Peter Anzani

Dear Mr Hodson Re: Regulation 28 Report to Prevent Future Death - Peter Anzani Inquest Thank you for your Report to Prevent Future Deaths (hereafter “PFD report”) dated 1 May 2025 concerning the death of Peter Anzani on 24 November 2024. In advance of responding to the specific concerns raised in your PFD report, I would like to express my deep condolences to Peter’s family and loved ones. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (hereafter “the Trust”) is keen to assure the family, and the Coroner, that the concerns raised about Peter’s care have been listened to and reflected upon. I am advised that the Trust was not initially recognised as an Interested Person (IP) to this inquest nor provided with a copy of the statements and documentation from other IPs ahead of the inquest. I understand that the Trust was recognised as an IP following a verbal application made by the Trust’s legal representative during the inquest hearing. As a Trust, we fully recognise the importance of addressing the concerns raised by your PFD report to prevent similar instances in future. I have set out the concerns outlined in your PFD report below and the relevant work the Trust has undertaken.
1. I considered evidence from a who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded of confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I

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1006127061.1 have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms…”
2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of learning. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff.
3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. Immediate actions Following receipt of the PFD report, the Trust took immediate action to address the issues identified, specifically relating to timely and accurate recording of patient observations. Clear and visual notices have been placed in relevant clinical areas to remind staff of the importance of recording patient observations promptly and accurately. Also, additional observation machines have been made available to ensure staff have immediate access to appropriate tools for carrying out vital sign monitoring. In addition, the importance of accurate observation recording has been communicated directly to staff both via verbal briefings and written email communication. Also, a re-audit was completed on 21 June 2025 in relation to 20 patient who attended the clinic between 16 – 19 June 2025. The results show that a full set of clinical observations was recorded for 100% of patients, including those undergoing procedures. A copy of the audit has been provided in the Trust’s PFD response bundle. Digital record keeping system The Trust has undertaken a review of how our current systems and processes to support accurate and timely clinical documentation. One of the key tools supporting this work is implementation of our new electronic patient record system called Apollo, which is used Trust wide to facilitate consistent, legible and auditable documentation of patients’ clinical notes. The Outpatient Observation Form now includes all baseline observations, and this essentially follows the process used in the Trust’s Main Outpatient Department. A paper format will be utilised during any period of digital downtime, when access to the digital system is limited, or not available. In addition to the above, the Trust recognises that it needs to be able to record patient observations taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). This is currently in development with the digital team and implementation date is anticipated to be March 2026, although the timeframe is restricted by the external digital company called System C. In the meantime, the Outpatient Observation Form will be the primary source for recording clinical observations for patients attending outpatient appointments. Standard Operating Procedure A new Standard Operating Procedure (SOP) has been developed and is in the process of being implemented to provide a clear, visual guide for clinical staff working in outpatient settings. The SOP includes a flowchart to ensure ease of understanding and practical application across all relevant clinics. It outlines mandatory baseline observations for all outpatient appointments. The SOP is scheduled to be approved at the next Patient Safety Meeting on 08 July 2025.

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1006127061.1 The SOP further specifically requires completion of pre- and post-procedure observations in higher-risk outpatient procedures, including Baclofen, Fertility, Botox and Suprapubic Catheter (SPC) clinics. We consider these actions are essential to ensure patient stability before and after interventions that may involve medication administration, sedation, or procedural risk. Quality Accreditation Programme The Trust has adopted a local Quality Accreditation Programme (QAP), and we are using this as a structured and sustainable mechanism to drive improvements across all clinical areas. As part of the QAP, all wards, units and departments at the Trust will aim to achieve the highest level of quality accreditation to improve efficiency, productivity, patient outcomes and to enhance patient and staff experience. This underpins the goals of the Trust’s Nursing and Allied Health Professional Strategy, the Trust’s Quality Strategy and wraps a framework around demonstrating regulatory compliance and best practice. The objective and focus of this work are to align the QAP to CQC’s key principles of Safe, Effective, Caring, Responsive and Well Led. I have provided within our PFD response bundle the QAP audit in relation to documentation and record keeping. Where compliance was found to be less than 100%, the Trust has recommended steps to ensure increased compliance. Moreover, the quality accreditation process has helped guide Trust’s quality improvement priorities for the year. Some of the core objectives of the Trust’s quality improvement priorities include improvement of documentation and record keeping related to falls risk assessments and management plans. The Trust has also prioritised measures to improve the use of fluid balance charts across the Trust. The measures agreed to achieve these objectives are focused on improved compliance with completion of risk assessments, management plans and fluid balance charts (via tenable audits). A copy of the Trust’s Quality Priorities has been provided in the PFD bundle. NEWS2 compliance audit To evaluate adherence to national standards for the National Early Warning Score (NEWS2) system, a compliance audit was carried out by the Trust’s Patient Deterioration & Resuscitation Committee in January 2025. The objective of this audit was to review whether the Careflow Vitals (formerly VitalPAC) e- observation NEWS2 track, and trigger system supports prompt and appropriate escalation for a physical review by an appropriate competent clinician. The review involved a retrospective audit of NEWS2 clinical observations and escalation, which included a review of 565 observation datasets from 112 patients. The audit report highlighted the National Institute of Clinical Excellence’s (NICE) clinical guideline entitled ‘Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital’ (NICE clinical guideline 50). As outlined in the Trust’s audit report, one of the key recommendations in the NICE guideline is that as a minimum physiological observation such as heart rate, respiratory rate, systolic blood pressure, level of consciousness, oxygen saturation and temperature should be recorded at the initial assessment.

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1006127061.1 The audit report has made appropriate recommendations and actions for better outcomes, which has been provided in our PFD response bundle. I confirm that a repeat audit has been scheduled for April 2026. Deteriorating patient compliance audit The Trust also undertook a compliance audit in January 2025 pertaining to deteriorating patients, which involved a review of monitoring and escalation of patient care. This was a retrospective audit of 113 2222 medical emergency calls and cardiac arrests. This audit similarly refers to the NICE guideline referred to above and recommendation relating to recording of physiological observations. The audit makes mention of a report from the National Patient Safety Agency (NPSA 2007), which evidenced failure to recognise and act upon deterioration in 15% of serious incidents resulting in death reported on the national reporting and learning system (NRLS). The sub-themes identified were a failure to measure basic observations of vital signs, a lack of recognition of the importance of worsening vital signs and delay in responding to deteriorating vital signs. Accordingly, the Trust’s audit (amongst other recommendations) has emphasised learning around the global assessment of patients “including review of the patient’s baseline physiological trends and not solely upon the NEWS2 score”. I confirm that a repeat audit has been scheduled for February 2026. I hope the above offers you reassurance of the Trust’s ongoing commitment and work being undertaken, specifically relating to the issues raised in your PFD report. The following documents are included in the PFD disclosure bundle.
• The NEWS2 compliance audit (appendix 1)
• Deteriorating patient compliance audit (appendix 2)
• The latest MCSI observational audit of 21 June 2025 (appendix 3)
• Quality Priorities 2025-26 (appendix 4)
• Quality Accreditation Programme – Documentation and Record Keeping (appendix 5) Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information.