The Royal Wolverhampton
NHS / Health Body
Action Taken
The Royal Wolverhampton NHS Trust has incorporated a section for documenting investigations and results into the ED clerking document. They have also agreed to include training on reviewing blood results in the postgraduate doctor training portfolio, and allocated consultant time for reviewing blood results in the Clinical Webb Portal - ICE system. (AI summary)
View full response
Dear Mr Siddique
Inquest – Ms Rita Flynn – deceased
I refer to the death of patient Ms Flynn, this matter was heard before your court following an inquest hearing on the 20th June 2022. I am writing to you to respond to the Regulation 28 Notice to received on the 16th August 2022, addressed to the Trust’s Chief Executive.
As Chief Medical Officer, I have instructed the Directorate Management team within the Emergency Department to attend to your concerns raised upon hearing the evidence and more importantly in conjunction a joint plan of actions has been drafted attending to the issue as discharge of patients without blood test results in particular, where such results are indicative as to an infection. In response the Divisional team have attended to the specific tasks raised to address the following:
1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.
2. In addition, where test results show evidence of infection and the patient has been discharged home, then consideration should be given to contacting the patient at home urgently for follow up review.
Review of policy/discharge guidance
• Training There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level. Senior Consultants within the team who deliver individual training needs, as such will disseminate to postgraduate staff the importance of reviewing blood results in adhering to discharge protocol.
• Documentation An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.
• Electronic recording/Systems Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours). The above process and plans were agreed following a Divisional meeting held on the 5th September 2022 and Governance meeting held on the 27th September 2022. The process will be included within the ED policy/guidance for the discharge of patient pathway.
I attach for your attention an action plan devised by the team. The actions have been addressed and evidence of actions conducted will follow shortly.
Inquest – Ms Rita Flynn – deceased
I refer to the death of patient Ms Flynn, this matter was heard before your court following an inquest hearing on the 20th June 2022. I am writing to you to respond to the Regulation 28 Notice to received on the 16th August 2022, addressed to the Trust’s Chief Executive.
As Chief Medical Officer, I have instructed the Directorate Management team within the Emergency Department to attend to your concerns raised upon hearing the evidence and more importantly in conjunction a joint plan of actions has been drafted attending to the issue as discharge of patients without blood test results in particular, where such results are indicative as to an infection. In response the Divisional team have attended to the specific tasks raised to address the following:
1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.
2. In addition, where test results show evidence of infection and the patient has been discharged home, then consideration should be given to contacting the patient at home urgently for follow up review.
Review of policy/discharge guidance
• Training There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level. Senior Consultants within the team who deliver individual training needs, as such will disseminate to postgraduate staff the importance of reviewing blood results in adhering to discharge protocol.
• Documentation An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.
• Electronic recording/Systems Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours). The above process and plans were agreed following a Divisional meeting held on the 5th September 2022 and Governance meeting held on the 27th September 2022. The process will be included within the ED policy/guidance for the discharge of patient pathway.
I attach for your attention an action plan devised by the team. The actions have been addressed and evidence of actions conducted will follow shortly.