Ashford and St Peters Hospitals
NHS / Health Body
Action Planned
The Trust's Serious Incident Report recommends empowering junior doctors to escalate and seek senior review. Actions to facilitate this include discussion at the Junior Doctor Forum, policy reviews, strengthening electronic patient record escalation processes, and monitoring quality improvement projects. (AI summary)
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Dear Miss Crawford
Re: Mrs Wendy Hammon Regulation 28 Report to Prevent Future Deaths
Please find below my responses to your concerns raised in your email received on 29 July 2024 following the inquest into the death of Mrs Wendy Hammon. The Regulation 28 report sets out the matters giving rise to concerns numbered 1-3 below.
1. The fluid input and output charts completed for Mrs Hammon were inadequate and could not be relied upon to accurately assess her fluid input and output.
2. Mrs. Hammon’s rising CRP was not noted by any member of the clinical team – whether junior or senior - who saw Mrs Hammon during the period from 1 September onwards, despite rising CRP being a potential indicator of ischaemia in patients who are being conservatively managed for small bowel obstruction. The court is concerned that this was not an individual error and may be reflective of a wider lack of knowledge within the team.
3. The Early Warning Scores (NEWS2 Scores) for Mrs Hammon were often incomplete.
Serious Incident Report
Following the Inquest, the Trust’s Serious Incident Investigation Report has been completed and a copy is attached which I hope you will find helpful. The report incorporates key issues identified during the Inquest and has recommended the Junior Doctors be empowered to escalate and seek senior review. To facilitate this the following actions will be discussed at the Junior Doctor Forum as a regular standing agenda item.
• Clear concise documentation to be a standard process.
• Importance of escalating unwell patients by junior doctor team members and nursing staff to senior surgical team members (registrar or consultant) and barriers to doing so.
• Reinforcing the importance of the senior clinical teams that are available on site all the time. In addition to the surgical registrar who is on site 24 hours a day, 7 days a week, there is the CSNP team, who are advanced practitioners and can support junior staff and get senior staff to the patient when required. ITU staff can also be contacted if the critical care outreach team is unavailable.
Patients first Personal responsibility Passion for excellence Pride in our team
• Escalation and chasing of urgent CT scans with the radiology department.
1. Fluid Balance
The Trust has also implemented the following improvements in relation to the accurate monitoring of fluid balance in patients’ healthcare records since September 2022.
In May 2022 the Trust moved to an electronic patient record (EPR). Before this, the Trust used daily paper hard copy fluid balance charts for each patient that required fluid intake and output monitoring.
It was identified that the fluid balance area of the EPR does not automatically populate the fluid balance chart when parenteral nutrition is commenced. To manage this a quick reference guide (QRG) - appendix 1 - was developed and widely disseminated throughout the Trust. Fluid Management is a high priority on the list of projects for the Medication Administration Process within EPR which will commence in October 2024 following an EPR system upgrade. The Electronic Prescribing and Medicines Administration (EPMA) Pharmacists are undertaking work as part of a Discovery Phase to provide the EPR team with the fullest information to enable them to proceed. The EPR team will work with Subject Matter Experts (SME) to understand what needs to feed through to the fluid balance chart. A gap analysis will follow this to identify the updates needed to improve the accessibility and the viewing of the fluid balance chart. A secondary project to implement clinical support decisions to help the identification of patients who are at risk of hydration or renal issues will also be required.
New clinical staff to the Trust have training in accurate monitoring of fluid balance as part of the induction training (for Health Care Support Workers, newly registered nurses, and Internationally Educated Nurses). This training forms part of the Care Certificate for Health Care support workers and the Preceptorship competencies of newly registered nurses and internationally educated nurses. Student Nurses allocated to the Trust receive additional training on induction which consists of a workbook that includes how to complete fluid charts and the importance of accurate fluid balance records for patient care. Ward based Clinical Practice Educators work alongside staff with all aspects of nursing care including accurate recording of fluid balance and how to record this on the EPR.
The importance of fluid balance has been discussed at daily safety huddles across the wards. This has also been a focus of the ward's ‘Big 3’ where three important topics that are the focus for a week are discussed at all handovers and will be repeated at intervals until embedded in practice.
One ward has implemented a set time for emptying catheters, drains, and NG tubes to ensure output is recorded. Staff are expected to review charts before the end of each shift and the ward manager is monitoring compliance with this. The ward is also working on a quality improvement project to improve patient oral hydration and fluid balance. Both of these quality improvement initiatives will be rolled out across the Trust once their benefit and success are evaluated.
The divisional Clinical Practice Educators are providing ward focused education in the form of tea trolley training to ensure all staff are educated in the accurate recording of fluid balance.
Review of fluid balance charts forms part of the weekly care round where senior nurses visit each ward providing support and guidance in completing all aspects of the patient's EPR.
Patients first Personal responsibility Passion for excellence Pride in our team
2 & 3 Deteriorating Patient Working Group
A Trust wide Deteriorating Patient Working Group has recently commenced to address concerns around recognising, escalating, and managing the deteriorating patient. The group has representation from all clinical areas, medical, nursing, and allied health professionals, practice educators and training leads, and digital leads. The group is focussed on leading improvements in the following areas.
• Supporting the identification of and understanding of the barriers to recognition of the deteriorating patient across all patient groups.
• Reviewing and updating policies and guidance related to the recognition, escalation, and management of deteriorating patients and sepsis.
• Support and oversight of the training and education provided to clinical staff in relation to the recognition, escalation, and management of the deteriorating patient, including. o Vital sign observation recording, monitoring, and escalation o Appropriate and full NEWS2 scoring and escalation o Recognition and escalation of abnormal blood results (including CRP being a potential indicator for bowel ischaemia)
• Reviewing and strengthening the escalation process embedded with the electronic patient record, including; o Sepsis tools and alerts o NEWS2 alerts
• Monitoring change and quality improvement projects that are specifically aimed at improving the recognition and escalation of the deteriorating patient including; o Understanding of NEWS2 and Sepsis escalation procedures o Escalation for senior review, critical care outreach referral, and hospital at night support. o Undertaking and documentation of full vital sign observations and NEWS2 scoring o Monitoring and escalation of abnormal blood results (including CRP)
The group will meet regularly to monitor progress against these areas for improvement and report to the Trust Safety and Quality Committee bi-monthly.
I hope the changes the Trust has made to our practices are sufficient to demonstrate we have taken your concerns seriously and continue to take action to learn and improve the concerns you have raised in your report.
Please do not hesitate to contact me should you require further details or documentation.
Re: Mrs Wendy Hammon Regulation 28 Report to Prevent Future Deaths
Please find below my responses to your concerns raised in your email received on 29 July 2024 following the inquest into the death of Mrs Wendy Hammon. The Regulation 28 report sets out the matters giving rise to concerns numbered 1-3 below.
1. The fluid input and output charts completed for Mrs Hammon were inadequate and could not be relied upon to accurately assess her fluid input and output.
2. Mrs. Hammon’s rising CRP was not noted by any member of the clinical team – whether junior or senior - who saw Mrs Hammon during the period from 1 September onwards, despite rising CRP being a potential indicator of ischaemia in patients who are being conservatively managed for small bowel obstruction. The court is concerned that this was not an individual error and may be reflective of a wider lack of knowledge within the team.
3. The Early Warning Scores (NEWS2 Scores) for Mrs Hammon were often incomplete.
Serious Incident Report
Following the Inquest, the Trust’s Serious Incident Investigation Report has been completed and a copy is attached which I hope you will find helpful. The report incorporates key issues identified during the Inquest and has recommended the Junior Doctors be empowered to escalate and seek senior review. To facilitate this the following actions will be discussed at the Junior Doctor Forum as a regular standing agenda item.
• Clear concise documentation to be a standard process.
• Importance of escalating unwell patients by junior doctor team members and nursing staff to senior surgical team members (registrar or consultant) and barriers to doing so.
• Reinforcing the importance of the senior clinical teams that are available on site all the time. In addition to the surgical registrar who is on site 24 hours a day, 7 days a week, there is the CSNP team, who are advanced practitioners and can support junior staff and get senior staff to the patient when required. ITU staff can also be contacted if the critical care outreach team is unavailable.
Patients first Personal responsibility Passion for excellence Pride in our team
• Escalation and chasing of urgent CT scans with the radiology department.
1. Fluid Balance
The Trust has also implemented the following improvements in relation to the accurate monitoring of fluid balance in patients’ healthcare records since September 2022.
In May 2022 the Trust moved to an electronic patient record (EPR). Before this, the Trust used daily paper hard copy fluid balance charts for each patient that required fluid intake and output monitoring.
It was identified that the fluid balance area of the EPR does not automatically populate the fluid balance chart when parenteral nutrition is commenced. To manage this a quick reference guide (QRG) - appendix 1 - was developed and widely disseminated throughout the Trust. Fluid Management is a high priority on the list of projects for the Medication Administration Process within EPR which will commence in October 2024 following an EPR system upgrade. The Electronic Prescribing and Medicines Administration (EPMA) Pharmacists are undertaking work as part of a Discovery Phase to provide the EPR team with the fullest information to enable them to proceed. The EPR team will work with Subject Matter Experts (SME) to understand what needs to feed through to the fluid balance chart. A gap analysis will follow this to identify the updates needed to improve the accessibility and the viewing of the fluid balance chart. A secondary project to implement clinical support decisions to help the identification of patients who are at risk of hydration or renal issues will also be required.
New clinical staff to the Trust have training in accurate monitoring of fluid balance as part of the induction training (for Health Care Support Workers, newly registered nurses, and Internationally Educated Nurses). This training forms part of the Care Certificate for Health Care support workers and the Preceptorship competencies of newly registered nurses and internationally educated nurses. Student Nurses allocated to the Trust receive additional training on induction which consists of a workbook that includes how to complete fluid charts and the importance of accurate fluid balance records for patient care. Ward based Clinical Practice Educators work alongside staff with all aspects of nursing care including accurate recording of fluid balance and how to record this on the EPR.
The importance of fluid balance has been discussed at daily safety huddles across the wards. This has also been a focus of the ward's ‘Big 3’ where three important topics that are the focus for a week are discussed at all handovers and will be repeated at intervals until embedded in practice.
One ward has implemented a set time for emptying catheters, drains, and NG tubes to ensure output is recorded. Staff are expected to review charts before the end of each shift and the ward manager is monitoring compliance with this. The ward is also working on a quality improvement project to improve patient oral hydration and fluid balance. Both of these quality improvement initiatives will be rolled out across the Trust once their benefit and success are evaluated.
The divisional Clinical Practice Educators are providing ward focused education in the form of tea trolley training to ensure all staff are educated in the accurate recording of fluid balance.
Review of fluid balance charts forms part of the weekly care round where senior nurses visit each ward providing support and guidance in completing all aspects of the patient's EPR.
Patients first Personal responsibility Passion for excellence Pride in our team
2 & 3 Deteriorating Patient Working Group
A Trust wide Deteriorating Patient Working Group has recently commenced to address concerns around recognising, escalating, and managing the deteriorating patient. The group has representation from all clinical areas, medical, nursing, and allied health professionals, practice educators and training leads, and digital leads. The group is focussed on leading improvements in the following areas.
• Supporting the identification of and understanding of the barriers to recognition of the deteriorating patient across all patient groups.
• Reviewing and updating policies and guidance related to the recognition, escalation, and management of deteriorating patients and sepsis.
• Support and oversight of the training and education provided to clinical staff in relation to the recognition, escalation, and management of the deteriorating patient, including. o Vital sign observation recording, monitoring, and escalation o Appropriate and full NEWS2 scoring and escalation o Recognition and escalation of abnormal blood results (including CRP being a potential indicator for bowel ischaemia)
• Reviewing and strengthening the escalation process embedded with the electronic patient record, including; o Sepsis tools and alerts o NEWS2 alerts
• Monitoring change and quality improvement projects that are specifically aimed at improving the recognition and escalation of the deteriorating patient including; o Understanding of NEWS2 and Sepsis escalation procedures o Escalation for senior review, critical care outreach referral, and hospital at night support. o Undertaking and documentation of full vital sign observations and NEWS2 scoring o Monitoring and escalation of abnormal blood results (including CRP)
The group will meet regularly to monitor progress against these areas for improvement and report to the Trust Safety and Quality Committee bi-monthly.
I hope the changes the Trust has made to our practices are sufficient to demonstrate we have taken your concerns seriously and continue to take action to learn and improve the concerns you have raised in your report.
Please do not hesitate to contact me should you require further details or documentation.