Anne Hawkes

INHS

The Rotherham

NHS Foundation Trust

Our reference S| Rotherham Hospital
Moorgate Road

Your reference Pt Oakwood
Rotherham

$60 2UD

Telephone}
www.therotherhamft.nhs.uk

28 May 2024

Mrs S L Slater

Assistant Coroner for South Yorkshire (East District)
Coroner’s Court and Office

Crown Court

Doncaster

DN1 3HS

Dear Mrs Slater

Inquest Touching the Death of Anne Hawkes: Regulation 28 Preventing Future
Deaths Report

| write further to your letter dated 2 April 2023.

| understand that following review of the evidence heard at the Inquest dealing with the
circumstances of Mrs Hawkes’ death, a number of matters were raised that were of
sufficient concern to invoke your statutory duty under Paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

| was disappointed to hear that you were in a position whereby you did not receive
sufficient assurance through the evidence you heard. We take such matters very seriously
and we are truly sorry that this happened whilst Mrs Hawkes was in our care. | would like to
repeat our deepest condolences to her family and friends.

In order to fully respond to the concerns you raised, we have carefully reviewed the
evidence presented at the time of the Inquest and | hope my response below will provide
you with the necessary assurance that we have addressed the concerns raised.

For ease of reference | will address your concerns in the order presented as follows:

1. The delayed cardiology referral whilst Mrs Hawkes was on the orthopaedic
ward led to suboptimal management of her cardiac failure which in turn is
implicated in her death. There is no procedure in place at the Trust for
Clinicians to automatically refer in-patients with known cardiac failure to
cardiology for expert management

| understand that you heard evidence that there was a recognition that it is good practice to
refer in-patients with known heart failure to cardiology and the heart failure specialist
nursing service for advice and management and there is an expectation of both medical

xecutive, fhe Rotherham NHS Foundation Trust

je

and nursing staff to use their clinical judgement and recognise when patients require
referral to the heart failure service. In addition, you heard evidence that there is no
automatic referral of in-patients with known cardiac failure to cardiology for management.

In the first instance, | think it is important to highlight that all patients with heart failure have
a flag on their record within Meditech which appears as a ‘pop up’ whenever a user logs
onto the patient's records. Mrs Hawkes had such a flag on her record and | would like to
reiterate our apology to Mrs Hawkes’ family for the delay in referring her to cardiology for
specialist heart failure management.

| understand that during the Inquest, it was discussed at length that a crucial aspect of
heart failure management is fluid balance with the view of preventing fluid overload and to
monitor this, a patient's weight in an important consideration. It was recognised and
accepted at the Inquest that Mrs Hawkes’ admission weight was not accurate. Since this
incident, additional prompts have been incorporated into Meditech to direct clinicians to
complete daily weights for patients with heart failure. More specifically, the prompts have
been made to the Inpatient Admission Summary (a checklist completed for every patient
irrespective of where they are admitted to), the Trauma & Orthopaedic Admission, Trauma
& Orthopaedic Femoral Fracture Admission and Nursing Admission Checklist PCS
Assessment. This prompt will direct clinicians to answer the question of whether the patient
has a past medical history of heart failure. If the answer is ‘yes’ (as will be the case for
patients with heart failure) this will trigger a Daily Weight Monitoring assessment. If the
patient’s weight has increased by more than 3kg since admission, a pop-up message will
appear on the system prompting a referral to the Heart Failure Specialist Nursing Team.
For your ease of reference | have attached, at Appendix 1 a document which outlines the
process.

The aforementioned process is in addition to clinicians recognising other signs and
symptoms of heart failure which also prompt referral to cardiology/heart failure service.
Furthermore, orthopaedic inpatients are also reviewed by an orthogeriatrician during the
Friday ward round where specialist input and guidance can be sought as to the medical
management of the patient.

| acknowledge that you have highlighted there is no automatic referral for in-patients with
known cardiac failure. It should be acknowledged that not all patients with known heart
failure mandate a referral to the Heart Failure Service, unless there are signs of
decompensation (including shortness of breath, decreasing oxygen saturations and
tachycardia) and/or fluid overload (visible oedema and/or changes in body weight).

We have carefully considered this and concluded that automatic referral would place a
disproportionate amount of additional pressure on the service which ultimately would not
prove beneficial for patients.

There are several ways, for both medical and nursing staff to refer patients to other
specialities and this includes the cardiology and the Heart Failure Specialist Nursing
Service. These include completing the electronic Inpatient Referral Form which is inbuilt
into the Trust’s electronic patient record system, Meditech. Referrals can also be made via
telephone requesting to speak to a clinician or Consultant in that relevant speciality.

Be
Chief Executive, The Rotherham NHS Foundation Trust

2. The lack of communication between the services within the Trust (surgery,
cardiology and tissue viability) led to delayed and incohesive approach to the
wound management

On this occasion, it was recognised at the Inquest that the communication between
orthopaedics, cardiology and our Tissue Viability Nurse services (TVN) could have been
improved upon. However, this is not a reflection on the overall communication with the
TVN service. Tracey Green, Tissue Viability Nurse, gave evidence that there exists a good
working relationship between the surgical teams and the TVN service. It was acknowledged
that TVN could have been contacted earlier when Mrs Hawkes was on Ward A1 when her
wound started to break down and for this we reiterate our apology.

Since this incident, collaborative work has begun between the TVN service and the Trust’s
Quality Governance Team to communicate the referral criteria for the Service to the whole
Trust and repeat awareness of the Trust’s TVN Service.

| hope the above provides you with the assurance that the Trust has taken your concerns
seriously and please do not hesitate to contact me in the event | can be of further
assistance to you at this time.

Yours sincerely

Chief Executive

Bh ceca
Chiet Executive, The Rotherham NHS Foundation Trust

Heart Failure Patients — Daily Weight Capture (Appendix 1)

The question (below) will be added to the Inpatient Admission Summary, the Trauma & Orthopaedic Admission and
the Trauma & Orthopaedic Femoral Fracture Admission). It will also be added to the Nursing Admission Checklist
PCS Assessment.

*Does the patient have Yes No Comment:

past medical history of

heart failure?
if the response is, “Yes” it will provide a trigger to add the assessment below to the worklist in PCS.
PCS Assessment — Weight monitoring for Water Retention (Scheduled Frequency is Daily)

There would be 3 possible scenarios:

1. The patient cannot be weighed — The Reason becomes mandatory and everything else is greyed out.

Interventions
: Weight monitoring for Water Retention 1D v
(s] Assessments

& pau Weight Monitoring (Fluid retention risk) v

Are you able to weigh the patient? __ [
| Weight on Admission Result _ |
| Weight on Admission (if not previously aa

| Current Weight
| “Reason you are unable to weigh patient

Difference in Weight : : | ene
2. The patient can be weighed and the Admission Weight query has been completed elsewhere.
e The Admission weight is pulled into the Weight on Admission Result field
e The Current Weight field becomes Mandatory — everything else is greyed out.

Interventions

Weight monitoring for Water Retention 1D v
(J Assessments
& ety Weight Monitoring (Fluid retention risk) v

[Are you able to weigh the patient? |NOWVES| ONo — —_ a
80.5 kg = :

| Weight on Admission Result
Weight on Admission (if not previously recorded)

*Current Weight

| Reason you are unable to weigh patient
Difference in Weight ?

3. The patient can be weighed but the Admission Weight query has not been completed in other documents.
e The Weight of Admission Result field shows “Not recorded “
e The Weight on Admission (if not recorded) field becomes mandatory.
® The Current Weight field becomes Mandatory

Interventions
Weight monitoring for Water Retention 1D v
\= Assessments
& pray Weight Monitoring (Fluid retention risk) Vv

Are you able to weigh the patient? | aes ONo - _
Weight on Admission Result Not recorded
*Weight on Admission (if not previously
| recorded) =
Til

*Current Weight
Reason you are unable to weigh patient _
Difference in Weight

In scenarios 2 & 3 above, once the missing weights have been completed the “Difference in Weight’ is automatically
calculated

Scenario 2

Interventions . a

Weight monitoring for Water Retention 1D v
‘= Assessment

its
& oar Weight Monitoring (Fluid retention risk) v

|. Are you-able to weigh the patient? | @Yes O No
Weight on Admission Result F 80.5-kg
Weight on Admission (if not previously recor

Current Weight : 81.6
| Reason you are unable to weigh patient
Difference in Weight

Scenario 3

Interventions
Weight monitoring for Water Retention 1D
is: Assessments 1
@ el Weight Monitoring (Fluid retention risk)

Are you able to weigh the patient?
Weight on Admission Result

*Weight on Admission (if not previously
recorded

*Current Weight

Reason you are unable to weigh patient

___ [Difference in Weight, ~5.95 kg |

Interventions 7
Weight monitoring for Water Retention 1D v
(= Assessments
& one Weight Monitoring (Fluid retention risk) v

‘Are you able to weigh the patient? | @ Yes ONo
Weight on Admission Result Not recorded
*Weight on Admission (if not previously 108.25 kg
recorded)

*Current Weight
Reason you are unable to weigh patient

Difference in Weight (g) _ 3.45 kg

if there has been a positive increase in weight since admission of 3kg or more the pop-up message below is
displayed

@Yes ONo
Not recorded
108.25 kg

102.3 k