Eleanor Smith

,~1:!-1 
Northumbria Healthcare 
NHS Foundation Trust 

Patient Services and Quality Improvement 

Northumbria House 
Unit 7/8 Silver Fox Way 
Cobalt Business Park 
Newcastle upon Tyne 
NE27 0QJ 

7 June 2024 

IN CONFIDENCE 
MrAndrew Hetherington 
HM Senior Coroner for Northumberland 
Coroners Court 
County Hall 
Morpeth 
Northumberland 
NE61  2EF 

Dear Mr Hetherington 

INQUEST INTO THE DEATH OF ELEANOR SMITH 

RESPONSE  TO  REGULATION  28  REPORT;  PREVENTING  FUTURE  DEATHS 
RESPONSE 

We write in  response to your Regulation 28 report dated  12 April 2024 following your 
investigation  into the death  of Eleanor Smith.  This  response  has  been  prepared  by 
Northumbria  Healthcare  NHS  Foundation  Trust  (The  Trust)  and  addresses  the 
concerns set out by HM Senior Coroner. 

The Trust will respond to each of these concerns in turn. 

Re$ponse 

The Trust is  committed  to ensuring  that lessons  are  learnt when  any  patient safety 
incident occurs.  At the time  of the incident a  multidisciplinary  learning  from  deaths 
mortality  review  was  undertaken  by the Trust  and  some  key  learning  points  were 
identified,  the  most relevant of which  was that there  was a delay to the  decision to 
prescribe and  administer intravenous antibiotics which was inadequately recorded  in 
the electronic record.  The  mortality  review team was  clear in  its conclusion -that the 
delay to administration of antibiotics was not likely to have contributed to Mrs Smith's 
death as she was felt to be dying following the stress of surgery and the initial injury. 

 
 
 
 During  the  inquest  HM  Senior  Coroner  heard  oral  evidence  from  the  family  that 
demonstrated  that the  recording  of the  administration  of the  intravenous antibiotics 
was not consistent with their observations at the time and that the record keeping with 
regards to the difficulty of siting an  intravenous cannula was absent. 

Matters accepted by the Trust during the inquest: 

During the inquest, the Trust accepted the following: 

1. 

2. 

There was no record in the electronic medical record with regards to the difficulty 
in  siting the intravenous cannula, nor was there a care plan completed once the 
cannula was eventually successfully sited in the foot. 

Following the prescribing of intravenous antibiotics (Teicoplanin and Aztreonam) 
on  23  September  2023  there  was  insufficient  evidence  within  the  electronic 
prescription record to determine whether some or all the prescribed doses had 
been administered and when the dose was completed. 

On  reflection following the inquest, the Trust also notes that the management of the 
clinical  deterioration  of  the  patient  in  the  final  24  hours  of  life  could  have  been 
improved, and that if treatment was being pursued then antibiotics should have been 
prescribed earlier. 

It is also accepted that there should  have been documentation around the problems 
with cannulation that led to the delayed administration of the intravenous antibiotics. 

Below is set out the response to each of HM Senior Coroner's concerns: 

Concern 1 

The Trust  accepts  that  in  this  case  the  record  keeping  regarding  the  cannula  was 
absent. 

Cannula care plans are contained within the "Nervecentre" application that forms part 
of the  electronic  record.  It  is  Trust  policy  (IC16  V09  lntravascular  policy)  that  all 
vascular access  devices  should  be  assessed  daily for  leakage  or failure,  and  they 
should  be flushed  at least twice  daily.  The  procedure  should  be  documented  in the 
cannula  care  plan  on  Nervecentre.  The  policy  does  provide  a  link  to  the  Vascular 
Access  intranet  page which  provides a  clear guide as to how to access  help in the 
event  of difficult  IV  access,  including  escalation  to  the  on-call  Anaesthetic  team  if 
necessary. 

In the case of Mrs Smith intravenous access was obtained by the ward team, however, 
we  would  expect  there  to  have  been  documentation  regarding  missed  or delayed 
critical medicines such as intravenous antibiotics. 

Requests by nursing staff for cannula insertion can either be done digitally by creating 
a  task  on  Nervecentre,  or  via  a  face-to-face  request.  No  tasks  were  raised  in 
Nervecentre on this occasion. 

Interrogation  of  Nervecentre  data  shows  that  on  NSECH  Ward  1,  between  the 
beginning of September 2023 and end of December 2023,  there was an average of 
493 completed cannula care plans per month. This is for a 28-bed ward over 31  days. 

 This suggests regular use of the care plans but does not provide assurance that all 
cannulas  are  being  correctly documented.  We  therefore conducted  a  one-day  point 
prevalence audit of Ward  1 to assess compliance on 12 May 2024. The audit showed 
that on the day in question only 58% of patients with ·a cannula had a fully completed 
and up to date care plan. We have put an action plan in place to address this on Ward 
1  and  across the Trust.  The  action  plan  includes  highlighting  the  issue at the ward 
safety huddles, a clearer escalation process for staff in the event of difficult intravenous 
access and weekly reaudit to drive improvement. 

We are in the process of creating a safety message (see attached text and video) that 
will highlight: 

• 

• 

• 

The  pathway for escalating  difficult  intravenous access and  the  importance  of 
recording  in  the  clinical  record  when  there  has  been  difficulty  or  delay  in 
cannulation (Concern 1 ). 
The  overall  importance  of cannula  documentation  and  recording  of partial  or 
incomplete drug administration (Concern 2) 
A  step-by-step  guide  video  to  remind  people  how to  amend  the  details  of an 
incomplete/partial  dose  on  eMeds 
(see  attached  eMeds  Amending 
Administration.mp4). 

Microsoft Word 97 -

eMeds Amending 
2003 Document  Administration.mp4 

The  safety  message  and  videos  will  be disseminated  Trustwide  via  multiple  media 
platforms, along with being shared  on the Trust's intranet and will  also  be  sent to all 
staff by way of an email bulletin and on the communication digital newsletter. This will 
be sent separate to the normal safety message process. 

Concern 2 

The  Trust  accepts  that  there  was  incomplete  documentation  on  the  electronic 
prescription  record  (MedChart)  to  demonstrate that  the  intravenous  antibiotics  had 
been administered as prescribed. 

Medicines  Management  Policies  and  Procedures  (MM01)  Version  9.3  which  was 
implemented on 12 January 2023 states: 

"Healthcare staff must make a clear,  accurate and  immediate record of all medicines 
· administered, intentionally withheld, or refused by the patient, ensuring their signature, 
initials,  or electronic  signature  (as  appropriate  to  the  administration  record)  is  clear 
legible.  The  record  must  not  be  made  before  the  medicine  has  been 
and 
administered." 

In  the case of Mrs Smith, the dose of intravenous Teicoplanin  administered  at 17:56 
on 23 September 2023 (after being prescribed at 17:20 on 23 September 2023) was 
incomplete due to the leaking cannula and was then repeated at 21 :47. This was not 
recorded on MedChart or in the patient's clinical record. 

 The  Trust  collects  data  from  the  MedChart  to  monitor  whether  medications  are 
administered at the correct time, and this is then shared with the ward teams. The data 
for Ward  1 at  NSECH  for intravenous  drug  administration  shows  that  over 95%  of 
intravenous drug administration happened on time or early between 24 April 2022 and 
22 April 2024 (see figure 1 ).  Early administration occurs usually before a shift change, 
most commonly when the  night staff deliver that  morning  doses  before  handover to 
the day shift at 8.00 am. This allows the day team to start the busiest part of the day 
with some of the most time demanding tasks already completed. 

Ev,ty v-,;. Lat~ \r.ii On·limetrend bcl'M::'en 24 Apr 2022 - 22 Apr 2024 fur w-.J1<.J  NSEC  WARD 0 1 

Intravenous 

..t~ 

- ......  -

.. 

0-"'4 

. 

--

Figure  1 - Intravenous drug administration timing on ward 1 NSECH 

In the case in question the prescription was signed as administered after the antibiotic 
infusion  had  been  started,  however,  there  was  no amendment  made  to the  record 
when it became clear that the infusion had not -been completed due to the intravenous 
cannula not working properly. 

There was previously no clear guidance in policy MM01  on how to record partial doses 
(as might occur if the cannula leaks or is tissued). There is,  however,  a facility within 
the electronic  prescription  record  to  add  narrative text to  indicate  an  incomplete  or 
partial  dose and  this  is  regularly  used by clinical teams.  Data  taken  from  MedChart 
shows  that  for  Ward  1  at  NSECH,  50  individual  staff  members  used  this  facility 
between  1  June 2023  - 31  December  2023.  Table  1  below  shows  the  number of 
administration event changes during this period: 

Table 1 

Month (2023) 
Jun 2023 

Jul2023 

Aug 2023 

Sep 2023 
Oct 2023 

i  Nov 2023 

1  Dec 2023 

1  Grand Total 

Number of Administration Event Changes (NSECH Ward 1) 
90 

72 
72 

104 

107 

111 
119 
675 

,_  

 Table 2 

Shows the original administration event compared to the updated administration event. 

Eg  142 cases (highlighted) where a patient's administration was originally recorded 

as Administered but then updated to Missed. 

Updated Administration Event 
Adjust 
Infusion 

Administered  Delayed 

Infusion 
Started 

5 

Missed  Not 

Withheld  Grand 
Total 

Taken 

, __- - -

115 

142 

31 

103 

' 

112 
7 
. 42 

264 

-

80 
7 

5 
92 

4 

3 
7 

10 

1 

3 
156 

1 

4 
. 36 

115 

-

5

471

134 

8 

57 
675 

-

Original 
Administration 
Event 
Adjust Infusion 

Administered 

-Missed 

Not Taken 

Withheld 

Grand Total 

5 

Table 3 

This shows the updated reasons as to why an administration event was amended. 

Dose was due during MedChart downtime, and status unknown. (Refer to offline chart for details)

Administration Event Reasons 

(blank) 

Cancel to edit previous event 

-Clinical reason (please state) 

Decrined I refused 

Dose given early at nurse discretion 

Dose given late as patient off ward

Dose given late at prescriber's request 

-
-

Error in recording dose 

Medication unavailable 

Medication unavailable (D/W Pharmacy) 

Missed by staff/ unclear if dose administered 

1 

Nil by mouth 

No available access 

Other 

Patient asleep 

Patient asleep I drowsy 

-Patient away from the ward 
-Patient on !eave I absent 

Patient omitted to take 

Patient self-administered 

Patient vomited 

Retrospective recording of administration 

Valid Clinical Reason 

Withheld for cl"nical reason (Please specify) 
Grand Total 
-

Number  of 
Instances 
15 

- -

4

9 

78 

7 

2 

3 

1 

2 

8 

2 

5 

---- -

3 

2 

195 

3 

5 

2 

40 

2 

--15 

249 

15 

2 
6 
675 

-

-

 From the evidence presented at Mrs Smiths' inquest although this facility is being used 
appropriately  in  many  cases  there  are  instances  where  this  has  not  been  done. 
Moreover, within the recorded  amendments there are a significant number that have 
been  recorded  as either other (195) or blank (15), which  does not provide sufficient 
clinical context.  To  address this gap,  we  have created  a  new training  video for staff 
that demonstrates  how  to  effectively  use this facility  in  a  step-by-step  manner (see 
attached eMeds Amending Administration.mp4 in Concern 1 ). 

This  video  will  form  part  of  the  safety  message  referred  to  in  Concern  1  and 
disseminated to the organisation. 

In  conjunction  with  this,  Medicines  Management  Policies  and  Procedures  (MM01) 
Version 9.3 has now been amended to reflect the importance of partial dose recording, 
including reasoning. The key changes to policy are detailed  below and the amended 
policy is attached: 

"6.9.3.16  Healthcare staff must make a  clear,  accurate and  immediate record  of all 
medicines where an incomplete or partial dose of a medication has been administered 
(for example if signs of leakage are noted when re-checking the administration site as 
per  Appendix  16  2.3.4).  Healthcare  staff  must  ensure  their  signature,  initials,  or 
electronic signature (as appropriate to the administration record) is clear and legible. 
If the medication is a critical medication refer to 6.9.3.13." 

MM01  Medicine 
Policy Version 9.4 20; 

The  MM01  policy changes were  approved  by the Chief Pharmacist on  4  June 2024 
and will be ratified at Policy Assurance Committee on 9 July 2024. 

Clinical response to evidence of Mrs Smiths' deteriorating condition 

Sepsis  is when an  infection  begins to have a  more  global  impact on the body  both 
physiologically  and  biochemically.  However,  Sepsis  is  just  one  condition  that  can 
cause physiological and biochemical deterioration: At Northumbria Healthcare, it is the 
belief of our Deteriorating Patient Board that to truly improve care we need to focus on 
the recognition  of patients with all cause deterioration. By doing this we will  not only 
capture at risk patients with sepsis but with other key clinical conditions that need the 
same level of awareness and timely intervention. 

The message we aim to deliver is:  If you think someone is deteriorating, call for help 
and consider key generic interventions, which  may include intravenous antibiotics to 
halt or reverse  deterioration  whilst  you  continue to  make  a  unifying  diagnosis.  The 
Deteriorating Patient is one of the Trust's eight key safety priorities for this year. These 
safety priorities are chosen and then scrutinised by Safety, Quality and _Improvement 
Committee. 

We hope that the  information provided during the inquest and  in  writing provides the 
necessary assurances that The Trust already has in  place effective measures, which 
they continue to monitor and  improve to  ensure the effective delivery and recording of 
medications and the robust documentation of intravenous cannulas.  We are grateful 

 to  the Senior Coroner and  family  of Mrs  Smith for highlighting  the  areas for further 
improvement and will deliver the additional measures detailed  in this response. 

Yours sincerely 

Chief Executive