Royal Cornwall Hospital NHS Trust and Cornwall Partnership NHS Foundation Trust and Un
Noted
The response expresses condolences and summarises the concerns. It states the transfers were clinically appropriate and information was shared between hospitals, and Mrs. Tellam received reasonable support. (AI summary)
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Dear Mr Covell,
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your Regulation 28 Report to Prevent Future Deaths (‘the report’) of 2 December 2024 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Norma Ann Patricia Tellam which concluded on 8 April 2024.
This response is prepared on behalf of the three NHS provider organisations (Cornwall Partnership NHS Foundation Trust, University Hospitals Plymouth NHS Trust and the Royal Cornwall Hospitals NHS Trust) in receipt of the Regulation 28, following discussion together. Our discussions have also included South West Ambulance Service NHS Foundation Trust (SWAST) who were involved in Mrs Tellam’s transfers by ambulance.
It is deeply saddening to hear of the circumstances of Mrs Tellam’s death and the organisations providing her care would like to express their sincere condolences to her family. All the NHS Trusts involved receive
Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN
Call us on 01208 834 600 | Visit our website at cornwallft.nhs.uk
Page 2
concerns with the utmost seriousness, and we are committed to the provision and continued improvement of high-quality patient care.
Matters of concern Concern 1 Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her.
Following receipt of the report, Cornwall Partnership NHS Foundation Trust (CFT), who were not present at the inquest but are responsible for Liskeard Community Hospital, reviewed their records with the Hospital Matron and Ward Sister. The records show that shortly before the transfer referred to, Mrs Tellam was recorded as having a raised temperature and it was queried whether this was an infection (which would include sepsis) that required urgent investigation and response. At this time, it was not known if this was a generalised infection, or an infection in the surgical wound. This is corroborated in the clinical record made by SWAST which states ‘It was reported that patient became pyrexic around 15:30 with temp of 38, sats 95 on air, BP150/85, pulse 98, resps 24. Pt was reviewed by OOH at 23:43 due to escalation of pain, shivers and NEWS 2 of 5. It reports on arrival she appeared well, chatting, nil resp distress, appears good colour.
Liskeard Community Hospital ‘faces’ the University Hospitals Plymouth NHS Trust (UHP). This means that when a patient in south east Cornwall requires urgent transfer to an emergency acute setting, the hospital commissioned to provide care and treatment to patients, is Derriford Hospital. This hospital is the closest in mileage in comparison to the emergency facility at Royal Cornwall Hospital in Truro (RCHT).
Conveyance to hospitals on an urgent basis is provided by South West Ambulance Service NHS Foundation Trust (SWAST) who were consulted following receipt of the report. The decision about where to convey a patient is dependent on clinical need and hospital waiting times. The decision to take Mrs Tellam to Derriford Hospital was the correct one when considering her clinical presentation.
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It would not have been appropriate for the ambulance crew to convey Mrs Tellam to RCHT for review by the orthopaedic team. At the time of the assessment by the crew, it was unclear if Mrs Tellam had an infection in her surgical wound, or a more generalised infection, but it was clear that Mrs Tellam required further assessment and access to an acute care facility, with UHP being the closest hospital for prompt access to healthcare. The clinical records from UHP demonstrate that no surgical revision was required, noting that Mrs Tellam had had a slight displacement of the fracture fixation and had been prescribed antibiotics for a chest infection. On 5 February, Mrs Tellam was transferred back to Liskeard Community Hospital to continue her rehabilitation with consent and had a desire to return home as soon as she could to live as independently as possible.
On occasion, if it is considered by community hospital staff that a particular hospital would be a more appropriate transfer destination to ensure continuity of care, this can be shared when the 999 call is made. However, clinical decision-making by the assessing ambulance crew is paramount when considering where to convey a patient.
Concern 2
When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery.
Following receipt of the report, Mrs Tellam’s UHP clinical records were reviewed, which state that she had been ‘admitted due to Liskeard staff concern re infection, raised body temp and inflammatory markers, not partic tender, no swelling or discharge of the wound. Admit for IV antibiotics then back to Liskeard but caught covid and discharged for further rehab once safe. Mrs Tellam’s care was discussed by CFT and UHP, and it was noted that, during the acute admission, she did not have an urgent need for orthopaedic revision surgery. She had been unwell due to a chest infection and then unfortunately caught covid during her admission. The UHP management plan was for her to have a period of recuperation after her chest infection and prior to consideration of any revision/further surgery on her hip. During that time the aim was for Mrs Tellam to be
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transferred to her original care provider, RCHT, as this is also her local hospital and closer to her relatives. A Consultant Orthopaedic Surgeon reviewed her on the ward at UHP on 14 February 2023 and made a plan for a doctor to doctor handover to the team at RCHT. A referral was on that basis on the same day.
On receipt of the referral, the RCHT orthopaedic team discussed a potential admission with their trauma coordinators, and the patient record in UHP documented there was a discussion at 15:00 via telephone. The discussion with the orthopaedic team concluded that community-based hospital care was appropriate, and the transfer to such a hospital should be facilitated by the Cornwall Onward Care Team. Unfortunately, there appeared to be some confusion in the subsequent days where, in the medical records at UHP, the plan was variably referred to as ‘transfer to RCHT’ and ‘transfer to community hospital’. There was no clinical need for further liaison with RCHT regarding Mrs Tellam until around the time of her transfer in March 2023.
On 15 and 17 February, whilst at UHP, Mrs Tellam was noted to have a National Early Warning Score (NEWS) of 0 which meant she had no infection markers and was considered stable. On 21 February, she was appropriately transferred to Liskeard Community Hospital with a plan for an out-patient follow up appointment at RCHT. The clinical records show that during her second admission to Liskeard Community Hospital, Mrs Tellam was able to mobilise and move herself to the side of the bed and was able to stand up independently to use the Molift (a patient transfer aid) for transfers and use it to get on and off the toilet.
Due to a lack of mobilisation in the following weeks, an x-ray was requested by staff at Liskeard Community Hospital, and this took place on 16 March 2023. On 19 March 2023, Mrs Tellam also reported some pain and an outpatients appointment at RCHT was made for 20 March. Mrs Tellam was unable to be seen on that date but returned to RCHT the following day. We believe events after this time were explored at the inquest.
Concern 3 Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
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When considering the clinical information from the period of care being reviewed, the transfers between Liskeard Community Hospital and UHP were appropriate based on Mrs Tellam’s clinical presentation. Whilst Liskeard Community Hospital was further away from Mrs Tellam’s home, this was unfortunately the only available setting for Mrs Tellam at the time when a community hospital was considered appropriate for her clinical needs.
Mrs Tellam was not transferred following her brief first admission to UHP as the clinical opinion was that she did not require an orthopaedic review. On the second admission to UHP, on 14 February, it is clear that there was clinical discussion and sharing of clinical information between the two acute care hospitals, and on the basis of the clinical presentation she did not require surgical intervention requiring transfer to RCHT but was for community based hospital care. Mrs Tellam returned to Liskeard Community Hospital where she continued to receive support and rehabilitation, which we consider was reasonable based on her presentation.
Should the Coroner have any further questions from the public bodies concerned in this report please do not hesitate to contact us.
Once again, we extend our deepest condolences to Mrs Tellam’s family.
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your Regulation 28 Report to Prevent Future Deaths (‘the report’) of 2 December 2024 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Norma Ann Patricia Tellam which concluded on 8 April 2024.
This response is prepared on behalf of the three NHS provider organisations (Cornwall Partnership NHS Foundation Trust, University Hospitals Plymouth NHS Trust and the Royal Cornwall Hospitals NHS Trust) in receipt of the Regulation 28, following discussion together. Our discussions have also included South West Ambulance Service NHS Foundation Trust (SWAST) who were involved in Mrs Tellam’s transfers by ambulance.
It is deeply saddening to hear of the circumstances of Mrs Tellam’s death and the organisations providing her care would like to express their sincere condolences to her family. All the NHS Trusts involved receive
Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN
Call us on 01208 834 600 | Visit our website at cornwallft.nhs.uk
Page 2
concerns with the utmost seriousness, and we are committed to the provision and continued improvement of high-quality patient care.
Matters of concern Concern 1 Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her.
Following receipt of the report, Cornwall Partnership NHS Foundation Trust (CFT), who were not present at the inquest but are responsible for Liskeard Community Hospital, reviewed their records with the Hospital Matron and Ward Sister. The records show that shortly before the transfer referred to, Mrs Tellam was recorded as having a raised temperature and it was queried whether this was an infection (which would include sepsis) that required urgent investigation and response. At this time, it was not known if this was a generalised infection, or an infection in the surgical wound. This is corroborated in the clinical record made by SWAST which states ‘It was reported that patient became pyrexic around 15:30 with temp of 38, sats 95 on air, BP150/85, pulse 98, resps 24. Pt was reviewed by OOH at 23:43 due to escalation of pain, shivers and NEWS 2 of 5. It reports on arrival she appeared well, chatting, nil resp distress, appears good colour.
Liskeard Community Hospital ‘faces’ the University Hospitals Plymouth NHS Trust (UHP). This means that when a patient in south east Cornwall requires urgent transfer to an emergency acute setting, the hospital commissioned to provide care and treatment to patients, is Derriford Hospital. This hospital is the closest in mileage in comparison to the emergency facility at Royal Cornwall Hospital in Truro (RCHT).
Conveyance to hospitals on an urgent basis is provided by South West Ambulance Service NHS Foundation Trust (SWAST) who were consulted following receipt of the report. The decision about where to convey a patient is dependent on clinical need and hospital waiting times. The decision to take Mrs Tellam to Derriford Hospital was the correct one when considering her clinical presentation.
Page 3
It would not have been appropriate for the ambulance crew to convey Mrs Tellam to RCHT for review by the orthopaedic team. At the time of the assessment by the crew, it was unclear if Mrs Tellam had an infection in her surgical wound, or a more generalised infection, but it was clear that Mrs Tellam required further assessment and access to an acute care facility, with UHP being the closest hospital for prompt access to healthcare. The clinical records from UHP demonstrate that no surgical revision was required, noting that Mrs Tellam had had a slight displacement of the fracture fixation and had been prescribed antibiotics for a chest infection. On 5 February, Mrs Tellam was transferred back to Liskeard Community Hospital to continue her rehabilitation with consent and had a desire to return home as soon as she could to live as independently as possible.
On occasion, if it is considered by community hospital staff that a particular hospital would be a more appropriate transfer destination to ensure continuity of care, this can be shared when the 999 call is made. However, clinical decision-making by the assessing ambulance crew is paramount when considering where to convey a patient.
Concern 2
When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery.
Following receipt of the report, Mrs Tellam’s UHP clinical records were reviewed, which state that she had been ‘admitted due to Liskeard staff concern re infection, raised body temp and inflammatory markers, not partic tender, no swelling or discharge of the wound. Admit for IV antibiotics then back to Liskeard but caught covid and discharged for further rehab once safe. Mrs Tellam’s care was discussed by CFT and UHP, and it was noted that, during the acute admission, she did not have an urgent need for orthopaedic revision surgery. She had been unwell due to a chest infection and then unfortunately caught covid during her admission. The UHP management plan was for her to have a period of recuperation after her chest infection and prior to consideration of any revision/further surgery on her hip. During that time the aim was for Mrs Tellam to be
Page 4
transferred to her original care provider, RCHT, as this is also her local hospital and closer to her relatives. A Consultant Orthopaedic Surgeon reviewed her on the ward at UHP on 14 February 2023 and made a plan for a doctor to doctor handover to the team at RCHT. A referral was on that basis on the same day.
On receipt of the referral, the RCHT orthopaedic team discussed a potential admission with their trauma coordinators, and the patient record in UHP documented there was a discussion at 15:00 via telephone. The discussion with the orthopaedic team concluded that community-based hospital care was appropriate, and the transfer to such a hospital should be facilitated by the Cornwall Onward Care Team. Unfortunately, there appeared to be some confusion in the subsequent days where, in the medical records at UHP, the plan was variably referred to as ‘transfer to RCHT’ and ‘transfer to community hospital’. There was no clinical need for further liaison with RCHT regarding Mrs Tellam until around the time of her transfer in March 2023.
On 15 and 17 February, whilst at UHP, Mrs Tellam was noted to have a National Early Warning Score (NEWS) of 0 which meant she had no infection markers and was considered stable. On 21 February, she was appropriately transferred to Liskeard Community Hospital with a plan for an out-patient follow up appointment at RCHT. The clinical records show that during her second admission to Liskeard Community Hospital, Mrs Tellam was able to mobilise and move herself to the side of the bed and was able to stand up independently to use the Molift (a patient transfer aid) for transfers and use it to get on and off the toilet.
Due to a lack of mobilisation in the following weeks, an x-ray was requested by staff at Liskeard Community Hospital, and this took place on 16 March 2023. On 19 March 2023, Mrs Tellam also reported some pain and an outpatients appointment at RCHT was made for 20 March. Mrs Tellam was unable to be seen on that date but returned to RCHT the following day. We believe events after this time were explored at the inquest.
Concern 3 Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
Page 5
When considering the clinical information from the period of care being reviewed, the transfers between Liskeard Community Hospital and UHP were appropriate based on Mrs Tellam’s clinical presentation. Whilst Liskeard Community Hospital was further away from Mrs Tellam’s home, this was unfortunately the only available setting for Mrs Tellam at the time when a community hospital was considered appropriate for her clinical needs.
Mrs Tellam was not transferred following her brief first admission to UHP as the clinical opinion was that she did not require an orthopaedic review. On the second admission to UHP, on 14 February, it is clear that there was clinical discussion and sharing of clinical information between the two acute care hospitals, and on the basis of the clinical presentation she did not require surgical intervention requiring transfer to RCHT but was for community based hospital care. Mrs Tellam returned to Liskeard Community Hospital where she continued to receive support and rehabilitation, which we consider was reasonable based on her presentation.
Should the Coroner have any further questions from the public bodies concerned in this report please do not hesitate to contact us.
Once again, we extend our deepest condolences to Mrs Tellam’s family.