Angela Jackson

Dear Mr Walsh RE: ANGELA MARY JACKSON Thank you for making the NHS Trusts involved in Mrs Angela Mary Jackson's care aware of your concerns arising from the inquest touching on and concerning her death.

1371 101 600 1616 inch.nhs.uk Please accept this letter as Liverpool Heart and Chest Hospital NHS Foundation Trust's, Lancashire Teaching Hospitals NHS Foundation Trust's and Manchester University NHS Foundation Trust's response to your Prevention of Future Death Report sent on 25 September 2018. It is hoped that a joint response will give assurance as to the collaborative approach adopted by the Trusts involved in Mrs Jackson's care in implementing measures to 600 181F improve public safety and to assuage your concerns. Your concerns were set out in the Regulation 28 Report as follows:
2. I request the Trusts governing the Preston hospital, the Wythenshawe hospital and the Liverpool hospital to review the referral systems and to consider clear and unequivocal pathways for the treatment of patients with aortic aneurysms and the distribution of such pathways to district hospitals and all healthcare professionals within the areas serviced by their hospitals.

Response of Liverpool Heart and Chest Hospital NHS Foundation Trust (LHCH) The national organisation of thoracic aortic services is currently the subject of a review by NHS England. This is in recognition of the fragmented nature of current services in the UK and the variability shown in diagnosis, access to treatment and outcomes (refer to Bottle et al 2017 - Variation in the Quality of Care for patients with diseases of the Thoracic Aorta). Joint Cardiac and Vascular Commissioning discussions have begun, with formation of a committee, to examine services for managing disease from "root to visceral segment". The Excellent, Compassionate and Safe care for every patient, every day

resulting service arrangements will likely result in a national hub and spoke system, channelling patients through pathways, depending on complexity. This joint commissioning service reflects the necessary collaborative working between Vascular Surgery and Cardiac Surgery, to provide the best care for these patients who have rare and complex disease requiring extremely specialized treatments. The service specification will cover elective and urgent/emergency services and include all forms of treatment including open and endovascular strategies. The North West of England has been in a better position than most regions within the UK to provide care for patients with elective and emergency thoracoabdominal aortic disease with three cardiac centres providing specialist thoracic aortic services including Blackpool, Manchester and Liverpool. Liverpool in particular is a nationally and internationally recognised centre offering patients the entire range of treatments, open and endovascular, from aortic root to the aortic bifurcation. Patients are referred in from the entire UK including Scotland, North of England, Midlands and occasionally South of England. This is particularly the case for surgery on the thoracoabdominal aorta and complex redo surgery. Up until 2017 referrals from the region into the trust were largely based on reputation however the Trusts CEO (Jane Tomkinson), who is also the Senior Responsible Officer for the Cardiovascular Disease Programme of the Cheshire and Merseyside Health and Care Partnership, recognised the lack of a formal pathway in the locality and commissioned a review. A pathway was agreed between LIVES and LHCH and published known as Liverpool Acute Network for Thoracic Aortic Services (LANTAS), (Appendix 1). This was distributed around the region and placed on the LHCH Website. Blackpool and Manchester typically manage elective and emergency proximal thoracic aortic disease, referring on to LHCH, most patients requiring open surgery on the thoracoabdominal disease. No formal pathways have existed in Lancashire and Cheshire to channel patients into pathways depending on complexity. Pathways were largely ad hoc and susceptible to the random nature of individuals' on-call and their knowledge, experiences and ability to navigate the natural barriers to transferring patients around the country. Mrs Jackson's case has highlighted the need to formally organise services beyond just Cheshire and Merseyside Health and Care Partnership, to the entire North West, and ahead of formal national service specification, with agreed sign posting and pathways for patients, with their destination dependent on complexity. National Aortic Service Specification will eventually provide statutory requirements to organise service within the North West of England. The North West Aortic Syndrome/Emergency Pathway Coordination of a response has taken two approaches. The first was a discussion between key clinicians to review current barriers to best patient care and suggest models of what good care should like. From these discussions has come pragmatic solutions to improve care for patients with urgent/emergency thoracoabdominal aortic disease. 2

The second is a discussion between managers within each relevant trust to understand the problem and the solutions from a served provision perspective. Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expeditiously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements. In addition to the referral pathways is a Memorandum of Understanding published by the Critical Care Networks of England, Wales and Northern Ireland, (2018) which offers guidance on transferring emergency patients in Intensive care for specialist care (Appendix
5). This is crucial and feeds into facilitating transfer of patients described in our pathways (Appendix 1, 3 and 4). The essence of this is encapsulated in the points below:
1) Lack of an ITU bed should not stop admission for patients needing rapid life-saving intervention. Patients should be admitted straight to theatre for assessment, consenting and treatment providing of course there is theatre and staffing capacity.
2) If the team is already operating and this cannot be supported it is the trusts responsibility to find an alternative specialist destination, not the referring A&E.
3) Neighbouring specialist centres likewise should not pass on emergencies on the basis they have no bed, nor should they ask their local A&Es to refer to us but should do so themselves. Response of Lancashire Teaching Hospitals NHS Foundation Trust The Trust accepts the concerns raised by the Coroner and understands the need for clear pathways for the management of aortic aneurysms across the region. Prior to the inquest of Mrs Jackson, work had already begun within our organisation on producing a pathway for the Lancashire and South Cumbria Vascular Network. It is clear that this work needed to be extended to include the whole of the North West region incorporating all the specialist cardiothoracic centres and referring hospitals. Following the Inquest of Mrs Jackson, the above pathway (which was developed in conjunction with the Cardiothoracic Centre at Blackpool Victoria Hospital) was finalised and approved by the Clinical Reference Group for Lancashire and South Cumbria and an Action Plan was produced in response to the specific concerns raised by the Coroner. This is attached for your information at Appendix 6. 3

In summary, the actions include:
•
•
• The development of a locally and regionally approved pathway for the management of aortic aneurysms across Lancashire and South Cumbria. The development of a clinical algorithm to support effective implementation of the pathway. Sharing both the pathway and clinical algorithm with all Medical Directors and Emergency Departments across the Lancashire and South Cumbria Vascular Network. Confirming awareness of the pathway and algorithm in doctors working within our vascular service at Lancashire Teaching Hospitals both through presentation at clinical meetings and individual discussions. The implementation of an electronic referral and tracking system for vascular patients which can be accessed across the Lancashire and South Cumbria Network and will allow for real time documentation and tracking of the patient's care through the pathway visible to all doctors involved in both referral and treatment. The above actions will be monitored and independently validated. We would be pleased to provide you with updates on the progress of the actions and evidence of completion, if required. To assist with wider awareness of the issues raised, the Medical Director for Lancashire Teaching Hospitals will share the concerns raised at inquest and subsequent actions taken at the North West Medical Directors' Forum. We have attached the following documents for the Coroner's consideration:
•
•
• Pathway for the management of aortic aneurysms (Lancashire and South Cumbria Network) (Appendix 4) Clinical Algorithm (Appendix 7) Action Plan (Appendix 6) Response of Manchester University NHS Foundation Trust The concerns have been discussed Trust-wide at Executive level and with cardiac and vascular surgical leads at Manchester Royal Infirmary's Manchester Heart Centre, part of the Trust's Oxford Road Campus site, and at Wythenshawe Hospital, part of the Trust's Wythenshawe, Trafford, Withington and Altrincham site, The Trust has liaised directly with Liverpool Heart and Chest Hospital NHS Foundation Trust (LHCH) and Lancashire Teaching Hospitals NHS Foundation Trust, and a joint meeting was held between our three Trusts on 26th October 2018. The concerns are acknowledged in their entirety by Manchester University NHS Foundation Trust. Steps have been taken in order to create and work towards implementing formalised written guidance on the referral system to the Trust for treatment of patients with aortic aneurysms and other conditions. The pathway has now been formally agreed at the Trust 4

and distributed to those Hospitals and healthcare professionals who the Trust's service covers for specialist tertiary advice for this and other conditions. The Trust's work on development of the necessary written guidance has been led by Mr Haris Bilal, Consultant Cardiac and Aortovascular Surgeon, Lead for Aortovascular Surgery and Director of Manchester Aortovascular Institute. Historically, Greater Manchester has been served by three hospitals for all acute aortic syndrome (AAS) patients. Manchester Royal Infirmary (MRI) and Wythenshawe Hospital in Manchester and LHCH, which are nationally, recognised tertiary aortic referral centres. There has however been variation in service delivery for this complex pathology. The discussions with LHCH and development of written guidance seeks to address this issue. This work has included drafting of guidance for the referral of patients with all acute aortic pathologies, which has been drafted and now formally agreed at the Trust, as above in consultation with LHCH. A copy of this agreed guidance is enclosed at Appendix 3, "Referral Pathway for Acute Aortic Syndrome for Greater Manchester". This guidance covers: -
•
•
•
•
•
• Definition of the acute aortic pathologies the guidance refers to, which includes aortic aneurysms amongst the list of other types of such pathology, which the guidance acknowledges require urgent cardio-vascular intervention; Clear guidance on the interventions provided at the Trust and those for which referral to LHCH is required; Guidance on diagnosis of the listed conditions and the nature of services provided by the Trust; Contact details and the specific referral pathway to be followed when referring patients with these conditions to the Trust for specialist cardiothoracic input - for the on-call Cardiothoracic Registrar at Manchester Royal Infirmary (MRI) to be contacted directly or via the MRI Switchboard as an alternative point of contact; Details of the steps that will be taken by the team at the Trust on receipt of such a specialist referral; Guidance on pre-operative management of such patients and arrangements for safe transfer; Reference to LHCH's own Guidelines and complex pathologies to be referred to LHCH rather than Manchester University NHS Foundation Trust. The guidance has taken into account NHS Resolution's "Getting it Right the First Time" (GIRFT) report to incorporate learning from clinical negligence claims in order to improve patient safety. In particular this report noted variations in the delivery of complex acute aortovascular service nationwide. The GIRFT report also made specific recommendations in respect of acute aortic syndrome patients including establishment of formal agreements between referring hospitals, receiving specialist units and others for transfer of patients with these conditions. The guidance seeks to address these recommendations. 5

Mr Bilal has consulted directly with colleagues at LHCH in respect of this written guidance; Mr Manoj Kuduvalli, Consultant Surgeon and Associate Medical Director for Surgery and Mr Mark Field, Aortic Lead, specifically considering alignment with the pathway provided by Mr Field on behalf of LHCH. Our Trust's guidance is agreed in principle by LHCH and is subject to ongoing consultation, discussions and modifications in line with wider cardiothoracic strategy and service specifications. We are grateful to the Coroner for his comments. Further comments Whilst each Trust has taken steps to address this issue within its locality, and in close liaison with each other, as identified within your report, this is a national issue and consequently each Trust will be greatly assisted by any guidance forthcoming from the Secretary of State for Health. However, as alluded to above, the current National Aortic Service Specification commissioned by NHSE will in due course address formal organisation of services and pathways for patients with thoracoabdominal aortic disease including in the North West of England. I hope that this response provides assurance to you and Mrs Jackson's family that Liverpool Heart and Chest Hospital NHS Foundation Trust, Lancashire Teaching Hospitals NHS Trust and Manchester University NHS Foundation Trust have worked hard and continue to focus on ensuring that lessons have been learned and improvements have been made to the expediency and efficiency of referrals into its services. Please do not hesitate to contact the Trusts if you require any further information in relation to the response.