Royal Cornwall Hospitals NHS Trust
NHS / Health Body
Action Taken
The Trust has implemented a sepsis safety brief, made sepsis training mandatory, provided sepsis update training for doctors, and applied the sepsis screening tool to all blood pressure machines. They plan to implement a sepsis trigger within the new E-care system scheduled for roll-out in November 2025. (AI summary)
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Dear Mr Davies,
Re: The Late Michael Ramon Jervis – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 30 December 2024 and received on the 31 December 2024. This was issued as a result of the inquest into the death of Mr Jervis which concluded on 24 October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Jervis for their loss. During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required, but this did not happen,
• There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 01872 250000
Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required but this did not happen: The Trust has undertaken the following action since the death of Mr Jervis; In the Acute Medical Unit (AMU) the matron has formulated an action plan to promote learning within the ward and wider care-group. This plan includes improving and monitoring compliance with mandatory sepsis training. The actions are:
a. To improve policy awareness and compliance by implementing a sepsis safety brief which will be shared Trust wide. This will be signed off and shared by April 2025. A copy can be provided if required.
b. The patient’s story will be shared with AMU staff (following consent), emphasising patient impact, to enhance staff awareness and understanding. The aim is to have this completed within the next six months and this will specifically focus upon neutropenic sepsis, hypothermia and the sepsis six bundle.
c. An educational awayday is being arranged for AMU staff, with a focus on sepsis and the deteriorating patient. This will be convened within the next six months.
d. To increase the compliance with sepsis training, improving to ‘amber’ (80%) compliance within four months and reaching a target of ‘green’ (90%) compliance within six months (excluding those on leave (i.e. maternity leave)
e. Sharing learning via Governance Leads in their areas at their local Governance meetings. Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have been arranged for our doctors with regards to sepsis and this has been implemented.
Image 2. Sepsis Screening Tool.
To continue to raise awareness and increase visibility, the Trust’s sepsis lead is applying the sepsis screening tool to all blood pressure machines. Sepsis awareness also forms part of the sepsis safety brief and communications have commenced from February 2025 with a sepsis digital sidebar and screen savers on all Trust computers.
There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six: Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is implementing a new e-Care digital electronic patient record (EPR) system and the sepsis lead nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the ‘sepsis six’ needs to be actioned. To summarise the above, the Trust are taking the following actions
1. Sepsis safety brief shared trustwide.
2. A patient story to be shared with AMU, which will have a focus on neutropenic sepsis, hypothermia and the sepsis bundle.
3. Sepsis training for nurses and health care assistants has become part of the mandatory and essential training from August 2024.
4. Sepsis update training has commenced with our doctors.
5. An educational awayday to be arranged for AMU staff, with a focus on sepsis and the deteriorating patient.
6. A training poster will be placed for reception staff in acute clinical areas (e.g. ED) to ensure that they are aware of the need to flag patients requiring neutropenic sepsis care.
7. RCHT plans to implement a sepsis trigger within the new E-care system – scheduled roll-out November 2025.
I hope that this letter provides both you and Mr Jervis’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Re: The Late Michael Ramon Jervis – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 30 December 2024 and received on the 31 December 2024. This was issued as a result of the inquest into the death of Mr Jervis which concluded on 24 October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Jervis for their loss. During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required, but this did not happen,
• There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 01872 250000
Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required but this did not happen: The Trust has undertaken the following action since the death of Mr Jervis; In the Acute Medical Unit (AMU) the matron has formulated an action plan to promote learning within the ward and wider care-group. This plan includes improving and monitoring compliance with mandatory sepsis training. The actions are:
a. To improve policy awareness and compliance by implementing a sepsis safety brief which will be shared Trust wide. This will be signed off and shared by April 2025. A copy can be provided if required.
b. The patient’s story will be shared with AMU staff (following consent), emphasising patient impact, to enhance staff awareness and understanding. The aim is to have this completed within the next six months and this will specifically focus upon neutropenic sepsis, hypothermia and the sepsis six bundle.
c. An educational awayday is being arranged for AMU staff, with a focus on sepsis and the deteriorating patient. This will be convened within the next six months.
d. To increase the compliance with sepsis training, improving to ‘amber’ (80%) compliance within four months and reaching a target of ‘green’ (90%) compliance within six months (excluding those on leave (i.e. maternity leave)
e. Sharing learning via Governance Leads in their areas at their local Governance meetings. Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have been arranged for our doctors with regards to sepsis and this has been implemented.
Image 2. Sepsis Screening Tool.
To continue to raise awareness and increase visibility, the Trust’s sepsis lead is applying the sepsis screening tool to all blood pressure machines. Sepsis awareness also forms part of the sepsis safety brief and communications have commenced from February 2025 with a sepsis digital sidebar and screen savers on all Trust computers.
There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six: Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is implementing a new e-Care digital electronic patient record (EPR) system and the sepsis lead nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the ‘sepsis six’ needs to be actioned. To summarise the above, the Trust are taking the following actions
1. Sepsis safety brief shared trustwide.
2. A patient story to be shared with AMU, which will have a focus on neutropenic sepsis, hypothermia and the sepsis bundle.
3. Sepsis training for nurses and health care assistants has become part of the mandatory and essential training from August 2024.
4. Sepsis update training has commenced with our doctors.
5. An educational awayday to be arranged for AMU staff, with a focus on sepsis and the deteriorating patient.
6. A training poster will be placed for reception staff in acute clinical areas (e.g. ED) to ensure that they are aware of the need to flag patients requiring neutropenic sepsis care.
7. RCHT plans to implement a sepsis trigger within the new E-care system – scheduled roll-out November 2025.
I hope that this letter provides both you and Mr Jervis’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.