Manchester University Hospitals NHS Foundation Trust
NHS / Health Body
Action Taken
The MRI Transplant team has modified the weekly Wednesday Ward Patient Review meeting to make it an MDT for discussion of complex patients, with the outpatient team now attending to support any issues on discharge. Also, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting. (AI summary)
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Dear Mr Morris
Miss Jyoti RAO – Regulation 28: Prevention of Future Deaths
Thank you for your Regulation 29 Report to Prevent Future Deaths dated 25 September 2024 addressed to Mr Mark Cubbon in his capacity as Trust Chief Executive of Manchester University NHS Foundation Trust (MFT) following the Inquest into the death of Miss Jyoti Rao which you heard on 16 September 2024.
I have now had the opportunity to acknowledge and consider the matters of concern that were raised within your report and which emerged during the inquest of Miss Rao.
On behalf of the Trust, I would like to extend my sincere condolences to the family of Miss Rao for their very great loss.
The response required from the Trust) is in relation to the following:
• Under the current Consultant of the Week model, complex transplant patients are not allocated a named consultant, who not only (in conjunction with others) can seek to ensure continuity of care is provided but also who can take a longer term view of the patient’s post-operative course and trajectory when complications arise
MFT comprises several adult hospital sites within which Consultant of the Week models are utilised. Organisationally the Trust provides clear guidance to clinical teams via the Role and Responsibilities of the Lead (Responsible) Consultant Policy (attached) and there is an organisational focus on consultant attribution. Whilst the remit of this improvement work is wider than the specialty transplant service subject of your Regulation 28 report; I hope to offer you additional assurance that across the organisation discussions in relation to consultant attribution, ownership and oversight of care are taking place across all clinical teams. I anticipate that this work will continue to strengthen the delivery of care to our patients utilising this model, preventing inconsistencies in practices across the organisation.
Specialties at Manchester Royal Infirmary (MRI), alongside the other hospitals within MFT and nationally, adopt the Consultant of the Week model which is widely recognised as being an advantageous care delivery model for patients admitted to hospital. Your concern in respect of how this model adequately supports complex transplant patients is however recognised. As the Inquest heard, and you referenced within your letter, there are advantages of this model
Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
with the presence of a consultant of the week being associated with reducing length of stay and improving continuity and communication.
For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant.
I acknowledge that whilst the Inquest heard about this process, there was a lack of evidence provided to the hearing demonstrating how these arrangements robustly account for the more complex transplant patient, particularly those receiving outpatient care. Since the Inquest, I can confirm that actions have been taken to strengthen this process, which I have explained below.
The MRI Transplant team have modified the weekly Wednesday Ward Patient Review meeting, mentioned above, to make it an MDT for discussion of complex patients. This provides a more robust multidisciplinary perspective with decision making that involves all relevant clinical staff. A significant change is the attendance of the outpatient team to support any issues on discharge.
In addition to this, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting.
Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues raised. If you require anything further, then please do not hesitate to contact me.
Miss Jyoti RAO – Regulation 28: Prevention of Future Deaths
Thank you for your Regulation 29 Report to Prevent Future Deaths dated 25 September 2024 addressed to Mr Mark Cubbon in his capacity as Trust Chief Executive of Manchester University NHS Foundation Trust (MFT) following the Inquest into the death of Miss Jyoti Rao which you heard on 16 September 2024.
I have now had the opportunity to acknowledge and consider the matters of concern that were raised within your report and which emerged during the inquest of Miss Rao.
On behalf of the Trust, I would like to extend my sincere condolences to the family of Miss Rao for their very great loss.
The response required from the Trust) is in relation to the following:
• Under the current Consultant of the Week model, complex transplant patients are not allocated a named consultant, who not only (in conjunction with others) can seek to ensure continuity of care is provided but also who can take a longer term view of the patient’s post-operative course and trajectory when complications arise
MFT comprises several adult hospital sites within which Consultant of the Week models are utilised. Organisationally the Trust provides clear guidance to clinical teams via the Role and Responsibilities of the Lead (Responsible) Consultant Policy (attached) and there is an organisational focus on consultant attribution. Whilst the remit of this improvement work is wider than the specialty transplant service subject of your Regulation 28 report; I hope to offer you additional assurance that across the organisation discussions in relation to consultant attribution, ownership and oversight of care are taking place across all clinical teams. I anticipate that this work will continue to strengthen the delivery of care to our patients utilising this model, preventing inconsistencies in practices across the organisation.
Specialties at Manchester Royal Infirmary (MRI), alongside the other hospitals within MFT and nationally, adopt the Consultant of the Week model which is widely recognised as being an advantageous care delivery model for patients admitted to hospital. Your concern in respect of how this model adequately supports complex transplant patients is however recognised. As the Inquest heard, and you referenced within your letter, there are advantages of this model
Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
with the presence of a consultant of the week being associated with reducing length of stay and improving continuity and communication.
For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant.
I acknowledge that whilst the Inquest heard about this process, there was a lack of evidence provided to the hearing demonstrating how these arrangements robustly account for the more complex transplant patient, particularly those receiving outpatient care. Since the Inquest, I can confirm that actions have been taken to strengthen this process, which I have explained below.
The MRI Transplant team have modified the weekly Wednesday Ward Patient Review meeting, mentioned above, to make it an MDT for discussion of complex patients. This provides a more robust multidisciplinary perspective with decision making that involves all relevant clinical staff. A significant change is the attendance of the outpatient team to support any issues on discharge.
In addition to this, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting.
Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues raised. If you require anything further, then please do not hesitate to contact me.