Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0618, written 12 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Nov 2024 |
|---|---|
| Reference | 2024-0618 |
| Deceased | John Doyle |
| Coroner | Linda Lee |
| Coroner area | Coventry and Warwickshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Coventry and Warwickshire NHS Trust · George Eliot Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 6 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28 Report to Prevent Future Deaths Coroners and Justice Act 2009 Coroners (Investigations) Regulations 2013 THIS REPORT IS BEING SENT TO: • NHS England • The Chief Executive Officer of University Hospital of Coventry and Warwickshire NHS Trust. The Chief Executive Officer of George Eliot Hospital NHS Trust. UK Kidney Association. British Transplant Society. Renal Association. • • • • 1. CORONER: I am Linda Lee, Assistant Coroner for the coroner area of Coventry and Warwickshire 2. CORONER’S LEGAL POWERS: I make this report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 of the Coroners’ (Investigations) Regulations 2013. 3. INVESTIGATION AND INQUEST: On 9 January 2024, an investigation was commenced into the death of John Frederick Doyle, who died on the 30 December 2023 aged 60. The investigation concluded at the end of the inquest on 8 November 2024. The conclusion was: 1a Multiple Organ Failure 1b Cytomegalovirus Infection 1c Chronic kidney disease (unknown aetiology, kidney transplant in 2022) II Hypertension Natural causes against a background of missed opportunities to diagnose and treat cytomegalovirus infection, together with the impact of the resident (formerly junior) doctors' strike on the provision of consistent patient care. 4. CIRCUMSTANCES OF THE DEATH: In March 2022, John underwent a kidney transplant at Manchester Royal Infirmary and subsequently received follow-up care and regular reviews at the Royal Derby Hospital (RDH). He was first admitted to George Eliot Hospital (GEH) on 2 December 2023, presenting with rectal bleeding and a persistent cough. Evidence was presented that GEH, like many hospitals, does not have an in-house renal team. As a result, GEH relied on telephone consultations with specialist hospitals for advice on investigations and treatment for renal-related issues. During John’s treatment, the team at GEH sought guidance from both RDH and University Hospital Coventry and Warwickshire (UHCW), the latter being the nearest specialist centre. Following John’s admission, tests were ordered to rule out cytomegalovirus (CMV) colitis. However, without receiving these test results, John was discharged on 6 December, despite evidence suggesting he was still very unwell. He was re-admitted via emergency ambulance on 8 December. Unsuccessful attempts were made to test for the presence of CMV during his stay at GEH. John’s condition continued to deteriorate, and he was transferred to UHCW on 21 December. A diagnosis was not made until 28 December, when tests showed he had 27 million copies of CMV per millilitre of blood, an extremely high count. Treatment with ganciclovir and anti-CMV immunoglobulin was commenced. By this stage, it is likely that John had developed CMV encephalitis. He was intubated and ventilated, but his condition declined, leading to multiple organ failure. John died on 30 December 2023. Evidence was received that whilst CMV rarely causes more than cold or flu-like symptoms in the general population, it is one of the most common infectious complications of solid organ transplantation and is reported to increase graft loss and patient mortality. It was acknowledged that an earlier diagnosis and treatment of CMV could have potentially changed the outcome for John and would have increased the likelihood of successful treatment. Consultants from both hospitals testified that, due to the junior doctors' strike, they had to assume additional responsibilities and manage a higher patient load, which affected their ability to maintain a consistent overview of patients’ conditions and treatments. In John’s case, the impact was the failure to notice that the test results had not been received at both GEH and UHCW. The patient safety incident investigation by GEH identified human error and systemic issues in handling CMV testing and the care of renal patients: 1. Sample Collection Errors: Multiple errors were identified in sample collection for CMV testing: o The laboratory operated by UHCW failed to freeze one sample and one sample was incorrectly rejected as unusable o Clinicians used the wrong tubes, failing to use the necessary, purple-topped tube that prevents the blood collected from clotting. o Human error led to prompts for correct tube selection being ignored and the use of paper labelling did not prompt the use of the correct tube. o Expedited testing needs were not clearly communicated, leading to delays. o Staff were unaware of the testing schedule in place at UHCW for CMV testing 2. Documentation and Communication: Medical notes lacked thorough documentation on the selection and dispatch of samples, contributing to inefficiencies and miscommunication among staff. 3. Delayed Transfer to Specialist Care: John should have been transferred earlier to UHCW, which has the necessary renal services, including dialysis and specialised renal diets. GEH/UHCW lacked the protocols for timely patient transfer. The report also recommended that patients who are at risk of transplant failure should be managed proactively. Evidence given at the inquest showed there is currently no clear protocol at GEH regarding which hospital to contact for advice or when a patient should be considered for transfer to a specialist unit. Additionally, it was unclear whether the transfer should be initiated by the specialist centre or by GEH. Evidence was received that some training had been delivered on the correct procedure regarding sampling and that draft protocols were being drawn up but were not yet finalised or published. None of the consultants from GEH who gave evidence had expertise in renal medicine or experience with transplant patients. Additionally, although it was planned to develop guidance, only the renal consultant at UHCW was familiar with the Renal Association and the British Transplantation Society’s guidelines, specifically the ‘Clinical Practice Guideline Post-Operative Care in the Kidney Transplant Recipient’. This guidance states: “This document is intended for those engaged in the care of kidney transplant recipients (KTR) who are non-experts. With increasing efforts to deliver healthcare locally, many renal transplant recipients are followed up in centres remote from the main surgical transplant unit. At the same time, transplantation medicine has evolved into an increasingly complex and specialised field of nephrology. The following guidelines reflect this alteration in clinical practice and are intended for those healthcare professionals who look after renal transplant patients. They are also intended to be useful to both medical and surgical trainees, general practitioners, nurse specialists and other associated healthcare professionals involved in the care of renal transplant patients.” It was noted that the guideline aims to inform and support non-experts caring for transplant patients, not to replace assistance from specialist centres. It does not appear that there is any specialist guidelines or examples of best practice regarding collaborative ways of working between specialist and non-specialist centres. 5. CORONER’S CONCERNS: During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report these concerns to you. The MATTERS OF CONCERN are as follows: Concern 1: Contacting Specialist Centres Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals. Concern 2: Information Sharing with Specialist Centres The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined. Concern 3: Accessibility to Renal Care Guidelines Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients. This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal hospitals. Concern 4: Transfer Responsibility There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers. Concern 5: Decision-Making for Patient Location Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ, potentially affecting consistency in care approaches. Concern 6: Coordination Between Specialist and Non-Specialist Hospitals There may be variation in how specialist renal hospitals engage with non- specialist hospitals that rely on their expertise, impacting collaborative efforts Currently, there is no clear guidance on how specialist and in patient care. non-specialist teams should work together effectively to ensure consistent, high-quality care for these patients. 6. ACTION SHOULD BE TAKEN: In my opinion, action should be taken to prevent future deaths, and I believe you, have the power to take such action. 7. YOUR RESPONSE: You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 January 2025. I, the coroner, may extend the period if necessary. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Alternatively, you must explain why no action is proposed. 8. COPIES AND PUBLICATION: I have sent a copy of my report to the following interested persons: o o o o o o o o John’s family NHS England The Chief Executive Officer of University Hospital of Coventry and Warwickshire NHS Trust The Chief Executive of George Eliot Hospital NHS Trust UK Kidney Association British Transplant Society Renal Association I am also under a duty to send a copy of this report to the Chief Coroner and to publish it on the Judiciary website but may redact the report before publication if appropriate. 9. DATED: 12 November 2024 Linda Lee Assistant Coroner for Coventry and Warwickshire
6 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
INHS University Hospitals Coventry and Warwickshire NHS Trust University Hospital Clifford Bridge Road 1 Walsgrave Your os Coventry Our ref: CV2 2DX 6 January 2025 www.uhew.nhs.uk Ms Linda Lee Assistant Coroner for Coventry and Warwickshire Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL Dear Ms Lee Requlation 28 Report — Mr John Doyle Thank you for your email of 12 November 2024 enclosing a Regulation 28 Report to Prevent Future Deaths which is addressed to a number of organisations which include University Hospitals Coventry and Warwickshire NHS Trust (UHCW) following the inquest into the death of Mr Doyle. As you are aware from the evidence of the medical witnesses at the inquest on 8 November 2024, the renal team at UHCW have been developing guidelines to assist George Eliot Hospital (GEH), a non-renal specialist hospital, in the management of acutely unwell kidney transplant renal inpatients. We are pleased to report that these guidelines have been finalised and agreed between the Trusts and we enclose a copy. These guidelines have been shared and cascaded within the respective clinical teams which includes discussion as the Trust’s Renal Quality Improvement and Patient Safety meeting (QIPS). Once ratified through the usual governance processes these guidelines will be placed on the Trust's intranet to be accessible to all staff. In addition, both Trusts have agreed a Service Level Agreement (SLA) which means that a member of UHCW’s renal team will attend GEH and review their renal inpatients on GEH request up to twice a week. One of our senior Transplant Nephrologists has liaised with UK Kidney Association who are in agreement with the measures taken by UHCW and GEH in response to this report. We believe these combined measures address the 6 concerns set out in your Report and will undoubtedly improve patient care and lead to better collaborative working. Chief Executive Officer: Chair: Taking the concerns that you have raised in turn we respond as follows: Concern 1: Contacting Specialist Centres The SLA between the Trusts enables GEH to contact the UHCW renal team and request an on-site attendance. This will mean that a UHCW nephrologist will attend to review renal patients where their input is required up to twice a week. In addition, the current processes for GEH to contact specialist have been outlined in the guidelines, including contacting the renal team and also the virology team. Concern 2: Information Sharing with Specialist Centres The SLA and guideline set up a clear framework to ensure good communication between the Trusts including timely investigation and treatment. Additionally, processes to document communication between renal department and other hospitals, “referapatient.org” is being considered. Concern 3: Accessibility to Renal Care Guidelines The guidelines have been agreed with the relevant departments and shared with GEH. Both UHCW and GEH have worked closely to ensure the guidelines communicate the relevant information in an easily understandable manner, whilst ensuring the urgency is conveyed. Guidelines have been cascaded within the respective clinical teams and will be placed on the UHCW intranet once they have been through the governance process for ratification. Concern 4: Transfer Responsibility The SLA which provides that a renal specialist will attend GEH on request should help identify those patients requiring urgent transfer. UHCW will be responsible to accept all renal patients admitted to GEH, regardless of their parent hospital. In addition, the internal processes to highlight which patients need urgent transfer have been changed (we now have a daily huddle at 11.30am with the UHCW Medicine Operational team where a renal doctor is present, so that interhospital transfers can be highlighted and appropriately prioritised). Concern 5: Decision-Making for Patient Location The SLA will support decision-making for patient location by ensuring face to face communication between senior medical staff from UHCW and GEH. We anticipate that the guideline will also support this, in that investigations and results will be more timely available and reviewed. Concern 6: Coordination Between Specialist and Non-Specialist Hospitals It is usually the case that a non-specialist hospital will contact the parent specialist hospital where that particular patient has been having their routine renal care. However, following this Regulation 28, UHCW will now be the primary specialist transfer centre for all renal patients admitted to GEH regardless of their parent specialist unit. The agreed shared guidelines and SLA will ensure closer working and improved patient care. Chief Executive Officer: PY Chair: P| Please do not hesitate to get in contact should any further information be required. Yours sincerely Chief Executive Officer Chief Executive Officer: Professor Andrew Hardy Chair: Sue Noyes
George Eliot Hospital NHS Trust College Street Nuneaton Warwickshire CV10 7DJ Your Ref.: 10718704 Our Ref.: RN/LJW – Doyle 2 January 2025 PRIVATE & CONFIDENTIAL Ms L Lee HM Assistant Coroner Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL Dear Ms Lee RE: REGULATION 28 REPORT – JOHN DOYLE Further to your report dated the 12 November 2024, in accordance with paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009 and the regulations 28 and 29 of the Coroner’s (investigations) Regulations 2013, I offer the following response:- As reported on the day of the inquest (8th November 2024) the University Hospitals of Coventry & Warwickshire (UHCW) were compiling guidelines to assist the George Eliot Hospital (GEH) should the Trust have an inpatient with similar health conditions in the future as there is no renal specialist service at the GEH. The Trust has now received management guidelines from the Renal Team at UHCW and below is a table showing what actions the Trust has taken to embed the information received. Description New guidelines to be made easily accessible on the Trust’s intranet Quick reference guidelines for management of acute unwell kidney transplant recipients have been produced (a laminated poster will be displayed in clinical areas) Guidelines to be discussed at the daily doctors briefing To be discussed at all Trust wide Governance meetings for them to share with all consultants/relevant members of staff Action Taken Guidelines have been developed and are currently going through the Trust’s ratification process prior to uploading on to the Trust’s intranet. Posters have been shared for dissemination with the Directorate Governance Leads on the 12 December 2024. These will be discussed at the Directorate Governance Meeting. Information on the new guidelines and how to access them formed part of the daily brief for wards and departments from the 16 to the 20 December 2024. On the 17 December the guidelines and quick reference was e-mailed to all doctors and consultants. This will be reiterated at the Doctors Grand Round Shared with all Directorate Governance Leads on the 12 December 2024 for dissemination. Making staff aware of the referral process asking UHCW renal staff to visit a patient on the ward This is in the guidelines and is a consultant to consultant referral process. The process has been shared as per above. Your concerns were:- 1. Contacting Specialist Centres Following the inquest on 8 November 2024, our Consultant Governance Lead for the Medicine Directorate has continued to liaise with the Consultant Renal Specialist at UHCW to develop robust joint clinical guidelines. GEH will take every case individually as they present and will also contact the appropriate Trust where the patient is receiving their renal care. As well as guidelines from UHCW a laminated quick reference guide has been produced which contains the emergency contact numbers for renal services at UHCW. This will be displayed across the Trust. Patients who are pregnant with on-going renal conditions/transplant would be transferred to UHCW as part of the Maternal Medicine Pathway. 2. Information Sharing with Specialist Centres The guidelines (enclosure 1) illustrate the sample collection requirements, together with what to do if the results are positive and the telephone numbers to be used. Clinical staff will liaise at the earliest with the specialist centre as results dictate. This is documented on the enclosed guideline. 3. Accessibility to Renal Care and Guidelines The guidelines provided by UHCW will be available on the intranet once the Trust’s ratification process has been followed. Guidelines have already been shared with all Directorates to make sure that the relevant clinical staff are aware of the guidelines. 4. Transfer Responsibility Consultant to consultant clinical conversations will take place if there is a requirement to transfer the patient to the renal centre. There is a Service Level Agreement (SLA) in place for a renal specialist from UHCW to visit renal patients being cared for a GEH, twice a week. This patient familiarisation will assist in the timely transfer process should the patient need to be relocated to the specialist centre. 5. Decision Making For Patient Location There is a consultant to consultant referral process in place where decisions are made on the location based on the patients clinical need. 6. Co-Ordination Between Specialist and Non-Specialist Hospitals. The guidelines from UHCW are very clear on when they should be invoked and the quick reference guides will make it easier for GEH staff. I hope this answers your outstanding concerns, but please do not hesitate to contact me if you require any clarification. Yours sincerely Dr Najam Rashid Chief Medical Officer enc.1 Guidelines for Management of Acute Unwell Kidney Transplant Recipients - For use at GEH – in consultation with UHCW Renal Service
University Hospital
Clifford Bridge Road
Walsgrave
Coventry
CV2 2DX
Direct Line:
www.uhcw.nhs.uk
Your ref:
Our ref:
30 January 2025
Ms Linda Lee
Assistant Coroner for Coventry and Warwickshire
Warwickshire Justice Centre
Newbold Terrace
Leamington Spa
CV32 4EL
Dear Ms Lee
Regulation 28 Report – Mr John Doyle
Thank you for your email of 9 January 2025. In response to the additional points raised by the UK
Kidney Association (UKKA) and the British Transplantation Society (BTS) in their letter dated 21
December 2024, we comment as below:
Contacting off-site specialists and sharing information
• We recommend that all hospital switchboards, Emergency Departments and relevant
personnel have a master copy of local specialist centre contact details so any query at any
time can be appropriately directed.
Whilst this is a question that is best answered by our local non specialist hospitals, we are aware that
both South Warwickshire NHS Foundation Trust and George Eliot Hospital switchboards and their
Emergency Departments have local specialist centre contact details.
• We recommend that all staff are advised of internal escalation routes. Relevant clinical
colleagues should be aware of internal escalation routes to clarify whether off-site specialist
input is required. We would expect this to be achieved by asking the Consultant responsible
for the patient’s care or their deputy.
We confirm that staff at UHCW are aware of internal escalation routes. The escalation of concerns is
via the renal registrar and renal consultant. We confirm that UHCW has shared and agreed with
George Eliot Hospitals the indications for referral to us as a specialist unit, and the routes for referral.
• We advise that electronic information sharing in real-time should be the gold standard for
information sharing. In the case of kidney patients, we would expect to be informed about all
patients admitted for care in another hospital or elsewhere in our own hospital who have
chronic kidney disease stage 5 (CKD G5) or who are receiving dialysis treatment or who have a
kidney transplant.
Chief Executive Officer:
Chair:
There is an established and effective process for referring patients who are receiving dialysis to their
parent unit. UHCW has Service Level Agreements with George Eliot Hospital and with South
Warwickshire Foundation Trust that UHCW will provide onsite Renal Consultant Specialist inpatient
review at GEH and SWFT upon request up to twice a week. Additionally, UHCW has worked with UK
Kidney Association and agreed to be the primary specialist transfer centre for all renal transplant
patients admitted from referring hospitals regardless of their parent specialist unit.
Electronic patient sharing of blood test results in real-time exists for patients who are already known
to UHCW Renal Department, whether admitted to GEH or SWFT. In addition, “referapatient.org” is
being considered as a means of recording communication between referring centres and UHCW in
real time.
• We advise that Trusts review their processes to ensure that CMV results are available in a
timely fashion. This involves considering the transport and turnaround of samples with prompt
reporting in specialist virology laboratories as well as how to ensure that blood is taken in the
correct blood tubes.
Following the sad death of Mr Doyle, UHCW Renal and Virology teams have reviewed processes.
Guidelines have been developed which describe: the correct blood tubes, how to ensure urgent
turnaround, who to contact, when, and how to escalate to These have been shared with GEH.
Turnaround times for all pathology labs are published in CWPS Handbook V16 May 2024.pdf.
Accessibility to Renal Care Guidelines
• As access to Guidelines could lead to a misunderstanding of the significance and urgency
of required actions; the critical action in this case would be to contact the Specialist Centre
We agree with the UKKA and Royal College response.
• Whilst we acknowledge that being well-informed can help with communication and care
delivery, in this case we would advise that care be delivered by a Specialist who should not
necessarily need to refer to the Guidelines.
We agree the UKKA and Royal College response. In addition to our established process of contacting
the specialist team by phone, reinstating the SLAs ensures that referring centres can ask for specialist
consultant review onsite. Both communications support early and appropriate treatment and transfer
if needed.
Transfer of responsibility, care coordination and decision-making for patient location
• We recommend that when a Specialist Team is managing the care of a particular condition
at a distance or on-site, they assume responsibility for recommending the best location for
care delivery. This may require careful negotiation in cases where multiple conditions are
being managed.
We accept the responsibility for recommending best location for all patients referred to Renal
Services. Based on the clinical requirements patients could be transferred to UHCW or reviewed by
the UHCW renal consultant at the local hospital and transferred over later if necessary.
• We recommend that the responsible Specialist Team is from the local specialist renal centre
rather than the renal centre usually caring for the patient. If necessary, local specialists can
liaise directly with the relevant renal centre.
Chief Executive Officer:
Chair:
It is usually the case that a non-specialist hospital will contact the parent specialist hospital where that
patient has been receiving their routine renal care. However, as a result of this Regulation 28, UHCW
will now be the primary specialist transfer centre for all renal patients admitted to peripheral hospitals
regardless of their parent specialist unit. The agreed shared guidelines and SLA will ensure closer
working and improved patient care.
Action points for the UKKA and BTS
Each organisation is to take the following actions.
1. Share recommendations with the kidney care and transplant communities.
2. Contact patient associations to assist with considering the role of patients and their
carers in highlighting where their specialist care is undertaken/provided and who to
contact.
3. Share with the Royal College of Physicians Patient Safety Committee.
We note that the 3 points above are for consideration of the UKKA and the BTS and therefore make
no comment.
Please do not hesitate to get in contact should any further information be required.
Yours sincerely
Chief Executive Officer
Chief Executive Officer:
Chair:
NHS) Our vision is to EXCEL at patient care George Eliot Hospital ; NHS Trust George Eliot Hospital NHS Trust College Street Nuneaton Warwickshire CV10 7DJ Your Ref.: 10718704 Our Ref.: RN/LJW — Doyle 5 February 2025 PRIVATE & CONFIDENTIAL Ms L Lee HM Assistant Coroner Warwickshire Justice Centre Newbold Terrace Leamington Spa CV32 4EL Dear Ms Lee RE: REGULATION 28 REPORT — JOHN DOYLE Further to your e-mail dated the 9 January 2025, | am writing to confirm that the Trust has considered the response from UK Kidney Association (UKKA) and the British Transplantation Society (BTS) and we believe that the Trust had covered everything in our original response, with 2 exceptions. 1. The first recommendation is ensuring switchboard have a master copy of local specialist centre contact details and the Trust can confirm that this action has been taken. . ie 3. This recommendation is about notifying UKKA of all patients with chronic kidney stage 5 (CDK G5) or who are receiving dialysis treatment or who have a kidney transplant. University Hospitals of Coventry & Warwickshire update UKKA as the specialist centre for this specialty. The three action points at the end of the letter are for UKKA and BTS to undertake, however, | confirm that the Trust has received and acknowledged them. Please do not hesitate to contact me if | can be of further assistance. Yours sincerely Chief Medical Officer
Ms Linda Lee
Assistant Coroner for Coventry and Warwickshire
Warwickshire Justice Centre
Newbold Terrace
Leamington Spa
CV32 4EL
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
7 January 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – John Frederick Doyle
who died on 30 December 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12
November 2024 concerning the death of John Frederick Doyle on 30 December 2023.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to John’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about John’s care
have been listened to and reflected upon.
Your report raises concerns about a lack of understanding and awareness from non-
specialist medical staff as to when and how to contact specialist renal hospitals. You
have also raised concerns around coordination and consistency of care provided to
patients as they are transferred from non-specialist hospitals to renal hospitals, as well
as the information which is being provided to patients about their care and the options
available.
Renal services are covered by NHS specialised commissioning services. A specialist
Clinical Reference Group have developed service specifications that clearly define the
standards of care expected from organisations providing specialist care for patients
who undergo kidney transplantation, as well as patients with acute kidney injuries or
those undergoing dialysis. Further information can be found here: NHS commissioning
» Renal services.
Renal medicine is a specialist service that is delegated to individual Integrated Care
Boards. My regional colleagues in the Midlands have been sighted on your Report,
and have shared it with Coventry and Warwickshire ICB, for the appropriate oversight.
Getting It Right First Time (GIRFT) is a national NHS England programme designed
to improve the treatment and care of patients through in-depth review of services,
benchmarking, and presenting a data-driven evidence base to support change. The
Renal Medicine GIRFT also highlights the importance of having clear pathways in
https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/Renal-
place:
Medicine-Sept21k.pdf
I note that your Report has also been sent to University Hospitals Coventry and
Warwickshire NHS Trust (UHCW) and George Eliot Hospital NHS Trust (GEH). It is
appropriate that the providers involved in John’s care respond to the Coroner
regarding the concerns raised which relate to local arrangements and process. NHS
England has asked to be sighted on their responses and will consider these in due
course and whether any further actions are required from our Specialised
Commissioning Teams.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of John,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Brandon House, Building 20A1 Southmead Road, Filton Bristol, BS34 7RR Tel: 0117 414 8152 Email: ukka@ukkidney.org 31st December 2024 Mrs Linda Lee Assistant Coroner Warwickshire County Council Dear Mrs Lee, Re: Response to Regulation 28 Report to prevent future deaths following the inquest into the death of John Frederick Doyle. Following your email request received on 12th November 2024, the UK Kidney Association (UKKA; formerly the Renal Association) and the British Transplantation Society (BTS) have collaborated and produced the following recommendations in response to your concerns. Contacting off-site specialists and sharing information • We recommend that all hospital switchboards, Emergency Departments and relevant personnel have a master copy of local specialist centre contact details so any query at any time can be appropriately directed. • We recommend that all staff are advised of internal escalation routes. Relevant clinical colleagues should be aware of internal escalation routes to clarify whether off-site specialist input is required. We would expect this to be achieved by asking the Consultant responsible for the patient’s care or their deputy. • We advise that electronic information sharing in real-time should be the gold standard for information sharing. In the case of kidney patients, we would expect to be informed about all patients admitted for care in another hospital or elsewhere in our own hospital who have chronic kidney disease stage 5 (CKD G5) or who are receiving dialysis treatment or who have a kidney transplant. • We advise that Trusts review their processes to ensure that CMV results are available in a timely fashion. This involves considering the transport and turnaround of samples with prompt reporting in specialist virology laboratories as well as how to ensure that blood is taken in the correct blood tubes. Accessibility to Renal Care Guidelines • As access to Guidelines could lead to a misunderstanding of the significance and urgency of required actions; the critical action in this case would be to contact the Specialist Centre. • Whilst we acknowledge that being well-informed can help with communication and care delivery, in this case we would advise that care be delivered by a Specialist who should not necessarily need to refer to the Guidelines. Transfer of responsibility, care coordination and decision-making for patient location • We recommend that when a Specialist Team is managing the care of a particular condition at a distance or on-site, they assume responsibility for recommending the best location for care delivery. This may require careful negotiation in cases where multiple conditions are being managed. • We recommend that the responsible Specialist Team is from the local specialist renal centre rather than the renal centre usually caring for the patient. If necessary, local specialists can liaise directly with the relevant renal centre. Action points for the UKKA and BTS Each organisation is to take the following actions. 1. Share recommendations with the kidney care and transplant communities. 2. Contact patient associations to assist with considering the role of patients and their carers in highlighting where their specialist care is undertaken/provided and who to contact. 3. Share with the Royal College of Physicians Patient Safety Committee. As the UKKA and BTS do not have responsibility for the care of patients with other conditions who will be similarly at risk, we recommend that the Coroner considers how to escalate issues of specialist care provision in hospitals at a national level. Yours sincerely, Co-Chair UKKA Kidney Patient Safety Committee Consultant Nephrologist Newcastle Co-Chair UKKA Kidney Patient Safety Committee Renal Consultant Nurse East Kent Hospitals University NHS Trust on behalf of the British Transplantation Society Consultant Nephrologist, King’s College Hospital The UK Kidney Association (UKKA) is a trading name of the Renal Association, a registered charity (no 800733) and a company limited by guarantee, registered in England and Wales under company number 2229663.
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