Michelle Whitehead

Dear Dr Didcock, Please find below the organisational response to the recently received Preventing Future Deaths Report following the unfortunate death of Mrs. Whitehead_ The Maters of concem raised within the repor Unclear doseltype ofsedation medication given; possible excess dose given; poor documentation: A medication error did occur during Mrs. Whitehead'$ care. This involved the incotrect dose of administered Oral Diazepam being communicated t0 the Ward Manager and Duty Doctor. With this incorrect infomation they agreed t0 administer Rapid Tranquilieation in Ine iom 01an Intramuscular injection of Lorazepam: When wnting the above dose in the patent $ medication card, the Ward Manager recognised the error; and contacted the Doctor again t0 as8es8 the likely impact assessment was that the dosages given were within British National Fomulae guidelines, and as such would not negatively impact on Mrs. Whitehead $ physical health. This assessment has been considered by senior medical colleagues within the Trust; who are in agreement with the conclusion of this assessment Mrs. Whitehead was observed constantly following this, with member of staf within an am: length of her at all times_ The staff involved in the medication error engaged in supervieion with their manager following the incident and completed self-reiection pieces since this time. They are very aware of the error and Its potential implications Delayed recognition of Mrs: Whitehead s declining condition Mrs. Whitehead was administered Rapid Tranquilisation with the aim reducing her acute presentation Her physical observations were taken every 15 minutes ater this, scored using the Duty The

National Early Waming Scale (NEWS2) ad over the following hour remained stable. This was reported t0 the Doctor who conimed that the physical observation checks were no longer required and normal mental health focused observation should take over: The investigators were unable however; t0 see an assessment of consciousness levels within the above and have hypothesized that whilst Mrs_ Whitehead presented a8 confused during this time, this may have increased after the medication and her NEWS2 score may have increased indicating that more prolonged physical observations were required. As a response the Directorate has re-printed newv refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be vom on a lanyard alongside individual identification badges, acting a8 an immediate reminder: These have now been coniimed a8 having been redistibuted across our inpatient eites within Adul: Menial Health Services and have been shared with the other direc orates t0 ensure consistency across sites Additionally, the Division is rolling out handheld devices that allow staff t0 immediately enter physical observations into the NEWS2 electronic system (and patient reccrd}. This will automatically calculate the NEWS2 scores and alert if interventions or emergency care is required Coniimaion has been Teceived that these have been made available and are in use on all Adult Mental Health inpatient areas_ Two senior staff members have been identiied to Vrk with individuals and groups from te Lucy Wade Unit to ensure they fully understand how to undertake comprehensive NEWS2 assessments The key focus of the sessions is about confidence-building, paricularly regarding decision-making at the time of an urgent clinical incident They will additionally ensure that all staff are supported t6 recognise sign? of an Anaphylaxis reaction and its associated emergency treatment with Adrenaline. This will include individual and group training and the completion of medical emergency scenarios t0 knowiedge and processes in a more realistic; tnue-life environmentWe are initially prioritising the wards in the norh of the county and intend to have this area fully compliant with the training target in this area by mid-April 2022. Additionally, the intention is then for 80 percent completion target in line with the Trust training comipliance matrix for all Adult Mental Health inpatient nurses to have completed the fomal training and engaged in the scenaro-based training byend of
2022. Atthis tine, 34 staff (approximately one third of the required staff group in the north of the county) have completed the scenaro-based training and 59% 0f AMH inpatient nurses have completed the enhanced NEWS2 training: A copy of the scenario-based aspect of this training package is atached a8 Appendix 2. A letter dated 27 January 2022 describing the leaming from this event has been witten and was distrbuted throughout the Directorate' $ in-patient services via fommal letter and email copies the week followings its completion: A copy is enclosed with this leter titled Appendix 3. All direct care in-patient staff in the Trust complete Hospital Life Support training every eighteen months which includes the completion of NEWS2 aseessments and associated escalations; plus recognition of Anaphylaxis and its emergency treatment using Adrenaline. Currently Adult Mental Health services are at 84 percent compliance, which is wthin target for the directorate. The lesson plan for this core training is being reviewed t0 confim that sufficient tine is spent on all aspects of Making Tne Rescutce Duncan Macmia Fjuse PorcheserRojd, NocnghamKG3BAA Difference Trust Honesty Respect Compassion Teamwork Duty test May

the above, ensurng that staff are appropnately trained and have completed competency assessmentt0 conim this A further update in relation t0 this will be available by the end of May 2022, The Trust Resuscitation committee is convening (initially on 9 March 2022) t0 review the Rapid Tranquilisation Policy and explore , review and determine wha: actions should be taken should patient fall asleep post rapid tranquilisation administration At the initial meeting it has been agreed that an extemal intensivist will be consulted t0 advise a8 part of this process 4 clear understanding of how staff will make the assessment to detemine if the patient is sleeping or if the patient is unconscious will be confirmed and any additional leaming and development planned. Currently the Directorate are placing patients on constant observations until are mobile and using a Pulse Oximeter to continuously monitor blood oxygen saturation and pulse rates. This has been communicated t0 staff menbers via the aforementioned letter and within ward team meejngs and both group and individual supervision sessions No medical clerking from admission until her collapse Qntthe night of admission, 3 May 2021, Mrs. Whitehead was seen by the duty doctor Dr who clerked her in and made an entry a: 23.11. She also completed the core assessment on RIO at that time. On her approach; however; Mrs Whitehead was visibly afraid despite attempts by patients and staff t0 console her: She did not respond verbally t0 Dr Ittempts t0 speak to her: She was backing away and visibly frightened. Dr understood from nursing staff that Mrs Whitehead : behaviour had been the same since her amval on the ward and she had not spoken t0 any staff thus far. Dr attemipted to coniplerte a full clerking but because of Mrs Whitehead $ mental state and clinical presentation, by necessity, much of this information was taken from RIO and also the GP information from the poral, other than the objective observations she could make. She was unable t0 complete & physical examination; an ECG or bloode because Mrs. Whitehead was too frightened and disturbed. She recorded her reasons in RIO progress notes and she recorded a plan t0 hand over t0 the day team t0 request & re-attempt at comipleting the missing aspects of the clerking. This is in keeping with the Trust : policy on Physical Assessment and Examination of patients (~ppendix 4), which states that & physical examination should take place within the firet 24 hours but recognises that sometimes examination is not possible;euch &8 occasions when the patient refuses or i8 tO0 disturbed; and the situaiion should be reviewed at approprate intervals. The Policy also recommends reattempiing within the first 48 hours ad at regular intervals thereater: Dr emailed the ward doctors for the following daya and Dr This emai was received and acknoiledged by Drp who stated she would 8ee the patient the following day- The handover has been reviewed by the Aesociate Medical Director and by the Director of Medical Education, and they have considered tha: passing this virk t0 the ward doctor rather than the next day duty doctor was appropriate , given the presentation and physica needs would be ongoing for sone days, and following through from the initial clerking sits appropriately with ward doctors. The detail of the handover on the moming of 4 2021 a8 Dr inished her shift, ha? been clarified by the Associate Medical Director and did take place face to face a8 per advised practice. Making Tne Rescutce Dunca7 Macmilat Fouse, Pcrcheszr Rojd Nccnghamne3644 Difference Trust Honesty Respect Compassion Teamwork Vil they May

The daytime duty doctor for 4 2021 was made aware of the patient by nursing staff as Mrs_ Whitehead reniained unwell and they recognised that her prescribed PRN medication may have contained lactose. The duty doctor undertook some liaison with pharmacy colleagues about choice of medication given her allergies. There are no further entries in RIO progress notes about consideration of further atempts t0 complete a physical examination and baseline investigations but there i8 & clear description in the notes of Mrs. Whitehead continuing to present a8 mentally very unwell and not engaging with staff. When interviewed by the investigators Dr (stated that on Wednesday the 5 2021 she was not able t0 do a full examination a8 the pajient was very agitated, therefore towwards the end of her vprking time she handed the case over t0 the on-call doctor. She infomied him tha: Mr Whitehead was agitated, and he may be called to see her later in the shift She was examined physically by Dr Iduty doctor, on the evening of 5
2021. This was after rapid tranquilisation had occurred He records an entry in RIO at 17.45. He had been asked to see Mrs. Whitehead by ward nursing stafi, with concems about her mental state including agitation,verbal aggression and chaotic behaviour; along with physical symptoms of copious loose stools and nausei He physically examined the patient including her conscious level, hydration status nios: recen: physical obsenvatons chest examination; puls? heart auscultation, capillary refill time, abdominal examination including auscultation for bowel sounds The Associate Medical Director for the Mental health Division and the Director of Medical Education have jointly emailed all and consultant medical staff in the division t0 remind them of the physical examination policy, the importance of re-attempting physical assessment at regular intervals if unable to complete it at the point of admission, and the importance of documenting the reviewv of completing the physical ascessment in the notes No Consultant involvement after admission Lucy Wade wardis staffed by To consultants, Consultant Clinical Psychologist and Dr Consultant Psychiatrist Dr 3 & fully qualified approved clinician under the Mental Health Act; This is a new role, known a8 & Non-Medical ^pproved Clinician or also known a: Multi Professional Approved Clinician In order for medical aspects of inpatient care to be fully provided Dr hasa programmed activity in his job plan to suppor Drl Ithey have a regular Tuesday meeting t0 discuss her patients, and he sees sone of her patents directly if indicated. He provides senior medical input if needed durng the rest of the week. He aleo supervises the clinical work and education 0f the junior medical staff on the ward On the week in Question Dr was on annual leave , and his annual leave was covered by a colleague; Dr Consultant Peychiatnst a: The Millbrook Unit On admission Mrs Whitehead was assigned to be under the care of Dr Dr saw her in Ward Round on 5 May 2021, accompanied by Clinical Psychologist Dr and a stafi nurse Ai this tine Dr was self-isolating due to testing positive for COVID 19 was working remotely: She led the Ward Round on MS teams The Trust position durng the pandemic has been for clinicians to work remotely ifthey test positive and are well encugh to work. Drl was due t0 end her period of isolation the folloxing 6 May 2021. There Was a fulll MDT discussion; but Mrs Whitehead was unwell and unable t0 engage with Dr Ma MS teams Making Tne Rescutce Duncan Macmila Fouse Porcheszr Rojd, Nocngham N63 644 Difference Trust Honesty Respect Compassion Teamwork May vety May May junior and day;

The outcome of the Ward Round in relaion t0 consultant involvement was that kould atrempt t0 see her again the following day when she was out of isolation Dr lalso planned to consider transfer Of consultant caret0 Dr his retum t0 work because Of continuity of care as he had worked with Mrs Whitehead in conimunity. Dr could have accessed consultant psychiatnist support at this point in time from Dr They did not do 80 03, atthe ine, they did northink this wJ; necessany- Unfortunately, Mrs Whitehead had suffered the respiratory arrest and had been transferred before the face-o-face consultant review could take place Clinical Directors of the service plan the balance of workforce need and annual leave, with particular focus on high leave periods, such a8 school holidays, bank holidays and religious festivals . Annual Leave will not be agreed unless sufficient cover arrangements are in place, and this has been communicated throughout the workforce via conversations with lead consultants and email corespondence: Dynamic management of unplanned absences are harder t0 resolve however the medical workforce has committed t0 offer flexible cover arrangement in these circumstancesled by the Iocal area lead consultant To offer Divisional resource oversight; & daily report ofall Covid related absences during the Covid spikes is collated for the Associate Medical Director_ All cover arrangements are communicated to the ward and management teams; held on a cental database that can be reviewed; and routes of escalation are knovn: Inability to reach Duty Doctor for deteriorating patient The Trust takes the difficuity experienced by the nureing team in making contact with the duty doctor for deteriorating patient extremely serously- The nursing tean descnbe 'Tinging continually but the doctor did nor answer the phone" from about 20.45 on 5 2021 and repor inability t0 leave a message. From investigation of this issue, it i8 known that the duty doctor had one registered missed call, which he noticed at 21.10 that had been made at 20.55 and no message had been left_ He had been seeing another patientand he had taken blood samples across to the laboratory at Kingsmill Hospital and noticed the missed call a3 he was walking back_ We have explored this further and concluded that the most likely explanation is that he lost mobile signal_ In response, this has been reviewed with the Trust Chief Digital Information Officer and the Head of ICT Operations Ii has been recognised previously that a number of our sites lack mobile phone signal, and the solution Place for some years i8 t0 ensure all junior doctor smart phones are enabled for Wi-Fi calling: It is highly probable that connection with Wi-Fi calling was lost when he went t0 the laboratory a Kingsmill Hospital, and he also had no mobile phone signal The recommendation irom the SI report was t0 have a "crash bleep" This wias considered but discounted a8 the duty doctor covers 3 number of geographical sites and cannot provide an immediate response. Thereiore, the response t0 & medical emergency needs t0 remain as 999 Making Rescutce; Duncan Macmilan Hjuse Pocler Fojd Nccnohamksiean Difference Trust Honesty Respect Compassion Teamwork the May Tne

The option of a "back Up bleep" to be an alternative contact method if the mobile phone faile was then considered. Advice from IT was that there is a national target to remove bleeps from the NHS which was t0 be achieved by the end of 2021. Alterative options include various apps, but they all require & smartphone and a reliable signal or Wi-Fi calling-We have therefore reviewed all first on call rotas t0 establish all locations where the junior doctor may need t0 visit as part of their duties. For the duty doctor at Millbrook, in addition t0 Millbrook itself, this consists of all of Kingsmill Hospital Campus including Kingsmill Hospital Pathology Lab, along with Alexander House Bracken House and the road in betwveen.ICT have now developed a solution using Wi-Fi calling via a specific NHIS wireless network: Staff will need t0 select this netvork when inside Kings Mill and there is & requirement for them t0 register using irst name , last nama and Trust email address This is one-off registration per mobile phone device allowing auto-connect t0 occur at each subsequen: visit Once connected t0 the wireless netvork, smartphones with Wi-Fi calling enabled should be able to initiate and receive calls when there is no cellular mobile phone signal This solution is available with immediate effec: and extend: onto a non-Trust site. The Head of ICT Operations has communicated with medical education to ensure all junior doctors are informed and have the user (Appendix 5). Additionally; Millbrook Mental Health Unit i8 co-located within the grounds of the Kings Mill Acute Hospital. As such, Trust leads have liaised with acute colleagues a: Shervood Forest Hospital Trustto assess whether this proximity is sufiicientto allow the Acute Emergency Response "Crash" team t0 attend medical emergencies. This would offer the quickest and highest level of response to medical emergencies in the future. In February 2022 they agreed that this cover is possible. However; before fully operational we have to ensure appropriate additional equipment is in place develop a list of practical issues t0 cover 0ff, which is curently being managed by the Head of Nursing for the Physical Health Division and the Associate Medical Director for the Clinical Development Unit_ Throughout March 2022 the operational challenges will be worked through with the aim t0 implement this process a8 soon a3 it is deemed cafe t0 do s0 Intthe interim Perod the primary action remains t0 call for an ambulance via 999. Further updates can be provided t0 the Coroner8 Office once we can give assurance that this system is operational Delay in calling paramedics As detailed above, colleagues made atempts t0 contact the Doctor when they recognised thata medical emergency was unfolding: The primary message t0 staff, is that they must call for immediate support from the Ambulance service when they recognise tha: someone $ physical health is rapidly de eriorating and & medical emergency is or i8 likely to occur: This has been included clearly within the notification of learning letter already refered to within this response (Appendix 3). Summoning Iocal medical response to suppor their life support interventions is Se condary action: Additionally, senior leads, including the AMH General Manager has liaised with the East Midlands Ambulance Service to ensure they are aware 0f the nature of our Mental Health Units, ine limitations of the life support interventions that can be made, and ofi site working of medical colleagues_ Between them have agreed that when an emergency response is requested, i Making Tne Rescutce Duncan Macmila7 Rjuse, Porcheser Roji Nccnoramns3 644 Difference Trust Honesty Respect Compassion Teamwork guide and fully Duty they

becomes & prorty one call initiating an immediate response. This remains the case until the emergency crash process with Sherwood Forest Hospital Trust is in place and safely operational. Delay in Paramedics gaining access t0 the ward Once the ambulance response was confimed, staff focused on carrying out hospital life suppor interventions with the patent, a8 well as caring for the wider patient group: No one was allocated t0 g0 to the main reception t0 greet and hurriedly escort the ambulance team through to Mrs. Whitehead. This led t0 a delay in the ambulance team accessing the site. The Directorate has reviewed the formation and functioning of the Incident Response Team and now added the allocation of an Emergency Services Liaison Responder for each ward. This role is allocated on each ward by the nurse in charge as part of every handover at the start of each new shift. This individual functions within the team during nommal incident scenanos , however, when & medical emergency is identified, immediately go to the main reception , wait for the emergency services to attend, and will escort them immediately to the casualty- This role will also be used in the event 0i Police Fire Service support being required and will be allocated t0 & named individual each shif This process has been agreed with inpatient staff members and is identified as requiring allocation on the ward handover sheets (~ppendix 6). This will be audited on the inpajent units bi-monthlyt0 ensure compliance, and the outcome of the audit fed back to the senior management team: copy of initial audit will be made available to share with the coroner & office by end of May 2022. The managenent team is committed to leamn from these mistakes and have met with the authors to review each recommendation; their thinking behind them; and to clarify all the details that lie behind the repont: By doing this, we have ensured that the actions identified in our Quality Improvement Plan (QIP) efiectively respond t0 the learning identified in the report and are agreed by the investigators, local team based at Millbrook Mental Health Unit and the Directorate leadership team. Some of the themes are out of the Directorate $ sphere of influence and will require Divisional and Trust action Qverallprogress of the QIP however; will be coordinated by the Directorate General Manager; We have made effors t0 engage with the family and express our sincere apologies. have asked not t0 be approached at this point; but as the QIP develops efforts will be made again t0 share our leaming and changes with them: hope the infomation above provides the assurance that we have and continue t0 consider your recommendations serously, that We are actively seeking to improve the senvice; V provide by implementing the actions outlined; on which; ifyouare in agreement a full update be made available t0 you by the end of May 2022. Making Tne Rescutce Duncan Macmilan House Pctcnesem Rozd NocnghanLSle4A Difference Trust Honesty Respect Compassion Teamwork they vall They Mll