East Suffolk and North Essex Foundation Trust
NHS / Health Body
Action Taken
The Trust is starting 3 monthly ERCP Multi-Disciplinary Team meetings to discuss all cases and complications. A cross-site SOP has been drafted and approved entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant”. The Trust is also implementing changes to ensure a named Consultant is allocated to patients. (AI summary)
View full response
Dear Mr Sharpstone REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF DENISE ELLEN JOHNSON WHICH CONLUDED ON 10 DECEMBER 2024 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 30 December 2024. I would like to take this opportunity to extend my condolences to Denise’s family for their loss. The Regulation 28 Report to Prevent Deaths issued by yourself on 30 December 2024 highlighted concerns relating to Ipswich Hospital, those concerns were expressed as follows:
a. Timely notification to Endoscopic Retrograde Cholangio Pancreatography (“ERCP”) practitioners following serious complications, with formal case review;
b. Regular discussions about management plans and treatment options with Next of Kin/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues;
c. Lack of clarity around named Surgical Consultant cover for unexpected leave. The information presented below is intended to describe the actions which have been taken/are being taken at East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised. Timely notification to ERCP practitioners following serious complications, with formal case review The Trust’s endoscopy unit audit Post ERCP complications in an annual audit. Outpatient cases where complications develop are also audited and discussed at the Endoscopy governance meeting. The Trust’s endoscopy unit are now starting 3 monthly ERCP Multi-Disciplinary Team meetings, where all cases and complications will be discussed. Any inpatients who develop severe complications
including pancreatitis, cholangitis, perforation or bleeding post ERCP, will be identified by the clinical team looking after the patient and notified to the endoscopy lead. The case will then discuss at the appropriate Multi-Disciplinary Team meeting to enable a formal case review. Regular discussions about management plans and treatment options with Next of Kin/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues The Trust understands the importance of open and continuing dialogue between consultants, patients and their families, to formulate the most appropriate management plan for that patient. The Trust is leading a patient and carer focus on improving the way we communicate with our patients. This includes new name badges for staff (including phonetic spelling of surnames if desired) and more consistent training on how to have honest, and consistent conversations. A new visitor’s charter is also being introduced in late Spring 2025 with extended visiting hours from 8am until 8pm each day which will bring greater access for patients, carers and families to talk to staff. The Trust is also implementing changes to ensure a named Consultant is allocated to patients, which will provide greater accessibly for patients and families to discuss treatment plans. Lack of clarity around named Surgical Consultant cover for unexpected leave A cross-site SOP has been drafted and approved since the Inquest entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant” which addresses cover for patients in the circumstance of unexpected consultant leave. We will embed this SOP within the surgical division. Learning from both the incident and the new SOP will be used to drive improvement Trust wide. I can also provide assurance that there will be a more general reminder to all colleagues of the availability of the on call consultant to respond to acute deterioration/concern should the named consultant be unavailable. I hope the above information demonstrates the learning and training that has been implemented to cover the concerns of the Coroner. I once again would like to extend my sincerest condolences to the family of Denise for their loss. If I can be of further assistance, please do not hesitate to contact me.
a. Timely notification to Endoscopic Retrograde Cholangio Pancreatography (“ERCP”) practitioners following serious complications, with formal case review;
b. Regular discussions about management plans and treatment options with Next of Kin/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues;
c. Lack of clarity around named Surgical Consultant cover for unexpected leave. The information presented below is intended to describe the actions which have been taken/are being taken at East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised. Timely notification to ERCP practitioners following serious complications, with formal case review The Trust’s endoscopy unit audit Post ERCP complications in an annual audit. Outpatient cases where complications develop are also audited and discussed at the Endoscopy governance meeting. The Trust’s endoscopy unit are now starting 3 monthly ERCP Multi-Disciplinary Team meetings, where all cases and complications will be discussed. Any inpatients who develop severe complications
including pancreatitis, cholangitis, perforation or bleeding post ERCP, will be identified by the clinical team looking after the patient and notified to the endoscopy lead. The case will then discuss at the appropriate Multi-Disciplinary Team meeting to enable a formal case review. Regular discussions about management plans and treatment options with Next of Kin/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues The Trust understands the importance of open and continuing dialogue between consultants, patients and their families, to formulate the most appropriate management plan for that patient. The Trust is leading a patient and carer focus on improving the way we communicate with our patients. This includes new name badges for staff (including phonetic spelling of surnames if desired) and more consistent training on how to have honest, and consistent conversations. A new visitor’s charter is also being introduced in late Spring 2025 with extended visiting hours from 8am until 8pm each day which will bring greater access for patients, carers and families to talk to staff. The Trust is also implementing changes to ensure a named Consultant is allocated to patients, which will provide greater accessibly for patients and families to discuss treatment plans. Lack of clarity around named Surgical Consultant cover for unexpected leave A cross-site SOP has been drafted and approved since the Inquest entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant” which addresses cover for patients in the circumstance of unexpected consultant leave. We will embed this SOP within the surgical division. Learning from both the incident and the new SOP will be used to drive improvement Trust wide. I can also provide assurance that there will be a more general reminder to all colleagues of the availability of the on call consultant to respond to acute deterioration/concern should the named consultant be unavailable. I hope the above information demonstrates the learning and training that has been implemented to cover the concerns of the Coroner. I once again would like to extend my sincerest condolences to the family of Denise for their loss. If I can be of further assistance, please do not hesitate to contact me.