Anne Rowland

,.,,:k-1 

Surrey and Sussex  Healthcare 
NH S Trust 

Headquarters 
East Surrey Hospital 
Canada Avenue 
Redhill 
RH15RH 

131h  May 2024 

Ms  Susan  Ridge 
H M Assistant Coroner for Surrey 
Station Approach 
Woking 
GU22 7AP 

Dear Ms  Ridge, 

Regulation  28  Report - response by  Surrey & Sussex Healthcare NHS Trust 
Inquest touching  upon the death of Anne Johnston Rowland 

This  response  comprises  the  formal  response  of Surrey  &  Sussex  Healthcare  NHS 
Trust (the Trust),  pursuant to  section  7(2) to  schedule 5 of the  Coroners and  Justice 
Act 2009 and  Regulation 29 Coroners (Investigations) Regulations 2013, to the issues 
raised  in  the  Regulation  28  Report to  Prevent  Future  Deaths,  dated  20  March  2024, 
· made subsequent to the inquest into the death of Mrs Rowland, which was concluded 

on  20  March 2024. 

The  Trust  was  given  until  15  May  2024  to  respond  to  the  coroner,  pursuant  to 
Regulation 29(5) Coroners (Investigations)  Regulations 2013. 

I would  like  to  start  this  response  by  offering  our sincere  condolences  to  Mrs 
Rowland's family  for their loss.  The  Trust  accepts  fully  the  findings  of  HM 
Coroner, and that had the surgery taken place on the same day as  Mrs Rowland's 
admission  or the  day after,  she . would  have  had  a  higher chance  of surviving 
the injury. 

The Prevention of Future Deaths report identified the following areas of concern, 
and I address these in the response, with details of the actions that the Trust has 
undertaken  and 
those  that  are  planned,  along  with  the  details  of  the 
improvement to date that have already resulted from these actions: 

Continuing infrastructure risks at East Surrey Hospital have potential to 
compromise  the  Trust's  ability  to  perform  operations  on  patients  with 
fractured  hips  on  the  day  of admission  or the  day  thereafter,  which  is 
the timeframe set out in  the NICE Guidelines on  the Management of Hip 
Fractures. 

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 Response: 

The delay in  Mrs Rowland's surgery was due to high numbers of patients with 
fractures waiting for surgery at the time.  The high  numbers of patients waiting 
for surgery is a result of various factors.  The population served by the hospital 
has  grown  from  approximately  500,000  to  744,000  in  the  last  decade  and 
there has been an  increase in  the number of patients suffering fractured  neck 
of femur admitted  to  our  hospital  - from  500  to  590  in  the  last  year,  an  18% 
rise.  There  has  also  been  a  rise  in  the  number  of other time  critical  trauma 
patients requiring  surgery,  by  30% over the  last decade. 

At  East  Surrey  Hospital  there  have  been  a  number  of infrastructure  issues 
relating to the orthopaedic operating theatres over the last few years. This has 
involved chillers and air handling equipment that have been unreliable and led 
to  unpredictable  cancellation  of  planned  operating  lists,  adding  to  the  long 
waiting  lists for elective surgery that resulted  from  the Covid  pandemic. 

The delays in  our fractured  neck of femur patients  receiving  surgery  needed 
to be addressed and I have detailed below the actions taken since March 2023 
and further planned  actions:  • 

1.  The  orthopaedic  department  has  expanded  from  8 to  12  consultants 
and  are  well  supported  by  an  orthogeriatric team  of physicians  who 
focus  on  optimising  the  medical  care  for  elderly  trauma  patients  both 
pre and  post operatively. 

2.  The daily operation  of the  hospital  is  overseen  by the  site team,  ih the 
hospital  operations centre.  Since  March  2023 we  have added  a focus 
on  managing  the  daily trauma demand  within our site team meetings -
held daily at 08 :30,  12:30,  15:30 and  17:00.  The surgical team discuss 
in  that  meeting  the  numbers  of  fractured  neck  of  femur  patients 
awaiting  surgery,  the  capacity  within  theatres  to  operate  within  36 
hours and the capacity is  prioritised. 

3.  We  follow  a  policy  of trauma  escalation  to  cancel  planned  elective  . 
operations to accommodate trauma patients, including fracture neck of 
femur  patients,  if demand  on  any  given  day  outstrips  the  capacity  of 
the planned trauma lists. 

4.  Since  the  end  of October 2023,  we  have  also  converted  two  elective 
lists  per week into additional trauma  lists, specifically to accommodate 
fractured  neck  of  femur  patients.  At  the  weekly  theatre  planning 
meeting,  if extra theatre capacity  is  identified,  for example  an  elective 
list  is  cancelled  for  annual  leave,  then  this  is  replaced  with  another 
additional trauma list. 

5.  The Trust invested several  million pounds in  2022-23 to  build two new 
wards which opened in  October 2023. These 60 beds allowed us to re-
organise  our  entire hospital  bed  base  which  has  included  increased 
elective  surgical  capacity  and  the  provision  of 'ring-fenced'  fractured 
neck of femur  beds to  optimise  the  care  for these  most vulnerable  of 
patients. 

6.  The  Trust's  Executive  Committee  have  approved  the  case  for  a 

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 multimillion-pound  investment  in  2023-24  for  new  air  handling  and 
chillers  for  the  theatre  complex  which  will  correct  the  long-term 
problems experien·ced  in  the orthopaedic theatres and  will  prevent the 
cancellation of lists due to  infrastructure failings.  The first phase of this 
work  was  completed  in  April  2024,  with  new chillers  and  air  handling 
units  installed  for  half  of  the  theatre  complex.  The  second  phase 
requires more substantial capital work but will be completed by the end 
of 2024,  with  new chillers  and  air handling  units  installed  for the other 
half of the theatre complex. 

East Surrey Hospital use a metric of 48 hours within which to conduct such 
surgery and  not the  NICE timeframe for hip surgery.  Early  mobilisation  is 
recommended for hip fracture patients to reduce the risk of complications, 
including  pneumonia.  The  coroner  is  concerned  that  in  using  a  different 
metric  to  that  in  the  NICE  guidelines  and  the  outstanding  infrastructure 
repairs the Trust is  placing such  patients at risk of early death. 

Response: 

1.  The  Trust  continually  monitors  the  pathway  for  patients  with  fractured 
neck  of femur  using  several  key  metrics,  based  on  NICE  guidance  and 
the Best Practice Tariff. As regards the time to surgery, the Trust monitors 
weekly and monthly the proportion of patients who had surgery within the 
timeframe identified in  NICE guidance (36  hours) which  is also the target 
for the payment of the Best Practice Tariff. We also monitor the proportion 
of patients who have surgery within 48 hours. We do not do this because 
we  are  disregarding  the  36-hour  target,  we  do  this  so  that  we  have 
visibility  of any  delays  beyond  36  hours  and  whether  any  delays  are  a 
matter  of  a  few  hours  or  significantly  longer  than  that.  Performanc~ 
against the  36-hour target  is  reviewed  weekly  by  the  clinical  team  and 
monthly  by  the  Trust  Executive  committee;  then  the  Trust  Quality 
committee and then the Trust Safety and Quality committee and finally by 
the Trust Board. 

2.  The  Trust  tracks  the  mortality  rate  for  our  patients  who  have  had  a 

fractured  neck of femur monthly, through 'Dr Foster'. 

The  actions  we  have  already  taken  have  significantly  reduced  the  time  our 
fractured neck oUemur patients wait for surgery. In March 2023 the proportion 
of patients who had  surgery for fractured  neck of femur within  36  hours was 
35%.  In April  2024 it was 69% with  90%  having surgery within 48 hours. This 
demonstrates that most patients are now having surgery on the day of or day 
after admission,  those that don't only wait a few  hours  longer.  Nevertheless, 
the  Trust target  is  within  36  hours,  and  we  maintain  a focus  to  improve this 
further and the completion  of the planned  capital work will  assist. 

The outcomes for our patents have been  sequentially improving as we have 
taken  these  actions.  The  mortality  of patients  admitted  with  a  fractured  hip 
(measured  as  HSMR) has fallen  sequentially since October 2023 and  is  now 
100.2,  which  benchmarks  'as  expected'  compared  to  other  hospitals  and  is 

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 the lowest it has been at the Trus.t for three yea_rs . 

Yours sincerely 

Chief Medical  Officer 

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