University Hospitals Leicester
NHS / Health Body
Action Taken
The importance of communication regarding anticoagulation has been re-emphasised, and the learning from the case shared with ward leaders and matrons. The daily brief includes a reminder about clear information. Warfarin prescribing has been incorporated into the digital system, and by December 2025, a digital reminder will be embedded for MDT colleagues to include pertinent clinical information on digital warfarin dosage requests. (AI summary)
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Dear Professor Mason
Thank you for your Regulation 28 Report dated 27th June 2024, which arose out of your inquest into the death of Mr John Parry.
Whilst it was acknowledged that it did not have an adverse outcome, you were understandably concerned about the potential impact on patients which might result from ineffective communication among the treating clinical team.
We fully accept and recognise the paramount importance of communication between all members of the multidisciplinary team in ensuring safe and effective patient care.
Following on from the issues raised in your Regulation 28 Report we have re-emphasised the importance of clear and effective communication between all colleagues in particular regarding anticoagulation. This includes sharing learning from this case with all ward leaders, matrons and through our chief nurse forums. A reminder to all clinical teams via the daily brief of the importance of giving clear information was included in the week commencing 29/07/24 and was repeated in the week commencing 05/08/24. The daily brief has three key messages and is read out to all clinical teams at every huddle every day for a week. We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-into another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system. To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes. I trust that this gives you assurance that we take this matter very seriously as we look to strengthen our processes and make them more robust.
If you wish for any further information, please do not hesitate to contact me.
Thank you for your Regulation 28 Report dated 27th June 2024, which arose out of your inquest into the death of Mr John Parry.
Whilst it was acknowledged that it did not have an adverse outcome, you were understandably concerned about the potential impact on patients which might result from ineffective communication among the treating clinical team.
We fully accept and recognise the paramount importance of communication between all members of the multidisciplinary team in ensuring safe and effective patient care.
Following on from the issues raised in your Regulation 28 Report we have re-emphasised the importance of clear and effective communication between all colleagues in particular regarding anticoagulation. This includes sharing learning from this case with all ward leaders, matrons and through our chief nurse forums. A reminder to all clinical teams via the daily brief of the importance of giving clear information was included in the week commencing 29/07/24 and was repeated in the week commencing 05/08/24. The daily brief has three key messages and is read out to all clinical teams at every huddle every day for a week. We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-into another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system. To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes. I trust that this gives you assurance that we take this matter very seriously as we look to strengthen our processes and make them more robust.
If you wish for any further information, please do not hesitate to contact me.