Patricia Palin

Dear Mr Westerman Re: Regulation 28 Patricia Palin deceased Further to my letter of 21 August 2018, would like to once again offer my sincere apologies for the delay in responding to your Regulation 28 report note that the first point related to another organisation and SO will address each of the points you have set out in turn, which relate to Shrewsbury and Telford Hospitals NHS Trust Too few Doctors were on duty in general to cover patient needs and there did not seem to be programme in place for trying to third Doctor to replace the Doctor who phoned in sick The Trust does have process in place for trying to backfill vacant shifts in the Emergency Department. At the first instance we will attempt to contact our own doctors via the Departmental Consultants or Medical Staffing representative making contact We will also advertise via external agencies at the same time to ensure that every attempt is made to fill the gap: attach a copy of the flow charts used to backfill vacant shifts_ However, on occasion if the sickness is short notice, as with any organisation, it is less simple to get cover. However; we do everything in our power to ensure the shift is covered. Due to the fragility of the workforce both in the locality and nationally , we usually already have numerous requests out to agency, as as our own staff picking up additional shifts, therefore it is not always possible to cover when staff call in at the last minute to cancel their shifts Ertapenem was not in stock and led to some hours 25 minutes delay in administration. Other suitable drugs were in stock; but not considered_ The Doctor prescribing the Ertapenem was not made aware that it was not available in the department; SO was unable to consider an alternativve The outcomes of the Root Cause Investigation were discussed with the team for learning to ensure communication is improved in the future. Furthermore, the drug is now stocked in the Emergency Department; to avoid recurrence in the future_ Whilst there was general awareness of the dangers from sepsis from the Hospital witness evidence: a) Red flags of sepsis were missed b) Leg bandages were not removed to allow for a full top to toe examination c) Sepsis 6 care bundles were not followed in accordance with guidelines Proud To Care Make It Happen We Value Respect Together We Achieve get well

The Root Cause Analysis was shared with the staff involved in order for_lessons to be learnt by the individuals involved in Mrs Palin's care. This was reflected byDr Roylwho attested to this in the Inquest hearing: In addition to this the Trust has carried out work on Sepsis and much more is planned through the Trust: In the last few years our organisation partnered with Virginia Mason Hospital in America, in order to improve patient safety and care As part of this, one of the Value Streams has focused on Sepsis and improving care for patients with this condition. Some of the improvements which are rolled out include: Revised Sepsis Screening Tool a revised version was created by Surgical Assessment Unit (SAU) staff, which increased compliance to 100% in that area Sepsis Trolley the SAU team introduced a bespoke sepsis trolley to store all of the items required to provide timely treatment for patients who are diagnosed with sepsis generating greater efficiency and reliability based on 'set up reduction' Sepsis Box the box placed all the items required in one place in order that a diagnosis can be obtained quickly (Ward 28). The Critical Care Outreach Team have also developed new Sepsis Web page on the Trust Intranet with information and links_ On this the team will be doing 'Spotlight' of the month to highlight good practice from various wards around the hospital to raise awareness of sepsis, this should keep sepsis awareness fresh and in the minds of everyone. However; given that Mrs Palin's delays were based in the Emergency Department wish to you update you on the work which has taken place and the on-going plans to improve sepsis care in ED specifically. Our Critical Care Outreach Team commenced a programme of sepsis education in both Emergency Departments , as of last week; to date 20 staff have been trained. The education is targeting all clinical staff in the department; however this is limited to availability of staff due to work load: The training sessions are taking place daily, days week The feedback has been really positive from all staff. The areas covered within the teaching session are recognition using visual signs, as well as recognition using the Sepsis screening tool. The Team then look at the Sepsis Six pathway in detail and discuss the importance of delivering this within the one hour time frame. Finally reference cards are provided to staff to keep highlighting the sepsis six pathway and signslsymptoms. Alongside this we are reviewing the trolleys in the department; with the possibility of trialling trolley that will allow for us to put everything into the trolley for immediate care of the septic patient; this includes antibiotics and fluids. The existing trolley in place does not carry everything required for immediate care. We are also developing a Patient Group Directive which will allow Senior Band 5 Nurses and Band 6 Nurses to deliver the fluids and antibiotics within the one hour required time frame in the event that a Doctor is not available to meet the demands of the one hour time frame: This is a huge step for us and one that has been welcomed by all the nursing staff within the ED_ Both ED's have Practice Education nurses who will continue to ensure all staff are up to date with their sepsis training: Sepsis Champions have also been chosen to be a Iink within the ED, and they will work closely with the Critical Care Outreach Team to continue the education and provide support for all staff within the ED: The Team are also in the process of . working with the Medical Teams to ensure that all the Doctors are trained in Sepsis recognition and treatment; Critical Care Outreach will continue to support the education and training in these areas for as long is required. Proud To Care Make It Happen We Value Respect Together We Achieve being New

hope that have been able to assure you that whilst we recognise that Mrs Palin's care was not at the standard we aspire to provide to our patients, we are taking all the necessary steps to improve the care we provide to our patients in the future. This is not something which we can do overnight and will take some time and constant review, to ensure that the improvements we are making, are successful: Please do contact me if you have any further questions at this time