Royal Cornwall Hospital
NHS / Health Body
Action Planned
A multidisciplinary group has been established to advise on strengthening governance for prescribing medications following unexpected hospital admission after day case surgery, with implementation planned by May 2026. Four workstreams have been identified, and an audit is planned for September 2026. (AI summary)
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Dear Mr Cox,
Re: The Late Tracey Oldfield – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 11 November 2025 and received on the 13 November 2025. This was issued following the inquest into the death of Tracey Oldfield which concluded on 10 November 2025. I would like to take this opportunity to express my sincerest condolences to the family of Tracey Oldfield for their loss. During the inquest, the evidence revealed a matter giving rise to concern. Which is as follows:
• How surgical day case patients who are admitted at short notice have their usual medications prescribed in a timely fashion. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern. Response:
1. A multidisciplinary group of relevant clinicians has been established to advise strengthening existing governance related to safe, accurate and timely prescribing of a patient’s regular medications following unexpected hospital admission following Day Case Surgery. It will report to Clinical Effectiveness Group on 25th March 2026 for action plan sign off prior to implementation by 27th May 2026.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ
2. The following 4 workstreams have been identified:
i. Identify the systems used which alert all day surgery patients with an unplanned inpatient admission due to unexpected change in clinical condition including location, reason for admission and responsible consultant.
ii. Ensure all current patient data platforms triangulate and provide accurate information on this patient subset to the site co-ordination office, responsible senior and resident doctors. Influence the planning and implementation of the new integrated clinical care platform, eCare to further strengthen tracking these patients.
iii. Ensure a responsible consultant is identified and aware of the patient admission at the time of admission. This consultant can either be the operating clinician, or the relevant specialty on-call consultant if the admission occurs out of hours.
iv. Strengthen resident doctor and nursing staff training and awareness of the requirement to conduct a thorough documented clinical review (clerking) of all day surgery patients admitted as an inpatient post operatively due to unexpected clinical change.
v. Ensure medical and nursing staff adhere to existing pharmacy prescribing policies including medicines reconciliation with a focus on ‘high risk medications’ such as insulin, opioids, anticoagulants, psychotropics and immunosuppressants.
3. Following implementation, we will audit postoperative prescribing of all patients admitted as inpatients following day case surgery against each of the five workstream recommendations. This audit will be commissioned and monitored by the Clinical Effectiveness Group with an expected completion date in September 2026. Any learning and further work identified will be reviewed by the group 25th November 2026.
4. Immediate Response pending implementation of the above workstreams: The findings of the PSR2 and PFD report and response will be shared with Care group leadership and clinical governance teams at Patient Safety Incident Review Oversight Group (PSIROG), with a request to cascade to all clinical specialty groups and teams providing day surgery services to review and strengthen current practice to ensure patients unexpectedly admitted following day surgery under go full clerking by a resident doctor with review of regular medications with appropriate senior oversight. I hope that this letter provides both you and Tracey’s family with assurance that the Trust has taken seriously the concern you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Re: The Late Tracey Oldfield – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 11 November 2025 and received on the 13 November 2025. This was issued following the inquest into the death of Tracey Oldfield which concluded on 10 November 2025. I would like to take this opportunity to express my sincerest condolences to the family of Tracey Oldfield for their loss. During the inquest, the evidence revealed a matter giving rise to concern. Which is as follows:
• How surgical day case patients who are admitted at short notice have their usual medications prescribed in a timely fashion. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern. Response:
1. A multidisciplinary group of relevant clinicians has been established to advise strengthening existing governance related to safe, accurate and timely prescribing of a patient’s regular medications following unexpected hospital admission following Day Case Surgery. It will report to Clinical Effectiveness Group on 25th March 2026 for action plan sign off prior to implementation by 27th May 2026.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ
2. The following 4 workstreams have been identified:
i. Identify the systems used which alert all day surgery patients with an unplanned inpatient admission due to unexpected change in clinical condition including location, reason for admission and responsible consultant.
ii. Ensure all current patient data platforms triangulate and provide accurate information on this patient subset to the site co-ordination office, responsible senior and resident doctors. Influence the planning and implementation of the new integrated clinical care platform, eCare to further strengthen tracking these patients.
iii. Ensure a responsible consultant is identified and aware of the patient admission at the time of admission. This consultant can either be the operating clinician, or the relevant specialty on-call consultant if the admission occurs out of hours.
iv. Strengthen resident doctor and nursing staff training and awareness of the requirement to conduct a thorough documented clinical review (clerking) of all day surgery patients admitted as an inpatient post operatively due to unexpected clinical change.
v. Ensure medical and nursing staff adhere to existing pharmacy prescribing policies including medicines reconciliation with a focus on ‘high risk medications’ such as insulin, opioids, anticoagulants, psychotropics and immunosuppressants.
3. Following implementation, we will audit postoperative prescribing of all patients admitted as inpatients following day case surgery against each of the five workstream recommendations. This audit will be commissioned and monitored by the Clinical Effectiveness Group with an expected completion date in September 2026. Any learning and further work identified will be reviewed by the group 25th November 2026.
4. Immediate Response pending implementation of the above workstreams: The findings of the PSR2 and PFD report and response will be shared with Care group leadership and clinical governance teams at Patient Safety Incident Review Oversight Group (PSIROG), with a request to cascade to all clinical specialty groups and teams providing day surgery services to review and strengthen current practice to ensure patients unexpectedly admitted following day surgery under go full clerking by a resident doctor with review of regular medications with appropriate senior oversight. I hope that this letter provides both you and Tracey’s family with assurance that the Trust has taken seriously the concern you raised in your report and that the Trust has taken appropriate action to prevent future deaths.