Response form Manchester University NHS Foundation Trust
NHS / Health Body
Action Taken
Manchester University NHS Foundation Trust has implemented actions and recommendations arising from a Root Cause Analysis investigation, including training on the Trust’s new electronic patient record system (HIVE) which issues automated alerts for potential sepsis cases, and periodic audits to ensure appropriate recognition and timely treatment of sepsis. (AI summary)
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Dear Mr Meadows
Beryl Holt, Regulation 28: Report to Prevent Future Deaths (PFD)
Thank you for your PFD report, dated 31 August 2022 addressed to in his capacity as Medical Director for North Manchester General Hospital (NMGH). Your report related to the death of Mrs Beryl Holt on 06 July 2019 and whose Inquest was held on 11 November 2021.
I would like to start by extending my own personal condolences to the family of Mrs Holt. I am very sorry for their loss.
At the time of Mrs Holt’s death, North Manchester General Hospital was part of Pennine Acute Hospitals NHS Trust and under a management agreement with the Northern Care Alliance. As you know, on 01 April 2021 North Manchester General Hospital was acquired by Manchester University NHS Foundation Trust (MFT).
I understand that you concluded Mrs Holt died from natural causes. In coming to your conclusion, you noted that Mrs Holt had developed a rare but severe form of sepsis which led to the rapid death of tissues in the form of a severe infective process called necrotising fasciitis.
A Root Cause Analysis investigation was undertaken by NMGH following Mrs Holt’s death and completed in September 2019. This investigation was led by Pennine Acute Hospitals NHS Trust as it took place prior to MFT’s acquisition of NMGH. Evidence was heard at Inquest around the actions and recommendations arising from this investigation and how these had been implemented at NMGH. It is acknowledged that there was a missed opportunity for updated evidence to be provided from MFT’s perspective to assure you and Mrs Holt’s family that these same actions and recommendations have been appropriately embedded across MFT.
After hearing the evidence at Inquest, you raised the following matters of concern:
1. That MFT ensure that all their sepsis protocols and policies are up to date
2. That all appropriate clinical and nursing staff are familiar with them and have necessary training and updates as required
3. That new or locum clinicians as well as agency nursing staff are made aware of the sepsis policies and protocols and act in accordance with them
4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner
I have sought to address each of your matters of concern in turn below:
1. That MFT ensure that all their sepsis protocols and policies are up to date
MFT has a Trust wide Sepsis Policy (see attached) which was updated on 11 July 2022 and issued to all staff across MFT in September 2022 via the Group Sepsis Committee. The purpose of the policy is to give guidance and define standards of care in relation to the recognition and treatment of patients with sepsis and septic shock in adult patients. The recent updates made were to harmonise the existing MFT policy with the previous policy which had been in place at NMGH. These updates also incorporated changes arising from implementation of MFT’s new Trust wide electronic patient record (HIVE, see below). The policy is in line with current NICE guidance. It will be reviewed in September 2025 or sooner in the event of any significant recommendation to alter practice.
In September 2022, MFT implemented a Trust wide electronic patient record (HIVE). The Trust’s Policy has been amended to reflect changes to existing practice and particularly documentation associated with recognising, escalating, and treating patients with sepsis. Sepsis screening flags have also been built into the software to alert staff to patients who ‘trigger’ for sepsis based on their clinical observations.
2. That all appropriate clinical and nursing staff are familiar with them and have necessary training and updates as required
All clinical members of staff are required to complete Sepsis Mandatory training. Sepsis training falls within the ‘Acute Care Management’ module. It is mandatory that staff complete this module yearly; medical staff are expected to include confirmation of their mandatory training compliance within their annual appraisal that supports medical revalidation.
MFT has established the Acute Care team which is made up of eight Clinical Acute Care Educators (covering adults, maternity, and paediatrics) whose role is to provide sepsis education, drive sepsis quality improvement work and review the monthly sepsis compliance figures across the Trust. This refers to compliance with sepsis screening as well as the ‘Sepsis Six’ treatment bundle, a set of six key tests and interventions that need to be applied to a patient with red flag sepsis features within 60 minutes of sepsis being suspected. If a specific area/ward is under-performing the team will offer specific targeted sepsis education and review where improvements can be made.
In September 2022 MFT published new guidelines for acute care education (attached). All ward based registered adult nurses and nursing associates must attend the Trust Nursing and Midwifery Induction programme upon commencing employment at the Trust and will receive an overview on sepsis recognition and response, early warning score protocols and escalation procedures along with other topics around the acutely unwell patient.
Within 12 months of any registered nurse commencing employment within the Trust, the Acute Illness Management (AIM) course must be completed. Sepsis recognition and management is covered within this course. The Adult AIM course certificate is valid for three years (as per Greater Manchester Critical Care Skills Institute [GMCCSI]) and the course should be repeated once this expires. At least one registered nurse on each shift
must have attended and passed the Adult AIM course. All Nursing Associates must complete the AIM course within 12 months of employment (valid for three years).
All Foundation Year 1 doctors (FY1) starting at MFT complete an induction period which includes training in acute care and critical care outreach team awareness. The Adult AIM course is also completed within the induction period. This includes training on the recognition and management of sepsis (including application of the Sepsis Six bundle). Regular teaching sessions in acute care are mandatory for all FY1s across the Trust. A small number of doctors join MFT after their FY1 year for ‘standalone’ FY2 training; they too are inducted into the Foundation Programme including AIM training.
There is also dedicated additional sepsis training provided for all Foundation Year doctors twice a year as part of the local Foundation Training programme.
Secondary and tertiary responders (Foundation Year 2, Core Trainee (CT) Year 1/2, Specialty Training (ST) Year 1/2, ST3+ and other Registrar-equivalent grades) in the appropriate specialties all complete Trust induction which includes acute care training. All must attend Resuscitation Council (UK) Advanced Life Support (ALS) training. The Care of the Critically Ill Patient (CRISP) (for surgical trainees) and/or the Ill Medical Patients’ Acute Care and Treatment (IMPACT) course are also attended as appropriate. Registrar grade doctors that carry cardiac arrest bleeps must have current ALS. All consultant staff are instructed to undertake the ‘Acute Care Management’ eLearning module that has recently been updated to reflect the implementation of HIVE and now replaces the former ‘Maintaining Patient Safety in Acute Care’ module as part of their clinical mandatory training. In addition, they are able to access any of the acute care courses available as they require.
3. That new or locum clinicians as well as agency nursing staff are made aware of the sepsis policies and protocols and act in accordance with them
All NHS Professionals staff and long-term locum doctors will have a full induction programme and will be required to complete any relevant mandatory training prior to commencing shifts.
It is not possible for staff undertaking one-off shifts to complete all the Trust’s relevant mandatory training in advance of this however, they will receive an induction/orientation before. They will be shown how to access and use the Trust’s new electronic patient record system (HIVE) as well as the Trust’s policies and procedures.
All new NHS Professionals or agency nursing staff undertaking shifts at any of the hospitals across MFT will complete a local orientation/induction with the Nurse in Charge for the ward/area which they will be working for that shift. This includes orientation to the area as well as fire and emergency situations. Staff will also be shown where to locate Trust policies and guidance documents.
All staff undertaking shifts from September 2022 will have also received training on the Trust’s new electronic patient record system (HIVE). Therefore, if a patient is flagged as having potential sepsis based on their clinical observations (Early Warning Score of 5 or more), an automated alert will be issued via the system to initiate a timely clinical review of appropriate seniority based on the Early Warning Score. The HIVE system also incorporates clinical guidance about the Sepsis Six bundle of care including a timer to facilitate this promptly.
4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner
In 2022 an inpatient sepsis audit was established in line with the MFT Acute Care team audits. It has run for two cycles and the findings have been presented to the Clinical Effectiveness Committee. One outcome of the audit was to establish a Sepsis Task and Finish Group to improve sepsis education and awareness across MFT and harness HIVE to access real time meaningful data on sepsis screening compliance.
I hope that the above provides you and Mrs Holt’s family with assurance in respect of the matters of concern you have raised. The Trust is committed to ensuring patient safety is our priority. If you require any further information, please do not hesitate to contact me.
Beryl Holt, Regulation 28: Report to Prevent Future Deaths (PFD)
Thank you for your PFD report, dated 31 August 2022 addressed to in his capacity as Medical Director for North Manchester General Hospital (NMGH). Your report related to the death of Mrs Beryl Holt on 06 July 2019 and whose Inquest was held on 11 November 2021.
I would like to start by extending my own personal condolences to the family of Mrs Holt. I am very sorry for their loss.
At the time of Mrs Holt’s death, North Manchester General Hospital was part of Pennine Acute Hospitals NHS Trust and under a management agreement with the Northern Care Alliance. As you know, on 01 April 2021 North Manchester General Hospital was acquired by Manchester University NHS Foundation Trust (MFT).
I understand that you concluded Mrs Holt died from natural causes. In coming to your conclusion, you noted that Mrs Holt had developed a rare but severe form of sepsis which led to the rapid death of tissues in the form of a severe infective process called necrotising fasciitis.
A Root Cause Analysis investigation was undertaken by NMGH following Mrs Holt’s death and completed in September 2019. This investigation was led by Pennine Acute Hospitals NHS Trust as it took place prior to MFT’s acquisition of NMGH. Evidence was heard at Inquest around the actions and recommendations arising from this investigation and how these had been implemented at NMGH. It is acknowledged that there was a missed opportunity for updated evidence to be provided from MFT’s perspective to assure you and Mrs Holt’s family that these same actions and recommendations have been appropriately embedded across MFT.
After hearing the evidence at Inquest, you raised the following matters of concern:
1. That MFT ensure that all their sepsis protocols and policies are up to date
2. That all appropriate clinical and nursing staff are familiar with them and have necessary training and updates as required
3. That new or locum clinicians as well as agency nursing staff are made aware of the sepsis policies and protocols and act in accordance with them
4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner
I have sought to address each of your matters of concern in turn below:
1. That MFT ensure that all their sepsis protocols and policies are up to date
MFT has a Trust wide Sepsis Policy (see attached) which was updated on 11 July 2022 and issued to all staff across MFT in September 2022 via the Group Sepsis Committee. The purpose of the policy is to give guidance and define standards of care in relation to the recognition and treatment of patients with sepsis and septic shock in adult patients. The recent updates made were to harmonise the existing MFT policy with the previous policy which had been in place at NMGH. These updates also incorporated changes arising from implementation of MFT’s new Trust wide electronic patient record (HIVE, see below). The policy is in line with current NICE guidance. It will be reviewed in September 2025 or sooner in the event of any significant recommendation to alter practice.
In September 2022, MFT implemented a Trust wide electronic patient record (HIVE). The Trust’s Policy has been amended to reflect changes to existing practice and particularly documentation associated with recognising, escalating, and treating patients with sepsis. Sepsis screening flags have also been built into the software to alert staff to patients who ‘trigger’ for sepsis based on their clinical observations.
2. That all appropriate clinical and nursing staff are familiar with them and have necessary training and updates as required
All clinical members of staff are required to complete Sepsis Mandatory training. Sepsis training falls within the ‘Acute Care Management’ module. It is mandatory that staff complete this module yearly; medical staff are expected to include confirmation of their mandatory training compliance within their annual appraisal that supports medical revalidation.
MFT has established the Acute Care team which is made up of eight Clinical Acute Care Educators (covering adults, maternity, and paediatrics) whose role is to provide sepsis education, drive sepsis quality improvement work and review the monthly sepsis compliance figures across the Trust. This refers to compliance with sepsis screening as well as the ‘Sepsis Six’ treatment bundle, a set of six key tests and interventions that need to be applied to a patient with red flag sepsis features within 60 minutes of sepsis being suspected. If a specific area/ward is under-performing the team will offer specific targeted sepsis education and review where improvements can be made.
In September 2022 MFT published new guidelines for acute care education (attached). All ward based registered adult nurses and nursing associates must attend the Trust Nursing and Midwifery Induction programme upon commencing employment at the Trust and will receive an overview on sepsis recognition and response, early warning score protocols and escalation procedures along with other topics around the acutely unwell patient.
Within 12 months of any registered nurse commencing employment within the Trust, the Acute Illness Management (AIM) course must be completed. Sepsis recognition and management is covered within this course. The Adult AIM course certificate is valid for three years (as per Greater Manchester Critical Care Skills Institute [GMCCSI]) and the course should be repeated once this expires. At least one registered nurse on each shift
must have attended and passed the Adult AIM course. All Nursing Associates must complete the AIM course within 12 months of employment (valid for three years).
All Foundation Year 1 doctors (FY1) starting at MFT complete an induction period which includes training in acute care and critical care outreach team awareness. The Adult AIM course is also completed within the induction period. This includes training on the recognition and management of sepsis (including application of the Sepsis Six bundle). Regular teaching sessions in acute care are mandatory for all FY1s across the Trust. A small number of doctors join MFT after their FY1 year for ‘standalone’ FY2 training; they too are inducted into the Foundation Programme including AIM training.
There is also dedicated additional sepsis training provided for all Foundation Year doctors twice a year as part of the local Foundation Training programme.
Secondary and tertiary responders (Foundation Year 2, Core Trainee (CT) Year 1/2, Specialty Training (ST) Year 1/2, ST3+ and other Registrar-equivalent grades) in the appropriate specialties all complete Trust induction which includes acute care training. All must attend Resuscitation Council (UK) Advanced Life Support (ALS) training. The Care of the Critically Ill Patient (CRISP) (for surgical trainees) and/or the Ill Medical Patients’ Acute Care and Treatment (IMPACT) course are also attended as appropriate. Registrar grade doctors that carry cardiac arrest bleeps must have current ALS. All consultant staff are instructed to undertake the ‘Acute Care Management’ eLearning module that has recently been updated to reflect the implementation of HIVE and now replaces the former ‘Maintaining Patient Safety in Acute Care’ module as part of their clinical mandatory training. In addition, they are able to access any of the acute care courses available as they require.
3. That new or locum clinicians as well as agency nursing staff are made aware of the sepsis policies and protocols and act in accordance with them
All NHS Professionals staff and long-term locum doctors will have a full induction programme and will be required to complete any relevant mandatory training prior to commencing shifts.
It is not possible for staff undertaking one-off shifts to complete all the Trust’s relevant mandatory training in advance of this however, they will receive an induction/orientation before. They will be shown how to access and use the Trust’s new electronic patient record system (HIVE) as well as the Trust’s policies and procedures.
All new NHS Professionals or agency nursing staff undertaking shifts at any of the hospitals across MFT will complete a local orientation/induction with the Nurse in Charge for the ward/area which they will be working for that shift. This includes orientation to the area as well as fire and emergency situations. Staff will also be shown where to locate Trust policies and guidance documents.
All staff undertaking shifts from September 2022 will have also received training on the Trust’s new electronic patient record system (HIVE). Therefore, if a patient is flagged as having potential sepsis based on their clinical observations (Early Warning Score of 5 or more), an automated alert will be issued via the system to initiate a timely clinical review of appropriate seniority based on the Early Warning Score. The HIVE system also incorporates clinical guidance about the Sepsis Six bundle of care including a timer to facilitate this promptly.
4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner
In 2022 an inpatient sepsis audit was established in line with the MFT Acute Care team audits. It has run for two cycles and the findings have been presented to the Clinical Effectiveness Committee. One outcome of the audit was to establish a Sepsis Task and Finish Group to improve sepsis education and awareness across MFT and harness HIVE to access real time meaningful data on sepsis screening compliance.
I hope that the above provides you and Mrs Holt’s family with assurance in respect of the matters of concern you have raised. The Trust is committed to ensuring patient safety is our priority. If you require any further information, please do not hesitate to contact me.