Surrey and Sussex Healthcare
NHS / Health Body
Action Taken
Surrey & Sussex Healthcare NHS Trust outlines actions taken to improve timely surgery for fractured neck of femur patients including infrastructure improvements and process changes, resulting in improved surgery rates within 36 hours and a reduced mortality rate. (AI summary)
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Dear Ms Ridge, Regulation 28 Report - response by Surrey & Sussex Healthcare NHS Trust Inquest touching upon the death of Anne Johnston Rowland This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to section 7(2) to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 20 March 2024, · made subsequent to the inquest into the death of Mrs Rowland, which was concluded on 20 March 2024. The Trust was given until 15 May 2024 to respond to the coroner, pursuant to Regulation 29(5) Coroners (Investigations) Regulations 2013. I would like to start this response by offering our sincere condolences to Mrs Rowland's family for their loss. The Trust accepts fully the findings of HM Coroner, and that had the surgery taken place on the same day as Mrs Rowland's admission or the day after, she. would have had a higher chance of surviving the injury. The Prevention of Future Deaths report identified the following areas of concern, and I address these in the response, with details of the actions that the Trust has undertaken and those that are planned, along with the details of the improvement to date that have already resulted from these actions: Continuing infrastructure risks at East Surrey Hospital have potential to compromise the Trust's ability to perform operations on patients with fractured hips on the day of admission or the day thereafter, which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures. 1
Response: The delay in Mrs Rowland's surgery was due to high numbers of patients with fractures waiting for surgery at the time. The high numbers of patients waiting for surgery is a result of various factors. The population served by the hospital has grown from approximately 500,000 to 744,000 in the last decade and there has been an increase in the number of patients suffering fractured neck of femur admitted to our hospital - from 500 to 590 in the last year, an 18% rise. There has also been a rise in the number of other time critical trauma patients requiring surgery, by 30% over the last decade. At East Surrey Hospital there have been a number of infrastructure issues relating to the orthopaedic operating theatres over the last few years. This has involved chillers and air handling equipment that have been unreliable and led to unpredictable cancellation of planned operating lists, adding to the long waiting lists for elective surgery that resulted from the Covid pandemic. The delays in our fractured neck of femur patients receiving surgery needed to be addressed and I have detailed below the actions taken since March 2023 and further planned actions: •
1. The orthopaedic department has expanded from 8 to 12 consultants and are well supported by an orthogeriatric team of physicians who focus on optimising the medical care for elderly trauma patients both pre and post operatively.
2. The daily operation of the hospital is overseen by the site team, ih the hospital operations centre. Since March 2023 we have added a focus on managing the daily trauma demand within our site team meetings - held daily at 08:30, 12:30, 15:30 and 17:00. The surgical team discuss in that meeting the numbers of fractured neck of femur patients awaiting surgery, the capacity within theatres to operate within 36 hours and the capacity is prioritised.
3. We follow a policy of trauma escalation to cancel planned elective . operations to accommodate trauma patients, including fracture neck of femur patients, if demand on any given day outstrips the capacity of the planned trauma lists.
4. Since the end of October 2023, we have also converted two elective lists per week into additional trauma lists, specifically to accommodate fractured neck of femur patients. At the weekly theatre planning meeting, if extra theatre capacity is identified, for example an elective list is cancelled for annual leave, then this is replaced with another additional trauma list.
5. The Trust invested several million pounds in 2022-23 to build two new wards which opened in October 2023. These 60 beds allowed us to re- organise our entire hospital bed base which has included increased elective surgical capacity and the provision of 'ring-fenced' fractured neck of femur beds to optimise the care for these most vulnerable of patients.
6. The Trust's Executive Committee have approved the case for a 2
multimillion-pound investment in 2023-24 for new air handling and chillers for the theatre complex which will correct the long-term problems experien·ced in the orthopaedic theatres and will prevent the cancellation of lists due to infrastructure failings. The first phase of this work was completed in April 2024, with new chillers and air handling units installed for half of the theatre complex. The second phase requires more substantial capital work but will be completed by the end of 2024, with new chillers and air handling units installed for the other half of the theatre complex. East Surrey Hospital use a metric of 48 hours within which to conduct such surgery and not the NICE timeframe for hip surgery. Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The coroner is concerned that in using a different metric to that in the NICE guidelines and the outstanding infrastructure repairs the Trust is placing such patients at risk of early death. Response:
1. The Trust continually monitors the pathway for patients with fractured neck of femur using several key metrics, based on NICE guidance and the Best Practice Tariff. As regards the time to surgery, the Trust monitors weekly and monthly the proportion of patients who had surgery within the timeframe identified in NICE guidance (36 hours) which is also the target for the payment of the Best Practice Tariff. We also monitor the proportion of patients who have surgery within 48 hours. We do not do this because we are disregarding the 36-hour target, we do this so that we have visibility of any delays beyond 36 hours and whether any delays are a matter of a few hours or significantly longer than that. Performanc~ against the 36-hour target is reviewed weekly by the clinical team and monthly by the Trust Executive committee; then the Trust Quality committee and then the Trust Safety and Quality committee and finally by the Trust Board.
2. The Trust tracks the mortality rate for our patients who have had a fractured neck of femur monthly, through 'Dr Foster'. The actions we have already taken have significantly reduced the time our fractured neck oUemur patients wait for surgery. In March 2023 the proportion of patients who had surgery for fractured neck of femur within 36 hours was 35%. In April 2024 it was 69% with 90% having surgery within 48 hours. This demonstrates that most patients are now having surgery on the day of or day after admission, those that don't only wait a few hours longer. Nevertheless, the Trust target is within 36 hours, and we maintain a focus to improve this further and the completion of the planned capital work will assist. The outcomes for our patents have been sequentially improving as we have taken these actions. The mortality of patients admitted with a fractured hip (measured as HSMR) has fallen sequentially since October 2023 and is now
100.2, which benchmarks 'as expected' compared to other hospitals and is 3
the lowest it has been at the Trus.t for three yea_rs.
Response: The delay in Mrs Rowland's surgery was due to high numbers of patients with fractures waiting for surgery at the time. The high numbers of patients waiting for surgery is a result of various factors. The population served by the hospital has grown from approximately 500,000 to 744,000 in the last decade and there has been an increase in the number of patients suffering fractured neck of femur admitted to our hospital - from 500 to 590 in the last year, an 18% rise. There has also been a rise in the number of other time critical trauma patients requiring surgery, by 30% over the last decade. At East Surrey Hospital there have been a number of infrastructure issues relating to the orthopaedic operating theatres over the last few years. This has involved chillers and air handling equipment that have been unreliable and led to unpredictable cancellation of planned operating lists, adding to the long waiting lists for elective surgery that resulted from the Covid pandemic. The delays in our fractured neck of femur patients receiving surgery needed to be addressed and I have detailed below the actions taken since March 2023 and further planned actions: •
1. The orthopaedic department has expanded from 8 to 12 consultants and are well supported by an orthogeriatric team of physicians who focus on optimising the medical care for elderly trauma patients both pre and post operatively.
2. The daily operation of the hospital is overseen by the site team, ih the hospital operations centre. Since March 2023 we have added a focus on managing the daily trauma demand within our site team meetings - held daily at 08:30, 12:30, 15:30 and 17:00. The surgical team discuss in that meeting the numbers of fractured neck of femur patients awaiting surgery, the capacity within theatres to operate within 36 hours and the capacity is prioritised.
3. We follow a policy of trauma escalation to cancel planned elective . operations to accommodate trauma patients, including fracture neck of femur patients, if demand on any given day outstrips the capacity of the planned trauma lists.
4. Since the end of October 2023, we have also converted two elective lists per week into additional trauma lists, specifically to accommodate fractured neck of femur patients. At the weekly theatre planning meeting, if extra theatre capacity is identified, for example an elective list is cancelled for annual leave, then this is replaced with another additional trauma list.
5. The Trust invested several million pounds in 2022-23 to build two new wards which opened in October 2023. These 60 beds allowed us to re- organise our entire hospital bed base which has included increased elective surgical capacity and the provision of 'ring-fenced' fractured neck of femur beds to optimise the care for these most vulnerable of patients.
6. The Trust's Executive Committee have approved the case for a 2
multimillion-pound investment in 2023-24 for new air handling and chillers for the theatre complex which will correct the long-term problems experien·ced in the orthopaedic theatres and will prevent the cancellation of lists due to infrastructure failings. The first phase of this work was completed in April 2024, with new chillers and air handling units installed for half of the theatre complex. The second phase requires more substantial capital work but will be completed by the end of 2024, with new chillers and air handling units installed for the other half of the theatre complex. East Surrey Hospital use a metric of 48 hours within which to conduct such surgery and not the NICE timeframe for hip surgery. Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The coroner is concerned that in using a different metric to that in the NICE guidelines and the outstanding infrastructure repairs the Trust is placing such patients at risk of early death. Response:
1. The Trust continually monitors the pathway for patients with fractured neck of femur using several key metrics, based on NICE guidance and the Best Practice Tariff. As regards the time to surgery, the Trust monitors weekly and monthly the proportion of patients who had surgery within the timeframe identified in NICE guidance (36 hours) which is also the target for the payment of the Best Practice Tariff. We also monitor the proportion of patients who have surgery within 48 hours. We do not do this because we are disregarding the 36-hour target, we do this so that we have visibility of any delays beyond 36 hours and whether any delays are a matter of a few hours or significantly longer than that. Performanc~ against the 36-hour target is reviewed weekly by the clinical team and monthly by the Trust Executive committee; then the Trust Quality committee and then the Trust Safety and Quality committee and finally by the Trust Board.
2. The Trust tracks the mortality rate for our patients who have had a fractured neck of femur monthly, through 'Dr Foster'. The actions we have already taken have significantly reduced the time our fractured neck oUemur patients wait for surgery. In March 2023 the proportion of patients who had surgery for fractured neck of femur within 36 hours was 35%. In April 2024 it was 69% with 90% having surgery within 48 hours. This demonstrates that most patients are now having surgery on the day of or day after admission, those that don't only wait a few hours longer. Nevertheless, the Trust target is within 36 hours, and we maintain a focus to improve this further and the completion of the planned capital work will assist. The outcomes for our patents have been sequentially improving as we have taken these actions. The mortality of patients admitted with a fractured hip (measured as HSMR) has fallen sequentially since October 2023 and is now
100.2, which benchmarks 'as expected' compared to other hospitals and is 3
the lowest it has been at the Trus.t for three yea_rs.