stroud had concealed 9 tablets inside 
her incontinence pads because she  thought she  was  being poisoned,  clearly not supervised in 
taking those either. It was extremely unsafe to leave tablets in this way. Mrs Stroud had delirium 
and could not be left to take them herself.  There  were other confused and mobile patients on 
the same  ward who could have picked them  up.  On several occasions Mrs Stroud was found in 
her bed so soaked in urine (I  have seen photographs of this) that the urine was dripping off the 
edge of the bed and the family had to wash and change her themselves. Also wash  faeces from 
her body". 

Prior to Mrs  Stroud's  death,  we  had  been  informed  by  her family that they were  unhappy with the 
standard of care she was receiving, noting that they had found her in a wet bed on multiple occasions, 
and  a  meeting was  held  with the senior sister on  Necton  ward  on  28  August  2022,  where we  were 
able to apologise to the family directly for these  incidents. We completely agree this is  unacceptable 
and does not meet the standard of care we strive to provide for our patients, which they are entitled 
to receive. We understand that on each occasion this was dealt with appropriately after being brought 
to  our  attention.  We know there  will  unfortunately  be  occasions  where  a  family  is  aware  of their 
relative  having  wet their  bed,  or  needing to  be  changed,  before  a  member of the  nursing  team  is 
aware.  We would  of course  expect this situation to  be  managed wherever possible to try to reduce 
occurrences,  and to protect patients' skin  integrity and of course their dignity. 

www.qehkl.nhs.uk 

 
 
 18 April 2024 

The Queen Elizabeth Hospital  King's Lynn  NHS  Foundation Trust 

We are very sorry if Mrs Stroud's family feel there was more we could have done to prevent Mrs Stroud 
from  wetting the  bed.  Our  records show that Mrs  Stroud  was  being supported to  use the commode 
where  possible.  However,  she  was  having  a  lot  of  anxiety  around  using  the  commode,  and  was 
experiencing  panic attacks  even though she was  reassured  on several  occasions that she could  keep 
her oxygen mask on whilst using the commode.  It  is  not clear whether Mrs  Stroud's family witnessed 
this during their visits to her, or whether these issues had been discussed with the family,  either before 
or  after the  meeting  on  28  August  2022  (which  was  not  minuted).  We  sincerely  apologise  for  Mrs 
Stroud's  poor  experience,  and  that  Mrs  Stroud's family  had  cause  to  bring  this to  our  attention  on 
more than one occasion. 

We  have  been  provided with  a  photograph which  appears to show two nebuliser vials  on a  bedside 
cabinet,  next  to  a  mobile  phone.  The  vials  contain  a  solution  of  250  micrograms  of  lpratropium 
Bromide  in  ·a  1ml  dose.  This  would  be  used  with  a  nebuliser  - a  small  machine  which  turns  liquid 
medicine  into  a  mist  which  can  be  easily  inhaled  through  a  connected  face  mask.  Mrs  Stroud  had 
several  factors  which  would  have  caused  difficulty  breathing,  incll_iding  her  pre-existing  Interstitial 
Lung  Disease, as well as Covid  Pneumonia, and likely would have benefited from the use of a nebuliser 
to increase the flow of air in  and out of her lungs. 

At the time this photograph was taken, which we believe to be on or around 18: 15 on 18 August 2022 
based on the mobile phone screen visible in the photograph, this was Mrs Stroud's first day on Necton 
ward, which  is  the Trust's respiratory ward. She was documented as  being on  15  litres of oxygen with · 
a venturi mask, and was still only reaching 91 % saturation of oxygen in  her blood. Every time the mask 
was removed, she desaturated. Our investigation of this concern  has identified two potential reasons 
which  may have led to those nebuliser vials  being on Mrs  Stroud's bedside unit: 

•  The  nebuliser  vials  would  be  dispensed  as  part  of  the  medication  round,  which  is  where 
prescribed medications are dispensed to the patients. These vials would be dispensed together 
with  any  other  medications  the  patient  may  require,  but  whereas  the  patient  would  be 
supervised to take their medications in  liquid or tablet form at the time they are dispensed, the 
nebuliser  vials  need  to  be  given  via  nebuliser,  which  takes  approximately  6-7  minutes.  The 
medication  rounds are timed to coincide with  meals,  so the nebuliser vials would  be placed to 
on'e side so that the patient can enjoy their meal  hot. This can then be given after the mealtime 
is  over, so as to protect patients' mealtimes. As the photograph was taken at 18:15, it is  possible 
this  coincided  with  the  time  when  the  vials  had  been  dispensed,  but  not  yet  given  to  Mrs 
Stroud. 

•  Alternatively,  it  may  be  that  the  vials  had  been  dispensed  as  described  above,  however 
attempts to use the nebuliser with Mrs Stroud were unsuccessful due to her desaturating when 
her  oxygen  mask  was  removed.  Her  NEWS2  score  on  this  day  was  documented  as  5,  which 
indicates that there were clinical signs of her condition deteriorating. Although in  Mrs Stroud's 
case,  her score remained elevated for much of her admission due to her symptoms but was not 
increasing beyond that point, it may have been felt that attempting to use the nebuliser would 
be too much  of a  risk.  In  this case,  it would  be  reasonable for the vials  to be  left  in  the  hope 
that her condition would stabilise, and the nebuliser could be used before the next medication 
round.  We  can  confirm  that the  vials  could  only  have  been  there  since  that  morning  at the 
earliest,  because  Mrs  Stroud  was  only  transferred  to  Necton  around  21 :59  on  the  evening 
before,  17  August 2022. 

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The Queen  Elizabeth Hospital King's Lynn  NHS  Foundation Trust 

If  it was not possible to give  Mrs  Stroud her nebuliser immediately,  it may have  been understandable 
for these vials to  have been on  her bedside table.  For  example,  postponing the use  of a  nebuliser so 
that a  patient can enjoy a  hot meal is  beneficial for patient experience, and also aligns with the Trust's 
focus  on  nutrition  and  hydration,  which  is  one of the Trust's three  priorities  under the  new Patient 
Safety Incident Response Framework (PSIRF).  Equally,  it may have been an appropriate clini!.::al decision 
not to use the nebuliser when  Mrs .Stroud was consistently desaturating,  but to leave these available 
in  case  her condition stabilised  overnight and she was able to have the  benefit of the nebuliser at a 
later time.  We would  have  expected that if this was  brought to the attention of the ward staff, the 
reason  for· the  vials  being  there could  have  been  explained  to  her family,  to  reassure  them  and to 
explain  the  reasoning  behind  the  decision.  There  is  no  documentation  within  Mrs  Stroud's  records 
regarding the nebuliser vials,  or a conversation with the family to this effect. 

Having  reviewed Mrs  Stroud's medical  records and our incident reporting system (Datix),  as well as all 
correspondence with the family,  we have  not been able to trace any reference within  our records or 
other documentation that the family  had  been  concerned that Mrs  Stroud  had  not been supervised 
to take her medication, or that her medication had been found  unattended. We were in  contact with 
Mrs  Stroud's family  both  before and  after her death.  Sadly,  the first  time we  became aware of this 
being a concern of the family was on 20 November 2023, when we were provided with their statement 
during the inquest process. This was,  unfortunately, over a year after Mrs Stroud died, so we have not 
been able to investigate this aspect of your concerns to the level of detail we would like. We apologise 
for any inadequacies in  this aspect of our response. 

The  photograph described  above was very helpful  in  assisting  us  to understand the circumstance~ of 
the nebuliser vials  being left on her bedside unit, and we are grateful to the family for providing this. 
However, when addressing this aspect of the Coroner's concern we did not have the benefit of simflar 
photographs having  been  provided, showing the instances of pots of tabl.ets  being  left  unattended, 
or tablets  having  been found  concealed  in  Mrs  Stroud's incontinence  pad. This  may have assisted  us 
with  identifying  when  and/or  where  this  happened,  and  who  would  have  been  responsible  for 
supervising  Mrs  Stroud with her medication on these occasions. 

We  have  reviewed  records  from  our  Electronic  Medicines  Prescribing  and  Administration  system 
(ePMA)  to see whether we are able to identify a  particular period where Mrs  Stroud may have  been 
dispensed  nine tablets at once,  as  were  reportedly concealed  in  her incontinence  pad.  However,  we 
have  not  been  able  to  confirm  when  this  may  have  happened.  With  ePMA,  medications  are  not 
"signed for as given" in  a traditional sense, on a  paper drug chart.  Instead, the person dispensing the 
medication  would  be  logged  into the ePMA  system,  and would  confirm  that a  particular  dose  had 
been given,  and when. The system then records tha_t  person's identity against that dose. 

We  believe  a  copy  of these  ePMA  records  were  provided  to the family  on  or  around  23  November 
2022,  together  with  the  rest  of  Mrs  Stroud's  medical  records  from  this  admission.  This  may  have 
enabled  the  family  to- check  their  own  records  of  specific  dates  and  times  when  they  witnessed 
medica.tion being left unattended, against the ePMA records. This would have been after Mrs Stroud's 
death, and a  couple of weeks or months after the events occurred.  Unfortunately, as these dates and 
times were not passed on to us,  we have not been able to check this against our own records. We are 
very sorry that we have not been able to identify the specific occasions when this  happened, despite 
our best efforts. 

· 

If  we were  aware that Mrs  Stroud was either not taking  her  medications  or spitting these out,  and 
concealing these missed  doses about her person, we would absolutely expect that additional support . 
be  put in  place to try to  identify the  cause  of this.  This  could  have  been via  extra  supervision  both 
before and after Mrs  Stroud was given  medication to take.  If there was a  physical  difficulty with  her 

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The Queen Elizabeth Hospital  King's Lynn  NHS  Foundation Trust 

swallowing  the  tablets,  we  could  have  explored  whether  any  of the  medications  could  have  been 
given  in  another  manner,  or if not,  whether an  alternative  medication  could  have  been  prescribed 
instead. 

We  know that for some  periods of her admission  Mrs Stroud was  on  Level  4  1: 1 care,  meaning that 
she  had  a member of staff with  her at all  times.  This  would  have  allowed  us  to ensure  she  kept her 
oxygen  mask  on,  but would  also  have  ensured  she  was  supervised taking  her medication,  as  well  as 
afterwards, which should  have  mitigated any risk  of her concealing the tablets or spitting them out. 
We do however appreciate that the events described could have happened when Mrs Stroud was  not 
supervised to this degree. 

We would not expect that pots of medication would be left unattended on a patient's bedside cabinet. 
If we had been aware of such an  occurrence, we would expect that this would be documented within 
the patient's medical records,  and also documented as  an  incident on Datix so this can  be  reviewed by 
the Patient Safety Team.  If there was harm caused,  or the potential for harm, the incident would have 
been  discussed  at our Safety  Incident Review  Forum.  This  is  a multidisciplinary meeting  attended  by 
senior  representatives  across  all  areas  of the Trust,  where  incidents  can  be  debated,  and  next steps 
agreed. 

Under the new Patient Safety  Incident Response  Framework (PSIRF),  if an  incident is  brought to our 
attention, we now consider whether there is  any learning to be taken from the incident, and  review 
this in a number of different ways,  rather than our investigation being guided by the level of harm or 
potential harm. If a patient safety risk is  identified, under PSIRF we now look to identify wider themes 
to prevent future patient safety incidents,  rather than focusing on an  incident as  an  isolated event. If 
an  incident such  as  this had  been  reported  on  Datix, depending on the  issues  identified at our initial 
review,  we  might  look to  review  our  medication  round  processes  across  the  Trust.  We  might  have 
identified an  issue  within  a specific area,  e.g. the ward  itself,  or we may  be  able to identify another 
root cause  requiring a different approach.  Having this greater flexibility to respond to patient safety 
incidents will mean that if a similar situation is  brought to our attention in the future, we can  ensure 
this is  investigated and managed in the best way to protect patient safety. This is of course our priority 
at all times. 

We note your concern regarding patients being able to gain access to, and take, the medications which 
Mrs Stroud's family reported being left unattended. We hope we can  offer reassurance  by saying that 
we  have  reviewed th~  past two years'  worth  of Datix entries,  spanning the  period  before and  after 
Mrs Stroud's admission, and were not able to identify any instances where this has  happened. 

We fully recognise that the experience reported by Mrs Stroud's family both during her admission and 
as  part of the inquest process,  was  not what we would want for our patients and their families,  and 
we deeply regret that this is the impression they have been left with when remembering  Mrs Strpud's 
last weeks.  We  sincerely  apologise for this.  The  Trust is  always  looking for opportunities to improve 
the service we provide, and we are committed to continuous improvement in this respect,  in  line with 
the Trust's core values of kindness, wellness and fairness.  Since the incidents highlighted, many of the 
staff that would have been involved in Mrs Stroud's care  have left the Trust and new staff are in place 
on the wards where we know Mrs Stroud's care did not meet our expectations. 

These  new members of staff have already undertaken a Caring with Kindness course or are booked to 
attend. This  is  a two-day course  which has  been  running  on a monthly basis  over the past two years, 
and is  generally attended by a combination of Registered  Nurses,  Healthcare Assistants,  Allied  Health 
Professionals, Trainee Nursing Associates and some student nurses.  It has accreditation from the Royal 
College  of  Nursing  to  count  towards  participants'  CPD  requirements.  Where  appropriate,  some 

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The  Queen  Elizabeth Hospital King's Lynn  NHS  Foundation Trust 

sessions have been attended by  patients and/or their carers· or family,  giving them the opportunity to 
share their stories, which we find to ·be very powerful. This  is  a commitment on the Trust's  part which 
supports the governance process around patient experience and safety, and also links with our Patient 
Experience Workplan. We  believe this investment will  pay dividends. 

Since  the  time  of  Mrs  Stroud's  admission,  Stanhoe  Ward  also  has  an  entire  new  leadership  team 
including the  Band  7 Ward  Manager and  her four  Band  6 Junior Sisters.  We  have se.en a  significant 
decrease in the number of concerns and complaints reported to our Patient Advice and Liaison Service 
for both Necton and Stanhoe Ward since these measures including staffing changes and the emphasis 
on Caring with  Kindness  have been impl_emented. 

The Matrons' Ward Assurance Toolkit has also been reintroduced across the Trust,  providing guidance 
around  what  to  look  out  for  and  audit  tools  to  confirm  compliance.  This  includes  a  Medicines 
Management audit which  specifically asks the auditor to document whether medications  have  b'een 
stored safely,  and  in  particular, whether any have  been  left on  patient bedside cabinets or tables.  A 
copy of this Toolkit is  attached for your information. 

Finally,  we  would  reiterate  our  earlier  note  that  we  deeply  regret  that  we  did  not  have  the 
opportunity to investigate some of the concerns raised closed to the time of the incident, and that as 
a  result we are not able to provide a definitive answer on these points. 

-

We offered a  Local  Resolution  Meeting to Mrs  Stroud's family during a telephone call  on  18 October 
2022,  however although  Mrs  Stroud's daughter wished to take part, she did  not feel  able to engage 
with  this  process  at that  particular tinie  due to the  recent  death  of  her  mother,  which  is  of course 
entirely understandable.  She was going to let us  know when she felt able to meet with  us  to discuss 
the family's  experience and  care of her  mother. This  was the  last  documented communication  with 
the family regarding their PALS  concern, and it is  always a difficult balance deciding whethe'r to reach 
out to a family member who has said they prefer to be the one initiating further contact. On reflection, 
we  should  h~ve  considered  making  contact with  the family  again,  after  an  appropriate  amount of 
time  had  passed;  to  see  whether  they  wanted  us  to  close  their  enquiry,  or  schedule  an  LRM.  We 
recognise they may  have  had additional  questions after receiving the copies of Mrs  Stroud's medical 
records,  and  may  have  benefitted from  the opportunity to _discuss  the contents,  or other aspects  of 
theirs and Mrs  Stroud's experience, with appropriate members of the clinical team. 

We  recognise  how distressing  it can  be when  patients or their families  have  unanswered  questions, 
and we wanted to address the wider issue of improving access to raising complaints and concerns. This 
will  help ensure we r~tain this opportunity wherever possible, for the benefit of both our patients arid 
their families.  To  ensure that patients and  relatives  are able to  raise  concerns  much  more  easily,  we 
now have a  matron or senior nurse on site until 21.30 every day and during 08.00-16.30 on weekends 
and bank holidays, who visit every ward and department to ensure that standards are maintained and 
that any concerns are dealt with  promptly. 

We would be happy to provide you with further information if required. 

Chief Nurse 

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