The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust updated VTE guidelines with NICE guidance, introduced mandatory e-learning on VTE, rolled out NEWS2, mandated patient monitoring documentation in Tendable© audits, and implemented a Patient Safety Incident Response Plan, identifying VTE as a focus area. They are also working with other trusts on a joint Electronic Patient Record System implementation by 2025. (AI summary)
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Dear Ms Blake
Colin Greenway – Trust’s Response to Regulation 28
We write further to the Report for the Prevention of Future Deaths made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 18 July 2023.
We will respond to each of Ms Blake’s areas of concern in turn and set out the actions being taken in response, as follows:
1. Junior doctors incorrect prescribing despite clear guidelines.
We have reviewed Mr Greenway’s medical records and confirm that the junior doctor who clerked him on admission prescribed the incorrect dose of thromboprophylaxis. They noted his kidney function was impaired and prescribed a renal dose, which is lower than the standard dose on account of this medication being potentially dangerous to patients with kidney injury and/or failure. The junior doctor having left the Trust and since the hearing has been in contact to say that she prescribed the renal dose anticipating that renal function might deteriorate further. However, to be in strict compliance with the Trust’s Prevention of Venous Thromboembolism (VTE) Guidelines in place at the time Mr Greenway should have been prescribed the standard dose. Our local Guidelines relating to VTE are under review, and this is due to be taken to the next Drug and Therapeutics Committee Meeting for ratification on 31 October 2023, before being referred on to our Clinical Effectiveness Executive Group for final approval. In the meantime, these local guidelines have been removed from the Trust’s intranet and replaced with a link to the appropriate NICE guidance for VTE Adults.
We recognise the importance of standardising the prescription of thromboprophylaxis across our Integrated Care Service, particularly because junior doctors regularly complete training placements in more than one Trust across the group. We are therefore consulting with our colleagues at the other acute Trusts within the Norfolk and Waveney Integrated Care System (ICS) and also with our Integrated Care Board to see how we can better regulate this.
26 September 2023 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust We have reiterated the importance of accurate VTE risk assessment and thromboprophylaxis prescription (medication to prevent clot formation) via Trust-wide communications. We are also reviewing our induction materials to ensure these issues are given appropriate emphasis. VTE is part of our mandatory training, and our Anticoagulation team have produced a booklet which has been distributed to our junior doctors. We are looking into making this available via a QR Code, to improve accessibility.
2. VTE assessments not being completed on clerking a patient just on the electronic medicines prescription which is much less detailed.
Currently we have VTE risk assessments within our Clerking Documents, and also on ePMA, our Electronic Prescribing and Medicines Administration which is an electronic system designed to mostly replace paper drug charts. The purpose of these risk assessments is to identify potential risk factors for patients who may be at risk of VTE, and to identify any contra-indications to thromboprophylaxis. This is required because there are patients who will be at a higher risk of VTE, and those for whom thromboprophylaxis may not be suitable, such as those with a risk of bleeding. The ePMA risk assessment must be completed in order to prescribe thromboprophylaxis on the Trust’s ePMA system.
When Mr Greenway was admitted, the VTE risk assessment was completed on ePMA, but not on the paper Clerking Document. As noted at the hearing, the risk assessment in the Trust’s paper Clerking Document is more detailed than the version on ePMA, however the eMPA version is fully compliant with NICE guidance.
In consequence, we are removing the VTE risk assessment within the Clerking Documents, so that this must be completed on ePMA only. Following feedback from our clinicians, we have made the decision to retain the guidance on VTE risk factors and contraindications within the Clerking Documents. This is because our clinicians advised that they found this very helpful as a reference, and it includes more examples than the guidance on the ePMA risk assessments and is based on the Department of Health advice. When our Clerking Documents are revised and reprinted next, they will contain a check box for the Consultant to confirm that the VTE risk assessment has been completed, and the dosage checked. In the meantime, we have commissioned stickers to add these checks to the Clerking Documents, and these have been circulated to the ward clerks to be added to the existing stock of Clerking Documents.
3. Consultants stating it is the pharmacists’ job to check for errors when there is only a 3 day service by pharmacists to do this and it is intended as a safety net procedure only.
Medicines Reconciliation should be carried out within 24 hours of admission to an acute Trust, in accordance with NICE guidance. Although this is not a service which is carried out exclusively by Pharmacists, was previously a daily service provided by the Trust’s pharmacists.
Although the focus of the Coroner’s concern related to the Consultant’s perceived lack of ownership, it is important to set out the wider context in order to clarify how this can be resolved. Against a background of local and national Pharmacy staffing shortages, the Trust had reduced its ward pharmacy service including effective medicines reconciliation on admission and clinical medicines support for the medical teams by the Trust’s pharmacists, meaning that this was not taking place at weekends during Mr Greenway’s admission. The shortage of pharmacists has been identified as an area of risk, and is included on the Trust’s Risk Register.
26 September 2023 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust There have been a number of challenges to successful recruitment and retention within the Trust’s Pharmacy team, which is currently being mitigated by the employment of 10 agency Pharmacists, to ensure compliance with checking of inpatient prescriptions and medications to be taken with the patient on discharge. To mitigate the challenges of employment within the Trust’s local area, the Trust is looking to recruit 5 Pharmacists from inside the European Economic Area. It is hoped this recruitment, together with the provision of opportunities for career growth to the EEA Pharmacists, will encourage their settlement within the King’s Lynn area and allow for greater security for the Trust in a mutually rewarding arrangement.
In the longer-term, the Trust believes a focus on education is required to improve its ability to attract quality candidates and further improve retention. The Trust is looking to increase its available trainee undergraduate placements at the earliest opportunity, as well as offering one or more apprenticeships in the field. The Trust is to recruit a dedicated Education team within the Pharmacy group, to focus on education activities and ongoing training.
With respect to consultant responsibility for Medicines Reconciliation, we confirm that senior doctors should be taking responsibility for their patients’ medications, and for oversight of prescribing and other decisions made by junior doctors working within their team, in line with GMC Guidance and our own Trust values.
4. Consultants not accepting that it is their responsibility to monitor what their junior doctors are doing when prescribing new medications for patients.
As above, we confirm that is it the expectation of the Trust that consultants accept responsibility for the junior doctors within their team in line with GMC Guidance and Trust values. This relates to prescribing new medications for patients and also for other decisions made or advice given by the junior doctors.
With respect to the prescription of thromboprophylaxis, as above we will be updating our Clerking Documents to include a specific check box for consultants to prompt confirmation that they have checked the VTE risk assessment has been completed, and they have checked the dosage prescribed.
The Trust is working to reduce the level of locum consultant cover and foster better patient ownership with a more substantive workforce.
The concerns raised in the Regulation 28 report were disseminated to all Consultants by our Interim Medical Director as points to note for their own practice, and that of their colleagues. This case was also presented at the Acute Medicine Mortality Meeting, where it was emphasised that lack of ownership is against our Trust values and GMC Guidance, and this is within expected practice for our consultants.
5. Three different consultants seeing the same patient over three days, no continuity of care.
Although we would very much wish for every patient to be able to have the same consultant for the entirety of their admission, this is not currently within our ability to provide due to pressures within the NHS leading to staffing shortages across all levels and working time requirements. A shortage of substantive consultants affects our ability to assign consultants to the same area for an extended period of time. However, we will focus on effective handover of care between consultants and improving communication.
26 September 2023 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
6. Patients at higher risk of an embolus not being monitored correctly or at all after initial clerking.
We would expect that VTE risk assessments and thromboprophylaxis should be reviewed within 24 hours of admission or whenever the clinical situation changes, in accordance with the Trust’s VTE guidance as included in the Clerking Document. This review is to be recorded on ePMA.
The Coroner expressed particular concern that Mr Greenway’s fluid balance charts had not been fully completed, and that considering his known dehydration, this would have greatly assisted us in making an accurate assessment of his VTE risk. We know that completion of fluid balance charts is a nationwide issue, and there are particular difficulties with this across Norfolk and Waveney because fluid balance, observations and prescriptions run across multiple electronic and paper systems. The Trust has recently completed a joint procurement exercise in conjunction with Norfolk and Norwich University Hospitals NHS Foundation Trust and James Paget University Hospitals NHS Foundation Trust to agree a supplier for an Electronic Patient Record System which will be in place across all three Acute Trusts within the ICS. This EPR will streamline our processes with respect to patient monitoring, including Fluid Balance Charts, and is estimated to be in place by 2025. Engaging in a joint exercise across the ICS will mitigate the risk of processes differing across neighbouring Trusts, and we consider that ensuring that practices are aligned across the region will particularly help junior doctors as they rotate through placements.
In the meantime, we continue to audit compliance with patient monitoring and the completion of documentation. Fluid Balance Charts are included within Tendable© audits which are completed on a monthly basis, together with other patient documentation.
In addition, we have recently designed and implemented the Trust’s Patient Safety Incident Response Plan under the new NHS Patient Safety Incident Response Framework (PSIRF). As part of this Plan, we are required to identify three areas of focus which will receive multi-disciplinary input over the coming year to identify potential improvements which can be implemented to improve patient safety in this area. PSIRF provides a framework for Trusts to put in place a Plan tailored to patient safety issues identified within that Trust, with a view to preventing similar incidents before they occur. This is a more preventative process than the previous Serious Incident Framework, which reacted to patient safety incidents. I confirm the Trust has identified VTE as one of its areas of focus for its 2023/24 Patient Safety Incident Response Plan, and we believe this will allow us to drive improvement in this area across the Trust.
I would be happy to provide you with further information if required.
Colin Greenway – Trust’s Response to Regulation 28
We write further to the Report for the Prevention of Future Deaths made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 18 July 2023.
We will respond to each of Ms Blake’s areas of concern in turn and set out the actions being taken in response, as follows:
1. Junior doctors incorrect prescribing despite clear guidelines.
We have reviewed Mr Greenway’s medical records and confirm that the junior doctor who clerked him on admission prescribed the incorrect dose of thromboprophylaxis. They noted his kidney function was impaired and prescribed a renal dose, which is lower than the standard dose on account of this medication being potentially dangerous to patients with kidney injury and/or failure. The junior doctor having left the Trust and since the hearing has been in contact to say that she prescribed the renal dose anticipating that renal function might deteriorate further. However, to be in strict compliance with the Trust’s Prevention of Venous Thromboembolism (VTE) Guidelines in place at the time Mr Greenway should have been prescribed the standard dose. Our local Guidelines relating to VTE are under review, and this is due to be taken to the next Drug and Therapeutics Committee Meeting for ratification on 31 October 2023, before being referred on to our Clinical Effectiveness Executive Group for final approval. In the meantime, these local guidelines have been removed from the Trust’s intranet and replaced with a link to the appropriate NICE guidance for VTE Adults.
We recognise the importance of standardising the prescription of thromboprophylaxis across our Integrated Care Service, particularly because junior doctors regularly complete training placements in more than one Trust across the group. We are therefore consulting with our colleagues at the other acute Trusts within the Norfolk and Waveney Integrated Care System (ICS) and also with our Integrated Care Board to see how we can better regulate this.
26 September 2023 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust We have reiterated the importance of accurate VTE risk assessment and thromboprophylaxis prescription (medication to prevent clot formation) via Trust-wide communications. We are also reviewing our induction materials to ensure these issues are given appropriate emphasis. VTE is part of our mandatory training, and our Anticoagulation team have produced a booklet which has been distributed to our junior doctors. We are looking into making this available via a QR Code, to improve accessibility.
2. VTE assessments not being completed on clerking a patient just on the electronic medicines prescription which is much less detailed.
Currently we have VTE risk assessments within our Clerking Documents, and also on ePMA, our Electronic Prescribing and Medicines Administration which is an electronic system designed to mostly replace paper drug charts. The purpose of these risk assessments is to identify potential risk factors for patients who may be at risk of VTE, and to identify any contra-indications to thromboprophylaxis. This is required because there are patients who will be at a higher risk of VTE, and those for whom thromboprophylaxis may not be suitable, such as those with a risk of bleeding. The ePMA risk assessment must be completed in order to prescribe thromboprophylaxis on the Trust’s ePMA system.
When Mr Greenway was admitted, the VTE risk assessment was completed on ePMA, but not on the paper Clerking Document. As noted at the hearing, the risk assessment in the Trust’s paper Clerking Document is more detailed than the version on ePMA, however the eMPA version is fully compliant with NICE guidance.
In consequence, we are removing the VTE risk assessment within the Clerking Documents, so that this must be completed on ePMA only. Following feedback from our clinicians, we have made the decision to retain the guidance on VTE risk factors and contraindications within the Clerking Documents. This is because our clinicians advised that they found this very helpful as a reference, and it includes more examples than the guidance on the ePMA risk assessments and is based on the Department of Health advice. When our Clerking Documents are revised and reprinted next, they will contain a check box for the Consultant to confirm that the VTE risk assessment has been completed, and the dosage checked. In the meantime, we have commissioned stickers to add these checks to the Clerking Documents, and these have been circulated to the ward clerks to be added to the existing stock of Clerking Documents.
3. Consultants stating it is the pharmacists’ job to check for errors when there is only a 3 day service by pharmacists to do this and it is intended as a safety net procedure only.
Medicines Reconciliation should be carried out within 24 hours of admission to an acute Trust, in accordance with NICE guidance. Although this is not a service which is carried out exclusively by Pharmacists, was previously a daily service provided by the Trust’s pharmacists.
Although the focus of the Coroner’s concern related to the Consultant’s perceived lack of ownership, it is important to set out the wider context in order to clarify how this can be resolved. Against a background of local and national Pharmacy staffing shortages, the Trust had reduced its ward pharmacy service including effective medicines reconciliation on admission and clinical medicines support for the medical teams by the Trust’s pharmacists, meaning that this was not taking place at weekends during Mr Greenway’s admission. The shortage of pharmacists has been identified as an area of risk, and is included on the Trust’s Risk Register.
26 September 2023 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust There have been a number of challenges to successful recruitment and retention within the Trust’s Pharmacy team, which is currently being mitigated by the employment of 10 agency Pharmacists, to ensure compliance with checking of inpatient prescriptions and medications to be taken with the patient on discharge. To mitigate the challenges of employment within the Trust’s local area, the Trust is looking to recruit 5 Pharmacists from inside the European Economic Area. It is hoped this recruitment, together with the provision of opportunities for career growth to the EEA Pharmacists, will encourage their settlement within the King’s Lynn area and allow for greater security for the Trust in a mutually rewarding arrangement.
In the longer-term, the Trust believes a focus on education is required to improve its ability to attract quality candidates and further improve retention. The Trust is looking to increase its available trainee undergraduate placements at the earliest opportunity, as well as offering one or more apprenticeships in the field. The Trust is to recruit a dedicated Education team within the Pharmacy group, to focus on education activities and ongoing training.
With respect to consultant responsibility for Medicines Reconciliation, we confirm that senior doctors should be taking responsibility for their patients’ medications, and for oversight of prescribing and other decisions made by junior doctors working within their team, in line with GMC Guidance and our own Trust values.
4. Consultants not accepting that it is their responsibility to monitor what their junior doctors are doing when prescribing new medications for patients.
As above, we confirm that is it the expectation of the Trust that consultants accept responsibility for the junior doctors within their team in line with GMC Guidance and Trust values. This relates to prescribing new medications for patients and also for other decisions made or advice given by the junior doctors.
With respect to the prescription of thromboprophylaxis, as above we will be updating our Clerking Documents to include a specific check box for consultants to prompt confirmation that they have checked the VTE risk assessment has been completed, and they have checked the dosage prescribed.
The Trust is working to reduce the level of locum consultant cover and foster better patient ownership with a more substantive workforce.
The concerns raised in the Regulation 28 report were disseminated to all Consultants by our Interim Medical Director as points to note for their own practice, and that of their colleagues. This case was also presented at the Acute Medicine Mortality Meeting, where it was emphasised that lack of ownership is against our Trust values and GMC Guidance, and this is within expected practice for our consultants.
5. Three different consultants seeing the same patient over three days, no continuity of care.
Although we would very much wish for every patient to be able to have the same consultant for the entirety of their admission, this is not currently within our ability to provide due to pressures within the NHS leading to staffing shortages across all levels and working time requirements. A shortage of substantive consultants affects our ability to assign consultants to the same area for an extended period of time. However, we will focus on effective handover of care between consultants and improving communication.
26 September 2023 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
6. Patients at higher risk of an embolus not being monitored correctly or at all after initial clerking.
We would expect that VTE risk assessments and thromboprophylaxis should be reviewed within 24 hours of admission or whenever the clinical situation changes, in accordance with the Trust’s VTE guidance as included in the Clerking Document. This review is to be recorded on ePMA.
The Coroner expressed particular concern that Mr Greenway’s fluid balance charts had not been fully completed, and that considering his known dehydration, this would have greatly assisted us in making an accurate assessment of his VTE risk. We know that completion of fluid balance charts is a nationwide issue, and there are particular difficulties with this across Norfolk and Waveney because fluid balance, observations and prescriptions run across multiple electronic and paper systems. The Trust has recently completed a joint procurement exercise in conjunction with Norfolk and Norwich University Hospitals NHS Foundation Trust and James Paget University Hospitals NHS Foundation Trust to agree a supplier for an Electronic Patient Record System which will be in place across all three Acute Trusts within the ICS. This EPR will streamline our processes with respect to patient monitoring, including Fluid Balance Charts, and is estimated to be in place by 2025. Engaging in a joint exercise across the ICS will mitigate the risk of processes differing across neighbouring Trusts, and we consider that ensuring that practices are aligned across the region will particularly help junior doctors as they rotate through placements.
In the meantime, we continue to audit compliance with patient monitoring and the completion of documentation. Fluid Balance Charts are included within Tendable© audits which are completed on a monthly basis, together with other patient documentation.
In addition, we have recently designed and implemented the Trust’s Patient Safety Incident Response Plan under the new NHS Patient Safety Incident Response Framework (PSIRF). As part of this Plan, we are required to identify three areas of focus which will receive multi-disciplinary input over the coming year to identify potential improvements which can be implemented to improve patient safety in this area. PSIRF provides a framework for Trusts to put in place a Plan tailored to patient safety issues identified within that Trust, with a view to preventing similar incidents before they occur. This is a more preventative process than the previous Serious Incident Framework, which reacted to patient safety incidents. I confirm the Trust has identified VTE as one of its areas of focus for its 2023/24 Patient Safety Incident Response Plan, and we believe this will allow us to drive improvement in this area across the Trust.
I would be happy to provide you with further information if required.