Rosemary Scott

Dear Mr Allen Thank you for your letter dated 06 June 2018, in relation to the inquest touching the death of Rosemary Scott_ Your report details two matters of concern, which will respond to point by point for ease of reference_ Lack of a reminder system in relation to measuring venous blood gases, as you state it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BiPAP or CPAP. You requested that a review is undertaken to assess whether there should be a system installed to ensure that the staff for patient where venous blood gases should have been measured are 'reminded' of need to do sO, have been informed that it would be clearly indicated in the medical records that staff within the emergency department had been unable to access veins to venous gases: The decision, as to whether these would be clinically necessary would lie with the clinicians. As patient's condition changes, the clinical review of tests required can change. This is part of the individual clinician's judgement and assessment of the patient: Clinical opinion on the right treatment options, including tests, does vary according to the patient's needs. Therefore it is not possible to implement blanket prompt other than the handover process that is already in place. In this case, effectiveness of treatments can also be monitored and assessed in alternative ways, such as using pulse oximeter, The pulse oximeter ensures safe, non-invasive monitoring of the cardiorespiratory condition of patients in need of care The Trust does have clinical systems already in place to assist with the monitoring and recording of observations, reporting of test results and general alerts_ The insufficient number of machines to provide PEEP to patients who require it. caring the gain

The medical records dated 28 December 2017, indicate that on only three PEEP machines were available across the hospital and that there was difficulty in locating one for use by Mrs Scott; have investigated this matter and would advise you that the Trust actually has 6 machines. However; at the time of Mrs Scott's admission, two machines had been taken out of service as were physically damaged and were being repaired: This left the with four units_ This concern was discussed at a Divisional level and plan was put in place_ On 27 December 2017, a further unit was taken out of service for infection control reasons, which left three units across the hospital: The unit was decontaminated and returned to service on 29 December 2017 On 28 December 2017 , three loan units were rented for period of two months and were delivered to site on 29 December 2017_ This meant that between 08.OOhrs to 15.OOhrs three units were available, but by 16.OOhrs, six units were available. On reviewing the records and the events, Mrs Scott was without unit for only a few hours and this was neither detrimental to her care, nor a factor in her death. A suitable alternative was in place and in use, as per the consultant's care plan_ would also advise you that over this period the Trust had no incidents reported in relation to the unavailability of the units, and patient care had not been compromised. This incident was the first reported, therefore there is no evidence of systemic issuelfailure or a trend with respect to safety related to the unavailability of equipment: The rental units were in place within hours of the request being submitted, and a requisition for two replacement units was placed on 25 January 2018. hope that this addresses your concerns and provides you with assurance that the Trust is ensuring safe, high quality care and the availability of necessary equipment