Jordan Howarth

From Maria Caulfield MP 
Parliamentary Under Secretary of State for 
Mental Health and Women's Health Strategy 
Department of Health & Social Care 

39 Victoria Street 
London 
SW1H 0EU 

13 May 2024 

Alison Mutch 
HM Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Ms Mutch, 

Thank you for the Regulation 28 report to prevent future deaths of 1 May 2024 about the death 
of Mr Jordan Howarth. I am replying as Minister with responsibility for patient safety. 

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Howarth’s 
death and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to my 
attention. 

The report raises the following concerns: 
1.  Whilst  there  was  input  into  Mr  Howarth’s  care  from  both  the  microbiologist  and  the 
consultant physician there was not a joint approach to his care and no detailed discussions 
regarding the decision to withhold antibiotics. 

2.  The Critical Care Outreach Practitioner had identified that Mr Howarth needed to be moved 
to ICU urgently, which had to be ratified by the ICU Consultant if he was to be accepted 
into ICU. There was no documentation from the ICU consultant setting out their rationale 
for not examining Mr Howarth at that point and for declining to admit him at that point. 
3.  The Trust’s policy was that anyone who had a NEWS2 score of 5 and no ceiling of care 
should be  referred  to the Critical  Care Outreach team. The  inquest  heard evidence that 
this was not followed on a number of occasions and the fact it had been missed was not 
identified by more senior members of the nursing team. 

4.  The inquest heard oral evidence of conversations that it was told had taken place between 
consultants in a number of specialisms about Mr Howarth that were not documented in his 
notes. 

5.  The  inquest  heard  that  despite  the  complexity  of  his  case  there  was  no  evidence  of  a 
multidisciplinary discussion/approach to assess his position  fully and that  it  was unclear 
who was responsible for the continuity of his care. 

A1  
  
  
 
 
 
 
 
  
 
  
 
  
  
  
  
  
   
 
  
 
  
 
 
 
 
  
  
 
 
  
 
 
  
  
  
 
  
  
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
 
 
 
 
       
  
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 Most of these issues are operational in nature and I note that you have rightly sent your report 
to the hospital in question (Tameside General Hospital). It will be important that they consider 
these issues and findings fully and write to you with the actions and improvements they will be 
taking to address your findings and prevent a reoccurrence of what happened to Mr Howarth. 

In the meantime, it may be helpful if I outline the work we are doing at a national level to 
improve how the NHS detects and acts upon signs of deterioration. 

In February the Government and NHS England announced plans to implement Martha’s Rule 
in at least 100 acute or specialist NHS sites in England by March 2025. Martha’s Rule is an 
initiative that gives patients and their families who are concerned about deterioration in their 
physiological  condition  the  right  to  initiate  a  rapid review  of  their  case  24 hours  a  day  from 
someone outside of their immediate care team. When requested, this rapid review will inform 
whether  any new or additional  action needs to be taken to help ensure patients  receive the 
most appropriate care and treatment – which may include escalation. 

While some NHS Trusts already offer rapid review processes similar to Martha’s Rule called 
Call 4 Concern, others do not have an equivalent mechanism in place. In recognition of these 
variations in readiness, we are initiating a phased approach to implementing Martha’s Rule. 
NHS England are leading the process of identifying the 100+ sites that will participate in this 
first  phase  and  supporting  the  development  of  their  local  processes.  Alongside  this,  NHS 
England will develop proposals for national rollout in the next Spending Review period. 

Implementation of Martha’s Rule forms part of NHS England’s Managing Deterioration Safety 
Improvement Programme. This programme aims to reduce deterioration-associated harm by 
improving  the  prevention,  identification,  escalation  and  response  to  physical  deterioration, 
through  better  system  co-ordination  and  as  part  of  safe  and  reliable  pathways  of  care.  In 
addition  to  phase  one  of  Martha’s  Rule  implementation,  the  programme  consists  of  the 
following workstreams: 

•  Continued  testing  and  implementation  of  the  standardised  national  deterioration  tools 
addressing adults, children and young people, maternity and newborns across settings, 
incorporating patient, carer and family concerns; and 

•  Publication, implementation and spread of the PIER Framework 

(Prevent, Identify, Escalate and Respond to physical deterioration), to improve how the 
NHS  supports  staff  across  systems to manage deterioration  and encourage greater 
involvement from patients, families, and carers. 

I hope this response is helpful. Thank you for bringing these concerns to my attention. 

Best Wishes, 

MARIA CAULFIELD 

A2

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Karen James

Chief Executive Officer

Tameside and Glossop Integrated Care NHS Foundation Trust
Silver Springs

Fountain Street

Ashton under Lyne

Lancashire OL6 9RW

26 June 2024
Strictly Private and Confidential
FAO Ms Mutch

HM Coroner
Coroner's Court

4 Mount Tabor Street
Stockport

Cheshire

SK1 3AG

Dear Ms Mutch

| am writing further to the inquest regarding the death of Mr Jordan Howarth (who died
on 6" April 2024) which concluded on 20" March 2024 and the subsequent Regulation
28 Notice issued to the Trust. | hope to set out below my response in terms of what
we are already doing and what we plan to do in relation to your concerns.

You expressed concerns around the joint approach to Mr Howarth’s care from both
the microbiologist and the consultant physician, specifically around the decision to
withhold antibiotics. There were concerns around the documentation from the
Intensive Care Unit (ICU) Consultant, setting out/not setting out their rationale,
specifically no discussions between the medical consultant and the ICU consultant
within the medical notes. You were also concerned that the Trusts’ policy around
NEWS2 escalation had not been followed and that despite complexities with Mr
Howarth’s treatment, there was no. evidence of a _ multi-disciplinary
discussion/approach and it was unclear who was responsible for his continuity of care.
| aim to take these concerns in turn to provide you with a detailed update on the Trusts’
progress.

e The joint approach to Mr Howarth’s care from both the microbiologist and
the consultant physician, specifically around the decision to withhold
antibiotics.

In response to this particular point the ICU team have updated and amended the daily
review chart to include a specific section for microbiology input. All patients on ITU are

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Integrated Care
NHS Foundation Trust

reviewed daily by the Microbiology Team, with a middle grade doctor in attendance to
document and update the daily review chart. The attendance of the microbiologist on
the ICU enables real time multidisciplinary discussions to take place and for any
decisions to be recorded. The completion of the updated documentation will be audited
to ensure that this is being completed. The audit has been planned with the Trust’s
audit team and will form part of the local audit program for the ITU team.

In addition to the actions taken by the ITU the Microbiology Team have also reviewed
their processes. The Microbiology Team currently complete daily ward rounds across
the organisations, Monday to Friday. This clinical activity is already part of the
Microbiology Team’s job plan for each week. In the event that a clinician is not present
to discuss a patient at the time of review from Microbiology, Microbiology have
introduced a sticker that is placed in a patients notes to alert medical staff to the
management plan. Microbiology have given assurance that anti-biotics will not be
stopped until the blood culture results are available, management advice for bacterium
identified from blood cultures is left in the patient notes alongside the anti-biotic plan.
To further support clinical teams in accessing Microbiology advice the team are also
available to provide support and guidance to clinical colleagues over the phone.

e The documentation from the ICU consultant setting out/not setting out
their rationale, specifically no discussions’ between the medical
consultant and the ICU consultant within the medical notes

As you will know, the first phase of Martha’s Rule has been implemented across 100
NHS sites from April 2024. The purpose of this is so that patients, families, carers and
staff will have round the clock access to a rapid review from a separate care team if
they are worried about a persons’ condition/deterioration. Martha’s Rule will build on
the evaluation of NHS England’s Worry and Concern Improvement Collaborative and
involves encouraging staff, patients’, families and carers to escalate their concerns
around patient deterioration. Martha’s Rule is one of a series of measures
implemented to improve the way Trusts’ identify and document a decline in a persons’
condition.

Martha’s rule has 3 components:

1. All staff in NHS Trusts must have 24/7 access to a rapid review from a critical
care outreach team, who they can contact should they have concerns about a
patient.

2. All patients, their families, carers, and advocates must also have access to the
same 24/7 rapid review from a critical care outreach team, which they can
contact via mechanisms advertised around the Hospital, and more widely if they
are worried about the patient's condition.

- 3. The NHS must implement a structured approach to obtain information relating
to a patient’s condition directly from patients and their families at least daily. In
the first instance, this will cover all inpatients in acute and specialist Trusts.

Tameside and Glossop

Integrated Care
NHS Foundation Trust

NHS England has asked Trusts nationally to submit expressions of interest for the first
phase of the implementation plan. As such Tameside & Glossop Integrated Care NHS
Foundation Trust (TGICFT) submitted their expression of interest which has been
successful. As one of the selected pilot sites for the first phase of the implementation,
the Trust is developing a suite of information leaflets and posters to publicise to
patients, staff, carers and families the mobile number that will sit with the Critical Care
Outreach Team to respond to. The Trust is working under the direction of NHS
England and the anticipated launch date is September 2024.

In addition to the Matha’s rule implementation plan, TGICFT have introduced a new
process. The process supports members of the Critical Care Outreach Team,
including the Outreach Specialty Doctor to access an alternative opinion from an
Intensive Care Doctor should they have an unresolved concern or worry about a
patient. Please see attached a copy of the standard operating procedure (SOP) for
your consideration.

As a direct result of this case the Trust implemented an immediate response as part
of the Trust’s sepsis quality improvement project. The response was that a training
and poster campaign describing “Think Sepsis / Think Outreach” as well as running a
number of sepsis training. Sepsis is also now incorporated into the Outreach education
day and this is available to all Trust staff. Please see attached a copy of that poster.

The Trust has an established Critical Care Outreach Team which is comprised of a
number of highly skilled and experiences critical care nursing colleagues. The service
is available on 24 hours, seven days a week basis. In addition to this, the Trust
implement MERIT (Medical Emergency and Rapid Intubation Team) as part of its
response to the Covid-19 pandemic. Although the Trust, like others nationally have
stood down many of the supportive measures implemented in response to the
pandemic, the organisation has continued with the MERIT Team. The MERIT Team is
staffed by senior anaesthetic colleagues including consultant level from 08:30 to
18:00, and from 18:00 to 08:30 this is staffed by a middle grade anaesthetist. MERIT
is also available 24 hour, seven days a week basis. This is in addition to the medical
staff who support/advise and give guidance.

e The Trusts’ policy around NEWS2 escalation had not been followed

The NEWS2 is the latest version of the National Early Warning Score (NEWS), first
produced in 2012 by NHSE and updated in December 2017. It advocates a system to
standardise the assessment and response to acute illness.

In December 2018, the Trust implemented the NEWS2 chart and an associated
escalation document. There are ongoing Trust wide audits which measure compliance
with the guidance. These are undertaken on a weekly basis with action being taken to
address areas of concern. The aim of the audits are to ensure that observations are
undertaken as per NEWS2 guidelines, to identify areas of practice that can be
improved in relation to identifying and managing the deteriorating patient, to reinforce

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Integrated Care

NHS Foundation Trust

the importance of an accurate track and trigger score and to highlight the need of
timely escalation of the deteriorating patient.

The Trust also completes bi-annual NEWS2 audits every April and October. During
April 2024, the NEWS2 Observation Charts of a random sample of ten patients (or
less) per ward were reviewed by the Critical Care Outreach Practitioners. Patients
from 14 wards were included in the sample and all patients had been on the ward for
a minimum of 48 hours (24 hours for the Acute Medical Unit (AMU).

As a result of the annual audit in April 2024, several recommendations were made:

« Ward Managers/matrons to take urgent action where compliance is below 90%
this is monitored via exception reports within each clinical division.

* Ward Managers to continue weekly NEWS2 compliance spot checks and
provide feedback to staff, as appropriate.

* Ward Managers to monitor NEWS2 e-learning training compliance.

*« NEWS2 training to remain essential e-learning for all clinical staff Band 3 and
above.

¢ Continue to include NEWS2 in the Acute Illness Management Programme
(AIM) and Outreach refresher training.

* Outreach deliver a deteriorating patient study day, which now incorporates
sepsis, this was implemented in 2023 following the learning from this case.

« Implementation of an Electronic NEWS2 recording and scoring system to be
progressed

* Audit results and action to be monitored by the Managing Deteriorating Patient
Group

The Trust also reviews NEWS2 as part of the ward accreditation program and the
monthly ward audits, which include escalation of NEWS2 and if NEWS2 has been
scored correctly. The results of these audits are monitored and discussed at the
Sepsis Improvement Board which is chaired by the Associate Medical Director and
this is held monthly.

The Trust has agreed a business case to purchase an electronic NEWS monitoring
system, this is anticipated to be implemented in 2025. The Trust have also added
sepsis electronic icons on each ward whiteboard to easily identify those patients who
have sepsis.

To further support training in relation to sepsis, the Trust introduced sepsis simulation
training in July 2023, since then there have been 8 sessions held with further dates
booked. To date 107 multidisciplinary candidates have attended from across all
divisions. The Education and Training Team are currently in discussions to make the
sepsis simulation mandatory for all staff to attend yearly. Further to this the Acute

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Illness Management (AIM) course includes a workshop specifically focused on sepsis.
AIM is a blend of lectures, workshops and simulated learning that embed the ABCDE
approach to assessment and management of the patient with deteriorating illness. In
the last 6 months 104 members of staff have attended the AIM course.

e Despite complexities with Mr Howarth’s treatment, there was no evidence
of a multi-disciplinary discussion/approach and it was unclear who was
responsible for his continuity of care

The Trust follow the General Medical Council (GMC) guidance that supports the
recommendation, that every patient admitted to hospital will have a named, identifiable
clinician assigned to them. This will help to make sure care is properly coordinated.
Mr Howarth’s care was reviewed by several consultants during his admission: ISGU
each
discussed and referred this gentleman’s care to other specialisms as required.

The Trust adhere to the GMC guidance and all patients are appointed a consultant on
admission. The consultant’s name is inputted onto the electronic patient record system
(Lorenzo), this triangulates with the ward patient safety board that identifies the
consultant appointed for the patients care. The medical ward that Mr Howarth was
admitted to, have described their process in that all patients are appointed a consultant
on admission. Should this not happen it would be identified at the daily ward board
round as the electronic board identifies the patient with corresponding consultant. If
the electronic board does not identify a consultant to a patient is it rectified
immediately. It is the responsibility of the consultant appointed on admission to
coordinate all MDT discussions and document any discussions and decisions made.

e Documentation

Documentation is revisited at the Trust on a regular basis at the bi-monthly Medicine
and Urgent Care Divisional Meeting as well as the Surgery, Women’s and Children’s
Divisional Meeting. Legal Services also contribute to these meetings in relation to the
learning from inquests and it is an area the Trust are continuing to monitor and
develop. The importance of documentation has been reiterated at the Medicine and
Urgent Care, Patient and Staff, Quality and Safety Forum (PASQASF) and the
Surgery, Women and Children’s Patient and Staff, Quality & Safety Forum
(PASQASF) the on 16" May 2024.

To strengthen the documentation from ITU and Critical Care Outreach, the team have
developed a stamp to evidence NEWS2 escalation and these stamps are also used
by AMU nursing staff. The Trust is reviewing the need for issuing of these stamps
across all staff members. The stamp is used in conjunction with the completion of the
NEWS2 charts. NEWS2 training forms part of the Trust’s induction process and the

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integrated Care:
NHS Foundation Trust

Critical Care Outreach Team conduct case studies as part of that induction/training. In
addition to the stamp, all nursing staff have been reminded that a deteriorating patient
does not need to be scoring a NEWS2 of 5 and that any deteriorating .patient,
regardless of NEWS2 score, should be escalated to the Nurse in charge (NIC). As
mentioned above, the Trust also reviews NEWS2 as part of the ward accreditation
program and the monthly ward audits and the results of these audits are monitored
and discussed at the Sepsis Improvement.Board. Furthermore, the Critical Care
Outreach team now document within the patients’ medical records rather than the
nursing documentation. This ensures that all members of the multidisciplinary team
can access all information at any time rather than looking through different documents.

I hope this response has provided assurance that the Trust has taken your comments
and concerns seriously and action taken to minimise the risk of such an event
occurring again. Should you require any further information, please to not hesitate to
contact me through the Legal Services Team on

Yours sincerely,

Medical Director

On behalf of Karen James (Chief Executive Officer)
Tameside and Glossop Integrated Care NHS Foundation Trust