Kettering General Hospital NHS Foundation Trust
NHS / Health Body
Action Taken
Kettering General Hospital has updated its SOP for ED admissions (ED03) to clarify responsibilities, increased middle-grade shifts from 9 to 11 daily, and increased consultant presence with the aim of having two consultants in ED from 8:00 to 22:00. The EDU was decommissioned in March 2020, with plans to reinstate it post-COVID-19 with a new SOP addressing risks raised in the PFD report. (AI summary)
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Dear Sirs
Inquest concerning the death of Susan Sterland – PFD Response
Following the inquest of Susan Sterland that took place on the 23rd January 2020, Assistant Coroner considered his duty to issue a Prevention of Future Deaths Report (PFD) had been satisfied due to the evidence which he heard as part of the inquest.
The Coroner raised the following concern in relation to the Accident and Emergency Department – “my concern is that she was not seen by a senior doctor. If she had been seen by a senior doctor, the evidence was that she would have had further investigations which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there were some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust should wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.”
Executive Offices
Rothwell Road
Kettering
Northants
NN16 8UZ
Main Switchboard: 01536 492000
Direct Dial:
Fax: 01536 493767
Web: www.kgh.nhs.uk
When calling, please ask for
2 As a result of the concerns which were raised by the Coroner, the Trust considered the measures which could be put in place to ensure that this concern would not be raised again in the future. The Trust confirmed to the Coroner that the four measures listed below were being considered and so the Trust has provided the following update on all of the four measures: :
1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:
An updated Emergency Department (ED) Standard Operating Policy (SOP) ED01 was ratified on the 28th May 2020 in the Urgent Care Governance Meeting and a copy is enclosed with this letter. The SOP has been updated to reflect current practice to include the change of practice to Emergency Department (ED) admitting rights and reference to escalation and management as defined in the associated SOP ED03. The SOP now has a new expiry date of February 2022.
The updated SOP clearly reflects who is responsible for each patient within the ED.
The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.
2. Review of the documentation for admittance to the EDU:
The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.
When EDU is reinstated post COVID-19 it will have a different location and a new SOP will be created to reflect this and will take into account the specific risks raised within the PFD report. The SOP will clearly state which consultant will be responsible for daily ward rounds and patient ownership will be clearly stipulated. The EDU will not be re-commissioned until the new SOP is in place.
3
3. Confirmation of which consultant would be responsible for reviewing patients in the EDU:
Please refer to point 2.
4. Whether the EDU is being permanently removed:
Please refer to point 2.
As the Coroner will note the Trust has taken the necessary steps to address concerns raised. The Trust would like to offer assurance that the concerns have been actioned and appropriate measures put in place to avoid a similar incident happening again.
Inquest concerning the death of Susan Sterland – PFD Response
Following the inquest of Susan Sterland that took place on the 23rd January 2020, Assistant Coroner considered his duty to issue a Prevention of Future Deaths Report (PFD) had been satisfied due to the evidence which he heard as part of the inquest.
The Coroner raised the following concern in relation to the Accident and Emergency Department – “my concern is that she was not seen by a senior doctor. If she had been seen by a senior doctor, the evidence was that she would have had further investigations which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there were some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust should wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.”
Executive Offices
Rothwell Road
Kettering
Northants
NN16 8UZ
Main Switchboard: 01536 492000
Direct Dial:
Fax: 01536 493767
Web: www.kgh.nhs.uk
When calling, please ask for
2 As a result of the concerns which were raised by the Coroner, the Trust considered the measures which could be put in place to ensure that this concern would not be raised again in the future. The Trust confirmed to the Coroner that the four measures listed below were being considered and so the Trust has provided the following update on all of the four measures: :
1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:
An updated Emergency Department (ED) Standard Operating Policy (SOP) ED01 was ratified on the 28th May 2020 in the Urgent Care Governance Meeting and a copy is enclosed with this letter. The SOP has been updated to reflect current practice to include the change of practice to Emergency Department (ED) admitting rights and reference to escalation and management as defined in the associated SOP ED03. The SOP now has a new expiry date of February 2022.
The updated SOP clearly reflects who is responsible for each patient within the ED.
The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.
2. Review of the documentation for admittance to the EDU:
The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.
When EDU is reinstated post COVID-19 it will have a different location and a new SOP will be created to reflect this and will take into account the specific risks raised within the PFD report. The SOP will clearly state which consultant will be responsible for daily ward rounds and patient ownership will be clearly stipulated. The EDU will not be re-commissioned until the new SOP is in place.
3
3. Confirmation of which consultant would be responsible for reviewing patients in the EDU:
Please refer to point 2.
4. Whether the EDU is being permanently removed:
Please refer to point 2.
As the Coroner will note the Trust has taken the necessary steps to address concerns raised. The Trust would like to offer assurance that the concerns have been actioned and appropriate measures put in place to avoid a similar incident happening again.