Nancy Rogers

Dear Dr Shaw, Regulation 28 Report to Prevent Further Deaths Thank you for your report dated 9 July 2024. am sorry that you have had cause to make report; but we have carefully considered the concerns raised and | can now advise as follows meeting was held between the Clinical Lead Emergency Medicine (FGH), the Clinical Lead Emergency Medicine (RLI) , the Clinical Lead Urgent Treatment Centre WGH and the Deputy Medical Director (Education, Research, Workforce and Innovation) to discuss the cases of Shirley Potter and Nancy Rogers and another case that we had noted in the jurisdiction of the Senior Coroner Lancashire and Blackburn with Darwen. The discussion at meeting centred on the best way to disseminate information regarding aortic dissection, in order to reduce the risk of this diagnosis being missed in the future. An action plan was written and since the meeting, the following actions have been put in place: Contact has been made with the Aortic Dissection Charitable Trust and consent has been obtained to use their data and logos in any materials, teaching or discussions_ An A4 poster has been created (copy attached) and is displayed in the Emergency Department (ED) clinical areas and triage, for quick reference The QR code links to a video on the Aortic Dissection Charitable Trust's website. The video on the Aortic Dissection Charitable Trust website is being drawn to the attention of senior and junior medical staff at ED meetings at both of the Trust's main hospitals, between July and the end of September. A list of the Bay Our the

relevant staff has been compiled and new starters will be added. A tracker is being maintained of the dates when the video was viewed: A similar arrangement is also in place for nursing staff who perform triage. Similar awareness raising is taking place at the Kendal Urgent Treatment Unit and the Same Day Emergency Care and Acute Medical Units. Aortic dissection is now included in the new doctor induction in August: A Standard Operating Procedure (SOP) for the management of Aortic Dissection is being created, to ensure a consistent approach to the management of aortic dissection throughout the Trust This will be uploaded to Trust Procedural Documents library, which can be accessed from any Trust computer: There is currently a SOP in the medical guidelines and there are also regional guidelines. These are being combined for clarity and it is anticipated that this will be completed within the next 4-6 weeks. An audit of the SOP has been included in the Audit Calendar: this information is helpful but if you should require anything further, including a copy of the Action Plan, please do not hesitate to contact me.