Annette Hill

North Bristol
NHS Trust

Trust Headquarters

Southmead Hospital Bristol

Southmead Road

Westbury-on-Trym

Bristol

BS10 5NB

06 November 2018 Te):

Website: http:/Awww.nbt.nhs.uk

The Coroner's Court
Old Weston Road
Flax Bourton

BS48 1UL.

Dear Mr Moore
Re: Regulation 28 following Inquest into the Death of Annette Hill

| write further to the Regulation 28, dated 21 September 2018, issued as a result of
the inquest into the death of Mrs Annette Hill. At the read only inquest | understand
you noted specific concerns regarding the unresolved tension between the Sepsis
Six guidelines and the BTS COPD care bundle for the management of patients with
advanced respiratory disease. Firstly, | would like to apologise as it transpires that
the wording in the RCA may have misled you regarding the potential conflict. To
allow me to provide context to the RCA and the investigation we have completed, |
have set out the difference between the two documents and the potential impact
each may have on the Trust’s patients.

Background Information

By way of a brief synopsis, it is important to note that a care bundle allows practice
to be standardised and is a structured way of improving the process of care. It
reduces the variation in treatment and intends to improve patient outcomes, by
providing a set of interventions. Alternatively, clinical guidelines are evidenced based
recommendations of how healthcare professionals should care for people with a
specific condition. NICE Guidelines set out the care and services suitable for most
people with a specific condition or need. Below is more specific detail regarding the
two documents considered in the RCA.

A University of Bristol Teaching Trust
A University of the West of England Teaching Trust

COPD Care Bundle

The NBT COPD admission care bundle is based on the BTS COPD admission care
bundle, implementing the same care pathway, steps and timeframes. This care
bundle aims to improve care and reduce readmissions for patients admitted with
acute exacerbation of COPD (AECOPD). The first stage of the NBT care bundle is
to establish a correct diagnosis of AECOPD as soon as possible at the point of
hospital admission, and that the diagnosis should be supported by an ECG and
chest x-ray. The BTS and NBT COPD care bundle recommend that this is done
within 4 hours of admission. The BTS Pilot Care Bundle Project, A Care Bundles-
Based Approach to Improving Standards of Care in COPD and Community Acquired
Pneumonia (2014), evidenced that when the bundle was implemented patients were
almost twice as likely to be seen by the specialist respiratory team and those
patients were more likely to have received all appropriate treatments within 48 hours
of their admission. This care bundle focuses on ensuring patients receive the correct
diagnosis and standardised investigations during their admission to hospital whilst
under review of respiratory physicians.

Sepsis Six Pathway

UK Sepsis Trust developed the concept of the ‘Sepsis Six’ — a set of six tasks to be
instituted within one hour by non-specialist practitioners at the front line. The UK
Sepsis Trust and The College of Emergency Medicine’s Toolkit for Emergency
Departments highlight that in the most severe cases, septic shock, for every hour
that appropriate antibiotic administration is delayed there is an 8% increase in
mortality. \t is for this reason that sepsis is regarded as a time critical condition and
the Sepsis Six guidelines are nationally mandated by NHS England and CQUINs
were set up with the purpose of providing the correct treatment for sepsis asap. The
NBT Sepsis Screening & Action Too/ implements tasks identified in the UK Sepsis |
Trust ‘ED/AMU Sepsis Screening & Action Tool’.

The NBT Sepsis Six guideline identifies the importance of recognising, diagnosing
and early management of sepsis, with the importance of early identification of
treatment stemming. The NICE Guidelines recommend that patients only need to be
suspected of having sepsis in acute hospital settings, show at least 1 of the criteria
indicating high risk of severe illness or death, to have the first dose of iV antibiotics
and a review by a senior clinical decision maker. The Guidelines recommend that
this is done within 7 hour of the patient being suspected of being at risk of sepsis.
The criteria provided by the NICE Guidelines are intentionally wide to reduce the
risks of missing patients who do have sepsis. However, North Bristol NHS Trust
tries to reduce the number of patients receiving antibiotics unnecessarily by ensuring
that identified patients are reviewed by a senior clinician before antibiotics are |

A University of Bristol Teaching Trust
A University of the West of England Teaching Trust

prescribed. We also aim to do this within 1 hour of the patient being suspected of
being at risk of sepsis.

The need for time critical preventative treatment against suspected sepsis means
that the Sepsis Six guidelines are implemented immediately and each patient’s risk
of sepsis is considered once they attend the ED.

investigation

| would like to reassure you that before the Trust introduces a policy/guidelines/care
bundle, the implications are considered by the relevant division. If there are
departmental concerns regarding the implementation of a policy/guidelines this
would be escalated through the Trust's Clinical Governance structure to ensure that
a decision can be made based on the best interests of our patients. If the Trust
considers that harm may be caused through implementation this would be escalated
for regional consideration before NHS England, NHS Improvement or NICE. Given
the volume of guidance available, conflicts between guidance is likely, however, the
Trust takes appropriate measures to identify and implement approaches which will
be of greater benefit for its patients and take steps to reduce the risk as much as
reasonably possible.

The RCA identified the possible conflict between the British Thoracic Society COPD
care bundle and the Sepsis 6 guidelines in relation to the prescription of antibiotics in
patients with undiagnosed exacerbation of airways disease. It was recommended
that the potential conflict be reviewed at the Sepsis Group meeting. This group
convened on 16 October 2018 and was of the opinion there was no conflict with the
COPD care bundle. Furthermore they did not feel that the Trust's current approach
to sepsis needed to change. They highlighted that there will always be patients who
overlap clinical guidelines (sometimes several) and it is important to recognise the
guidelines are there to assist clinicians, but clinical judgment must always be used
which is why a senior clinician reviews each patient before antibiotics are
administered to those at risk of sepsis.

Since the inquest and receipt of your Regulation report, the concerns raised have
been explored with the RCA author (i Consultant Emergency
Physician) and contributor Consultant Respiratory Physician)
who have both confirmed they do not consider that the Sepsis Six pathway and the
BTS COPD care bundle actually conflict. Furthermore, it was established that
approximately 2 out of 3 of patients that attend the Trust with exacerbated COPD
have a definitive infective component therefore the majority of patients attending with
exacerbated COPD are also likely to benefit from the administration of antibiotics in
any event.

A University of Bristol Teaching Trust
A University of the West of England Teaching Trust

North Bristol NHS Trust's approach is to adopt the Sepsis Six guidelines but we do
not routinely follow the BTS COPD care bundle. The Sepsis Six guidelines are
implemented for each patient that attends the ED, whereas the BTS COPD care
bundle is only intended for use for those diagnosed with AECOPD. As a Trust, we
are satisfied that it is in the patients’ best interests to implement the Sepsis Six
guidelines before the BTS COPD care bundle, as the former addresses an
immediate risk to a patient's welfare. This approach is supported by the fact there is
no national guidance that says that Sepsis Six should not apply to patients with
COPD: the majority of patients suffering with exacerbated COPD have an infective
cause and are therefore likely to benefit from antibiotics; furthermore NICE estimate
that 20 deaths from anaphylaxis are reported each year in the UK, compared to
37,000 sepsis related deaths in the UK.

| am satisfied with the findings of the Trust’s Sepsis Group meeting in that a great
number of patients will overlap clinical guidelines and that on the evidence available
it is correct to prioritise the Sepsis Six Guidelines before the COPD care bundle with
the additional safety net of a review by a senior clinician before antibiotics are
administered. In doing so this is likely to be of benefit for the greater population of
our patients. | hope the above addresses your concerns surrounding the potential
conflict in the RCA and reassures you that we have a clear approach to sepsis and
why this approach is taken.

Yours sincerely

Chief Executive

A University of Bristo! Teaching Trust
A University of the West of England Teaching Trust

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