Leeds Teaching Hospital NHS Trust
NHS / Health Body
Noted
Leeds Teaching Hospitals NHS Trust reviewed communication between their Neurosurgical Unit and Huddersfield Royal Infirmary and concluded that discussions were timely and advice appropriate. They are satisfied current arrangements are appropriate and responsive. (AI summary)
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Dear Sir; Re: Gladys May Sayles, deceased Report to Prevent Further Deaths Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 Please find enclosed a copy of a response report received from The Leeds Teaching Hospitals NHS Trust Yours faithfully, MD Fleming Senior Coroner West Yorkshire Western Enc. Courts The Tyrls Bradford BDI ILA Telephone 01274 391362 11t KLt City
MHS Ref: Enquiry into the death of Gladys Sayles The Leeds DOB: 05/08/1928 NHS No: 4748684933 Teaching Hospitals Date: September 2019 NHS Trust Private & Confidential Trust Headquarters Mr M D Fleming; Leeds Teaching Hospitals Trust Senior Coroner St James's University Hospital West Yorkshire (Western) Coroner Area Beckett Street Leeds City Courts 4oir LS9 7TF Tlk7 " _r The Tyrls WW leedsth nhs uk Bradford BD1 1LA REC 1 8 SEP 79.4 BY= In the matter of an enquiry into the deathof Gladys May Sayles RE: regulation 28 report Dear Mr Fleming; Thank you very much for your letter dated 3 September 2019. In your letter you indicated that you were invited by representatives from Calderdale and Huddersfield NHS Foundation Trust and the family to ask that Leeds Teaching Hospitals NHS Trust be incorporated into the Regulation 28 report This is in respect of the effectiveness of the existing communications between Leeds General Infirary Neurosurgical Unit and Huddersfield Royal Infirmary_ The Regulation 28 report also refers to the fitting of collar and the patient's general care: In your letter you invite us to reconsider the current systems of communication between ourselves and referring hospitals such as Huddersfield Royal Infirmary: have now had the opportunity to review the communications between the referring team and the on call Neurosurgical Team note from the detailed records that the first contact was made by at Huddersfield at 14.54 hours_on 21 September 2018. A response was sent at 17.42 on the same by with advice that the cervical spine CT showed significant rotation and displacement of a fractured bone fragment inquired about the patients neurology and agreed to discuss this with the on call consultant: At 20.47 again contacted Huddersfield Royal Infirmary confirming that the images had now being reviewed by the on-call consultant and the operative care was not indicated_ The treating team Huddersfield Royal Infirmary were advised to manage the with a neck brace Without further prompting contacted the clinical team at Huddersfield on the following morning at 09.48. This was following a further review of the case and imaging at the morning handover meeting: The advice remained the same that conservative and supportive care was indicated and that the patient could be managed locally in Huddersfield. Further contact was made on the 2 October 2018 at
11.54 when the referring team sought an update on the management plan. Unfortunately the images were not sent electronically and the team at Leeds responded at 13.17, including a request for the scans. The images were sent across Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital Leeds Dental Institute Seacroft Hospital St James's University Hospital The General Infirmary at Leeds Wharfedale Hospital May day injury again
at 11.35 on the following day 3 October 2018. This was at 11:35 and there followed further communication between the two teams at 12.34, 15.53 and 17.36 the same It remained clear that Mrs Sayles was not suitable candidate for operative intervention and that continued best supportive care at Huddersfield would be sensible in the circumstances: was saddened to hear that Mrs Sayles had not recovered and subsequently died: Having reviewed the communications between the referring team and the Leeds Neurosurgical Unit; have come to the conclusion that the discussions were had in a timely fashion and that the appropriate advice was given: It is recognised that an electronic system such as this can be somewhat frustrating for the referring team but it does allow for robust data capture and t0 ensure a proper audit trail: am satisfied that the current arrangements are appropriate and responsive_ hope you have found this reassuring but would be more than happy to provide any further details if you felt that was necessary
MHS Ref: Enquiry into the death of Gladys Sayles The Leeds DOB: 05/08/1928 NHS No: 4748684933 Teaching Hospitals Date: September 2019 NHS Trust Private & Confidential Trust Headquarters Mr M D Fleming; Leeds Teaching Hospitals Trust Senior Coroner St James's University Hospital West Yorkshire (Western) Coroner Area Beckett Street Leeds City Courts 4oir LS9 7TF Tlk7 " _r The Tyrls WW leedsth nhs uk Bradford BD1 1LA REC 1 8 SEP 79.4 BY= In the matter of an enquiry into the deathof Gladys May Sayles RE: regulation 28 report Dear Mr Fleming; Thank you very much for your letter dated 3 September 2019. In your letter you indicated that you were invited by representatives from Calderdale and Huddersfield NHS Foundation Trust and the family to ask that Leeds Teaching Hospitals NHS Trust be incorporated into the Regulation 28 report This is in respect of the effectiveness of the existing communications between Leeds General Infirary Neurosurgical Unit and Huddersfield Royal Infirmary_ The Regulation 28 report also refers to the fitting of collar and the patient's general care: In your letter you invite us to reconsider the current systems of communication between ourselves and referring hospitals such as Huddersfield Royal Infirmary: have now had the opportunity to review the communications between the referring team and the on call Neurosurgical Team note from the detailed records that the first contact was made by at Huddersfield at 14.54 hours_on 21 September 2018. A response was sent at 17.42 on the same by with advice that the cervical spine CT showed significant rotation and displacement of a fractured bone fragment inquired about the patients neurology and agreed to discuss this with the on call consultant: At 20.47 again contacted Huddersfield Royal Infirmary confirming that the images had now being reviewed by the on-call consultant and the operative care was not indicated_ The treating team Huddersfield Royal Infirmary were advised to manage the with a neck brace Without further prompting contacted the clinical team at Huddersfield on the following morning at 09.48. This was following a further review of the case and imaging at the morning handover meeting: The advice remained the same that conservative and supportive care was indicated and that the patient could be managed locally in Huddersfield. Further contact was made on the 2 October 2018 at
11.54 when the referring team sought an update on the management plan. Unfortunately the images were not sent electronically and the team at Leeds responded at 13.17, including a request for the scans. The images were sent across Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital Leeds Dental Institute Seacroft Hospital St James's University Hospital The General Infirmary at Leeds Wharfedale Hospital May day injury again
at 11.35 on the following day 3 October 2018. This was at 11:35 and there followed further communication between the two teams at 12.34, 15.53 and 17.36 the same It remained clear that Mrs Sayles was not suitable candidate for operative intervention and that continued best supportive care at Huddersfield would be sensible in the circumstances: was saddened to hear that Mrs Sayles had not recovered and subsequently died: Having reviewed the communications between the referring team and the Leeds Neurosurgical Unit; have come to the conclusion that the discussions were had in a timely fashion and that the appropriate advice was given: It is recognised that an electronic system such as this can be somewhat frustrating for the referring team but it does allow for robust data capture and t0 ensure a proper audit trail: am satisfied that the current arrangements are appropriate and responsive_ hope you have found this reassuring but would be more than happy to provide any further details if you felt that was necessary