Delina Etienne

Dear Sir

Regulation 28 Report – Ms Delina Etienne

I am writing on behalf of East London NHS Foundation Trust to provide a formal response to the Regulation 28 Report that you issued on 12 September 2022 following the inquest touching the death of Ms Delina Etienne.

Your conclusion at the inquest was that Ms Etienne died of natural causes, and your Regulation 28 report notes that the actions of the senior nurse were not found to have caused or contributed to her death.

The Trust expresses its sincere condolences to Ms Etienne’s family. The Trust’s internal investigation found that various things did not happen as they should have done with Ms Etienne’s care, and although they did not ultimately affect the tragic outcome, the Trust is determined to address these issues so they do not re-occur. Your Regulation 28 Report is a helpful tool to focus the Trust’s efforts, and has been carefully considered at a senior level.

Your Regulation 28 Report raised five matters of concern, and I have set out below details of the actions which the Trust has taken (or will take) in relation to them. Please note that actions which have not yet been completed are anticipated to have a timescale of 6-12 months.

1) Response to cardiac arrest

Physical health simulations training is facilitated across the ELFT Trust inpatient units. Simulation training sessions are being undertaken at least monthly in all units. Emergency simulations have also taken place on Cazaubon Ward on the following dates and are ongoing.

•
11.08.21
•
08.10.21
•
21.04.22
•
14.10.22

From 10.10.22 a weekly ward managers meeting now has an agenda item to plan a simulation exercise for that week within the East Ham Care Centre unit.

The Trust identified particular concerns about two members of staff involved in the incident. The two members of staff have subsequently attended further Immediate Life Support Training. The training highlights the action to be taken by a staff member who finds a patient/person in a physical health emergency including a person with no pulse or other life signs. It teaches staff how to start compressions, get help, apply, and use an automated defibrillation machine (AED), check the paper copy of any do not attempt resuscitation prescription, call for an emergency ambulance and continuing resuscitation until paramedics take over and make any decision about discontinuing this attempt. Both nurses were placed on restricted duties until the Director of Nursing received confirmation that they had appropriately reflected on their actions, showed sufficient insight and understood the consequences of their actions as well as evidenced learning from the intermediate life support training.

The existing Trust policy on ‘Resuscitation’ has been discussed at Cazaubon Ward staff away days organised by the Cazaubon ward Matron and the following topics were discussed:

• May 2021 –Managing Sudden death on the ward
•
25.08.2021 –Sudden Unexpected Incidents
•
15.12.2021- Managing Medical Emergencies

Monthly audits of the ward in relation to resuscitation status record-keeping started in May 2022 and are ongoing.

All Cazaubon Ward staff have been advised on the location of the DNACPR forms red folder, and that this is the first point of reference in a medical emergency.

A DNACPR electronic alert is now available within the RiO medical records as a secondary aid.

CPR status is now a formal part of the handover for each nursing shift on Cazuabon Ward.

The author of the Trust policy for resuscitation will amend the policy to emphasise the correct procedure for recording in RiO and communicating CPR, and the use of a defibrillator at the earliest opportunity.

The Trust’s DNACPR forms will also be reviewed to see if improvements are required.

2) Escalation of raised blood pressure

NEWS 2-update training on blood pressure has been undertaken by 62 staff, and NEWS 2 scores template and recording within the RiO medical records has now been revised.

The electronic recording system for NEWS 2 now has automatic alerts for all physical health observations recorded which are outside expected limits. This highlights any concern and advises on action to be taken by the person entering the readings.

A training template was created and reviewed with each Cazaubon Ward staff member in May 2022.

Further training was undertaken with all staff on Cazaubon Ward concerning elevated blood pressures on an away day on 23.06.2022. As a result, staff should ensure that they recheck the blood pressure with another machine and also undertake a manual blood pressure if indicated.

The relevant NICE Guideline (NG 136) is visible on the ward.

Monthly audits of the ward in relation to management of blood pressure started in May 2022 and are ongoing.

3) Venous Thromboembolism (VTE) assessment

All patients have a VTE assessment undertaken on admission to Cazaubon Ward. This was audited on 03.11.22 and will continue to be audited weekly. A request has been made to have the Trust’s automated reporting system updated to facilitate the ability to run a report on each wards VTE screening assessments.

The author of the Trust policy for physical healthcare will amend the policy to emphasise that all patients need to have a VTE risk screening assessment undertaken on admission and the correct procedure for recording this in RiO.

The nurses’ physical health assessment is being amended to include a VTE screening assessment which would require a medical assessment to be completed if a risk was identified. Once this has been amended Cazaubon wards nursing staff will complete a screen for each patient as part of the wards weekly audit programme.

4) Medical review of chest pain

Training was undertaken regarding the correct escalation of a patient with chest pain at the Cazaubon Ward away day on 23.06.2022. A separate training programme was completed for all staff on an individual basis. This covered the requirement for a staff member to stay with the patient and mange chest pain like any other medical emergency, calling for the immediate attendance of a doctor or emergency services, continual monitoring of vital signs, the use of oxygen and preparing information for



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Dear Mr Irvine,

Thank you for your letter of 12 September 2022 about the death of Mrs Delina Etienne. I am replying as Minister with responsibility for Mental Health and Patient Safety at the Department of Health and Social Care.

Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mrs Etienne’s death. I can appreciate how distressing her death must be for her family and those who knew and loved her and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to prevent future deaths and I am grateful to you for bringing these matters to my attention.

In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC).

I understand that several actions have been taken by the East London NHS Foundation Trust following the death of Mrs Etienne. I am pleased to see that an action plan was produced and covered all the areas of concerns that you raise in your report, including medical simulation training, Life Support training and training on the correct escalation of a patient with chest pain for members of staff on the ward. I have also seen that the electronic recording system for National Early Warning Score (NEWS2) now has automatic alerts for all physical health observations recorded which are outside expected limits. As well as this, audits have been introduced on the ward to ensure that all patients have a venous thromboembolism assessment on admission.

I was particularly saddened to read that the family were only informed of the error regarding a Do Not Attempt Resuscitation (DNACPR) decision via the Serious Incident Report, rather than immediately after the incident. However, I understand this issue has been addressed by the Trust and that there was no intention to conceal an error by the staff member concerned. Further to this, there is now a monthly audit of the ward in relation to resuscitation

status record-keeping and CPR status is now a formal part of the handover for each nursing shift.

I am further reassured that the CQC have received updates on the Trust’s action plan and will continue to monitor its implementation through regular engagement meetings. Although an inspection has not been triggered as a result of this incident, the CQC will follow up with the Trust at its next inspection that the learning from this incident has been embedded.

I hope that this, along with the response from the Trust, has reassured you that action has been taken to address the concerns you have raised and to ensure a tragic death does not happen again.

Thank you for bringing these concerns to my attention.

Kind regards,

MARIA CAULFIELD MP