Royal Cornwall Hospitals
NHS / Health Body
Action Taken
The Trust has reviewed and amended the wording in the PCI pack to clarify Dual Anti-Platelet Therapy provision, with changes approved by the Safer Surgery Group and Forms Review Group. The Trust is also developing a training package for nursing teams and amending induction programs to include catheter lab pack and preparation, expected by 31 December 2024. (AI summary)
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Dear Mr Cox Re: Death of David Charles Martin - R28 PFD Report & letter I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the 10th of October 2024, issued as a result of the inquest into the death of Mr Martin which took place on 8th October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Martin for their loss. During the course of the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Could changes be made to the cardiac catheter lab pack and the WHO checklist that would make the process more robust and prevent similar incidents in the future.
• Could changes be made to the induction programme for locum doctors.
Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Can changes be made to the cardiac catheter lab pack and WHO checklist: The wording in the PCI pack has been reviewed in order to make the provision of Dual Anti- Platelet Therapy clearer to both the medical and nursing team. The proposed revised wording was first agreed by the Cardiology team and was then sent to the Safer Surgery Group (SSG) for ratification and approval. SSG approved the changes at a meeting on 15 November 2024. The revised wording was also submitted to the Forms Review Group on 13 November 2024 and they were ratified and agreed by this group on 18 November 2024. The updated forms have been sent to the publishers and are currently awaiting return. The Local Safety Standards for Invasive Procedure (LocSSiP) will be updated and will be available on the intranet for staff. A copy of the updated paperwork can be provided if required upon return from the publishers. Can changes be made to the Induction Programme for locums: The Trust is developing a training package for our Roskear Nursing Team and we are in the process of amending our nursing, junior doctors and locum induction programmes to include catheter lab pack and preparation. This is underway and is expected to be completed by 31 December 2024. To summarise the above, the Trust have taken the following actions
1. Reviewed and amended the wording in the PCI pack regarding provision of Dual Anti- Platelet Therapy.
2. Sent the revised wording to Forms Review Group and Safer Surgery Group for ratification and approval.
3. Sent updated forms to the publishers.
4. Update the Local Safety Standards for Invasive Procedures (LocSSip).
5. Develop a training package for Roskear Nursing teams – due for completion by 31 December 2024.
6. Add catheter lab packs and preparation to Nursing induction – due for completion by 31 December 2024.
7. Add catheter lab packs and preparation to Junior Doctor and Locum Induction – due for completion by 31 December 2024. I hope that this letter provides both you and Mr Martin’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.
• Could changes be made to the cardiac catheter lab pack and the WHO checklist that would make the process more robust and prevent similar incidents in the future.
• Could changes be made to the induction programme for locum doctors.
Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Can changes be made to the cardiac catheter lab pack and WHO checklist: The wording in the PCI pack has been reviewed in order to make the provision of Dual Anti- Platelet Therapy clearer to both the medical and nursing team. The proposed revised wording was first agreed by the Cardiology team and was then sent to the Safer Surgery Group (SSG) for ratification and approval. SSG approved the changes at a meeting on 15 November 2024. The revised wording was also submitted to the Forms Review Group on 13 November 2024 and they were ratified and agreed by this group on 18 November 2024. The updated forms have been sent to the publishers and are currently awaiting return. The Local Safety Standards for Invasive Procedure (LocSSiP) will be updated and will be available on the intranet for staff. A copy of the updated paperwork can be provided if required upon return from the publishers. Can changes be made to the Induction Programme for locums: The Trust is developing a training package for our Roskear Nursing Team and we are in the process of amending our nursing, junior doctors and locum induction programmes to include catheter lab pack and preparation. This is underway and is expected to be completed by 31 December 2024. To summarise the above, the Trust have taken the following actions
1. Reviewed and amended the wording in the PCI pack regarding provision of Dual Anti- Platelet Therapy.
2. Sent the revised wording to Forms Review Group and Safer Surgery Group for ratification and approval.
3. Sent updated forms to the publishers.
4. Update the Local Safety Standards for Invasive Procedures (LocSSip).
5. Develop a training package for Roskear Nursing teams – due for completion by 31 December 2024.
6. Add catheter lab packs and preparation to Nursing induction – due for completion by 31 December 2024.
7. Add catheter lab packs and preparation to Junior Doctor and Locum Induction – due for completion by 31 December 2024. I hope that this letter provides both you and Mr Martin’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.