Wrightington Wigan and Leigh NHS Trust
NHS / Health Body
Action Taken
Wrightington, Wigan and Leigh NHS Trust has notified emergency care staff that calls should not be put through to minors or majors, that treatment advice should not be given, and is reminding nursing staff of the requirement to document relevant care. The Accident & Emergency weekly mortality review will now include a review of any hospital attendances in the last four weeks. (AI summary)
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Dear Mr Walsh Regulation 28 Response: Patricia Forshaw (Deceased) Thank you for your Regulation 28 report dated 8 September 2017 . understand that an Inquest relating to the death of Patricia Forshaw took place on 21* August 2017 . I have been advised of the circumstances relating to Mrs Forshaws death and have read your report: I am grateful to you for bringing these concerns to my attention. I would like to take this opportunity to respond to the issues raised in report and to advise yoU of actions already undertaken by Wrightington, Wigan and Leigh NHS Foundation Trust (the Trust") and the ongoing action in respect of this matter. Iam aware that you have the following concerns regarding the care provided to Mrs Forshaw:
1. The telephone number on the card given to the Deceased when she was discharged from hospital related to appointments only but the purpose of the number is ambiguous and when the Deceased's husband telephoned the number on the card in the early hours of 20* October 2016 he believed he was speaking to the Emergency Department; particularly in view of the fact that he was given advice to give paracetamol to Deceased_ 2 The telephone call the Deceased's husband to the hospital in the early hours of 20t October 2016 and the advice to give paracetamol was not recorded in any hospital records: Furthermore, the consultation with Nurse who removed the dressing and who was aware of the Deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not Chairman: Robert ArMrstrong Chiel Executive: Andrew Foster CBE fully your the the from the AbQur 6
01548169
bring the information to the attention of the doctor at the time of his consultatlon with the Deceased
3. laccepted that; having heard the evildence of the family at the Inquest, routine observations (pulse, blood pressure, respiratory rate, temperature) and blood investigations should have been conducted when the Deceased presented to the Out Patient appointment on 21* October 2016. gave evidence that there has been some discussion between Consultants in the emergency department and there was mention that there should be a policy for checking routine observations in patients attending Clinic for wound revlew; particularly where there was an indication of infection: However confirmed that there was no formal policy In place: 4_ The evidence heard at Inquest confirmed that there had been a discusslon between Consultants In the Emergency Department in relation to the treatment and care of Mrs Forshaw but the treatment and care of Forshaw had not been escalated as a formal report for consideration of a Serious Incident Review: Accordingly a Serious Incident Review had not taken place in relation to Mrs Forshaws death, although it was accepted that, in retrospect; & Review should have taken place to enable any recommendations to be formalised within the Governance framework: Iapprecate that; in light of these concerns you have requested that the Trust conduct a review of policles, procedures and protocols In relation to:- I The information on appolntment cards II, The notes to be recorded by nurses, either In relatlon to telephone calls made to the hospital by or on behalf of a discharged patient or In relation to nurses conducting a preliminary examination to consultation with a doctor; III_ Routine observations and blood investigations In relation to patients attending hospital, particularly the Emergency Department or Out Patlent Clinic, where there Is evidence and dlagnosis of wound infection: I. The reporting and escalation of incidents in the Emergency Department leading to consideration of a Serious Incident Review and appropriate action within the Governance framework propose to respond to each of your concerns and recommendations in turn: Appointment cards For your information and assistance I enclose a blank example of the appointment card which would have been completed and given to Forshaw following her review in the Accident and Emergency Department on 19t October 2016. This card would have been populated with Mrs Forshaw's name and the date of her appointment in the Out Patient Clinic, which I believe was on 221d October 2016. As you will see under the name of the Hospital at the top of the card there is a telephone number: At the bottom of the card it Is stated; "If the condition for which this appointment has been made has cleared Up, there is no need to attend (please inform reception on above number) The number at the top f the card Is therefore intended to be used if appointment is no longer required or if the date needs to be changed. I apologise If Mrs Forshaw or her husband found this Mrs prior Mrs the
information to be ambiguous: I am aware that the Trusts outpatlent appolntment card is to be updated to include advice for patients to contact NHS 111 or thelr GP If their condition deteriorates: Ialso understand from the Clinical Dlrector for Emergency Care that a Memo has been sent to all Emergency Care staff to notify them that if a patlent or relatlve calls the department for advice, the caller is to be told that if they have any questions about their/the patients condition or treatment they are to consult their GP, call 111 or to re-attend Accident & Emergency: The Emergency Care Staff have been informed that under no circumstances should be provlding any medical or treatment advice. The Emergency Care Staff will also be notified that calls should not be put through to the minors or majors area in the Accident & Emergency Department as even though these calls are answered by a medical professional, the advice given Is not always recorded in a patlents notes and as such there is no audit trail. The Accident & Emergency Department is not to be treated as an advice and this information will be re-iterated to all Emergency Care Staff, Recordslnotes I appredate that Mrs Forshaws medical notes did not include a record of any discussion she had with the nursing staff either whilst waiting for her out patient appointment or during her initial nursing review before her examination by the Doctor; However, I understand that when reviewed Mrs Forshaw in the outpatlent clinic a description of her wound was recorded In the notes and it was noted that there was swelling around the wound, together with slight pretibial erythema (redness to the skin overlying the tibia): As a result of these signs of infectlon_ Iprescribed Clarithromycin as an antibiotic ad arranged a further revlew appointment four days later: A letter was sent to Mrs Forshaw's GP outlining this management plan: All of our nurses are aware of their duty to ensure patient records are accurate and to document relevant information as appropriate: However I understand that a notification has been circulated to all nursing staff by the Matron for Unscheduled Care to reiterate the requirement nurses to document in patients notes any relevant care or treatment provided The Clinical Director for Emergency Care will inform all the Consultants of this issue and this matter will also be discussed at Ciinicai Governance Meeting_ I have also been informed that this notification will be incorporated into the ongoing local induction for nursing staff; I can therefore assure you that If there Is any information or hlstory which Is brought to the attention of the nurse by a patient, all nursing staff have been notified of the need to inform the reviewing clinician so that this can be considered when determining the appropriate course of treatment: Routine Observations appreciate that during the course of the evidence at Inquest; candidly acknowledged that routine observations should have been conducted on Mrs Forshaw and had been done, and if her results had triggered the sepsis pathway, she would have been admltted and commenced on IV fluid and IV antibiotics: Both Ihave reassured me that all clinlclans working In the outpatient clinic are very aware of the sepsis pathway and conduct routlne observations and blood investigations where appropriate when a patient is displaying clear signs of infectlon: Following careful consideration and discussions between senior Emergency Care clinicians, they do not consider that it would be possible they line for the the they
to Implement a formal policy or standard operating procedure for conducting routine observations on patients in the Outpatients ClInic; Unfortunately patients and their symptoms do not fit into clearly defined categories as to when observations are required and when they are not Patients attend with a vast range of symptoms and as such, the standard practice at WWL is for the clinician to examine the patient; consider their presentatlon and determine the treatment and advice to be given on the basis of their dinical judgment: I do not believe this Is out of line with the procedure followed at all other NHS Trusts: has confirmed that he did not; in his clinical judgment based on Mrs Forshaws presentation on 22 October, consider her to be showing clear signs of infection which warranted routine observations and blood to be taken: limpression of Mrs Forshaw's presentatlon was one of localised wound infection: I have been assured that the clinical staff in the Outpatient Clinic are very aware of the Trust's sepsis guidelines and trigger the sepsis pathway whenever required: lhas discussed Mrs Forshaws care at a meeting of the Emergency Care Consultants to heighten awareness of wound Infectlon and sepsis and to gather feedback from the senior Consultants in relation to routine observations; this senior opinion has been incorporated into this response Mortality review Governance process As you may be aware one of our Consutlant Paedlatricians conducts a weekly mortality revlew to consider the care and treatment provided to all in patlents who have died during the course of the week: In Accldent & Emergency a slmilar mortality revlew Is undertaken by I have been informed that at the cllnical governance meeting on 27 September 2017 it was confirmed that the criteria of this revlew Is now to be widened to consider whether the patient has attended the hospital at any time In the previous four weeks. Thls wll enable the Consutlant conducting the Mortality Review to Identify whether there Is anything of significance from these previous presentations to be considered when revlewlng the care provided. In Mrs Forshaw's case; such a review would have Identified her attendance to A & E and her subsequent attendance at the Outpatient clinic in the 48 hours to her death. Consideration would therefore have been given to whether there was anything which could/should have been done at these presentations to have altered the outcome for Mrs Forshaw and the decision could then have been taken aS to whether this matter required further investigation and escalation through the governance procedures at the time of Mrs Forshaws death: I apologise that this did not happen and I hope that the improvements made to the mortality review process provide reassurance that any future deaths in the Accident & Emergency will now undergo a greater level of scrutiny to ensure that lessons can be learnt Wherever possible and improvements made to the care provided to patients. Continued action As noted above several changes have already been put in place following Mrs Forshaw's sad death and the following actions will be taken:- Emergency Care Staff are to be notified that calls should not be put through to the minors or majors area In the Accident & Emergency Department; Guidance has already been issued to staff to confirm that patients or relatives calling about a patients condition or treatment should be directed to their own GP, advised to call 111 or re-attend Accident & Emergency: Under no circumstances should treatment advice be given: prior
Nursing staff will continue to be notified at local induction sessions of the requirement to document in clinical notes any relevant care and treatment provided The Accident & Emergency weekly mortality review will now include a review of any hospital in or outpatlent attendances in the last four weeks prior to the final attendance, to consider any significant issues relevant to the patients care and treatment: The above actlons will be monitored via the Trusts Quality and Safety Committee which is chaired by a Non-Executive Director and attended by several members 0f the Executive team, including the Medical Director and Director of Nursing: hope the above response Is a testament to how seriously the Trust considers the concerns raised by Mrs Forshaws death; I @an reassure you that WWL has and will continue to learn lessons from Mrs Forshaws care and the Trust is constantly seeking to improve the service we offer to our patients Please can I pass my sincere condolences to Mrs Forshaw's family for thelr loss; If you have any comments or suggestions in relation to the proposed actions above; I would be only too pleased to hear from you:
1. The telephone number on the card given to the Deceased when she was discharged from hospital related to appointments only but the purpose of the number is ambiguous and when the Deceased's husband telephoned the number on the card in the early hours of 20* October 2016 he believed he was speaking to the Emergency Department; particularly in view of the fact that he was given advice to give paracetamol to Deceased_ 2 The telephone call the Deceased's husband to the hospital in the early hours of 20t October 2016 and the advice to give paracetamol was not recorded in any hospital records: Furthermore, the consultation with Nurse who removed the dressing and who was aware of the Deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not Chairman: Robert ArMrstrong Chiel Executive: Andrew Foster CBE fully your the the from the AbQur 6
01548169
bring the information to the attention of the doctor at the time of his consultatlon with the Deceased
3. laccepted that; having heard the evildence of the family at the Inquest, routine observations (pulse, blood pressure, respiratory rate, temperature) and blood investigations should have been conducted when the Deceased presented to the Out Patient appointment on 21* October 2016. gave evidence that there has been some discussion between Consultants in the emergency department and there was mention that there should be a policy for checking routine observations in patients attending Clinic for wound revlew; particularly where there was an indication of infection: However confirmed that there was no formal policy In place: 4_ The evidence heard at Inquest confirmed that there had been a discusslon between Consultants In the Emergency Department in relation to the treatment and care of Mrs Forshaw but the treatment and care of Forshaw had not been escalated as a formal report for consideration of a Serious Incident Review: Accordingly a Serious Incident Review had not taken place in relation to Mrs Forshaws death, although it was accepted that, in retrospect; & Review should have taken place to enable any recommendations to be formalised within the Governance framework: Iapprecate that; in light of these concerns you have requested that the Trust conduct a review of policles, procedures and protocols In relation to:- I The information on appolntment cards II, The notes to be recorded by nurses, either In relatlon to telephone calls made to the hospital by or on behalf of a discharged patient or In relation to nurses conducting a preliminary examination to consultation with a doctor; III_ Routine observations and blood investigations In relation to patients attending hospital, particularly the Emergency Department or Out Patlent Clinic, where there Is evidence and dlagnosis of wound infection: I. The reporting and escalation of incidents in the Emergency Department leading to consideration of a Serious Incident Review and appropriate action within the Governance framework propose to respond to each of your concerns and recommendations in turn: Appointment cards For your information and assistance I enclose a blank example of the appointment card which would have been completed and given to Forshaw following her review in the Accident and Emergency Department on 19t October 2016. This card would have been populated with Mrs Forshaw's name and the date of her appointment in the Out Patient Clinic, which I believe was on 221d October 2016. As you will see under the name of the Hospital at the top of the card there is a telephone number: At the bottom of the card it Is stated; "If the condition for which this appointment has been made has cleared Up, there is no need to attend (please inform reception on above number) The number at the top f the card Is therefore intended to be used if appointment is no longer required or if the date needs to be changed. I apologise If Mrs Forshaw or her husband found this Mrs prior Mrs the
information to be ambiguous: I am aware that the Trusts outpatlent appolntment card is to be updated to include advice for patients to contact NHS 111 or thelr GP If their condition deteriorates: Ialso understand from the Clinical Dlrector for Emergency Care that a Memo has been sent to all Emergency Care staff to notify them that if a patlent or relatlve calls the department for advice, the caller is to be told that if they have any questions about their/the patients condition or treatment they are to consult their GP, call 111 or to re-attend Accident & Emergency: The Emergency Care Staff have been informed that under no circumstances should be provlding any medical or treatment advice. The Emergency Care Staff will also be notified that calls should not be put through to the minors or majors area in the Accident & Emergency Department as even though these calls are answered by a medical professional, the advice given Is not always recorded in a patlents notes and as such there is no audit trail. The Accident & Emergency Department is not to be treated as an advice and this information will be re-iterated to all Emergency Care Staff, Recordslnotes I appredate that Mrs Forshaws medical notes did not include a record of any discussion she had with the nursing staff either whilst waiting for her out patient appointment or during her initial nursing review before her examination by the Doctor; However, I understand that when reviewed Mrs Forshaw in the outpatlent clinic a description of her wound was recorded In the notes and it was noted that there was swelling around the wound, together with slight pretibial erythema (redness to the skin overlying the tibia): As a result of these signs of infectlon_ Iprescribed Clarithromycin as an antibiotic ad arranged a further revlew appointment four days later: A letter was sent to Mrs Forshaw's GP outlining this management plan: All of our nurses are aware of their duty to ensure patient records are accurate and to document relevant information as appropriate: However I understand that a notification has been circulated to all nursing staff by the Matron for Unscheduled Care to reiterate the requirement nurses to document in patients notes any relevant care or treatment provided The Clinical Director for Emergency Care will inform all the Consultants of this issue and this matter will also be discussed at Ciinicai Governance Meeting_ I have also been informed that this notification will be incorporated into the ongoing local induction for nursing staff; I can therefore assure you that If there Is any information or hlstory which Is brought to the attention of the nurse by a patient, all nursing staff have been notified of the need to inform the reviewing clinician so that this can be considered when determining the appropriate course of treatment: Routine Observations appreciate that during the course of the evidence at Inquest; candidly acknowledged that routine observations should have been conducted on Mrs Forshaw and had been done, and if her results had triggered the sepsis pathway, she would have been admltted and commenced on IV fluid and IV antibiotics: Both Ihave reassured me that all clinlclans working In the outpatient clinic are very aware of the sepsis pathway and conduct routlne observations and blood investigations where appropriate when a patient is displaying clear signs of infectlon: Following careful consideration and discussions between senior Emergency Care clinicians, they do not consider that it would be possible they line for the the they
to Implement a formal policy or standard operating procedure for conducting routine observations on patients in the Outpatients ClInic; Unfortunately patients and their symptoms do not fit into clearly defined categories as to when observations are required and when they are not Patients attend with a vast range of symptoms and as such, the standard practice at WWL is for the clinician to examine the patient; consider their presentatlon and determine the treatment and advice to be given on the basis of their dinical judgment: I do not believe this Is out of line with the procedure followed at all other NHS Trusts: has confirmed that he did not; in his clinical judgment based on Mrs Forshaws presentation on 22 October, consider her to be showing clear signs of infection which warranted routine observations and blood to be taken: limpression of Mrs Forshaw's presentatlon was one of localised wound infection: I have been assured that the clinical staff in the Outpatient Clinic are very aware of the Trust's sepsis guidelines and trigger the sepsis pathway whenever required: lhas discussed Mrs Forshaws care at a meeting of the Emergency Care Consultants to heighten awareness of wound Infectlon and sepsis and to gather feedback from the senior Consultants in relation to routine observations; this senior opinion has been incorporated into this response Mortality review Governance process As you may be aware one of our Consutlant Paedlatricians conducts a weekly mortality revlew to consider the care and treatment provided to all in patlents who have died during the course of the week: In Accldent & Emergency a slmilar mortality revlew Is undertaken by I have been informed that at the cllnical governance meeting on 27 September 2017 it was confirmed that the criteria of this revlew Is now to be widened to consider whether the patient has attended the hospital at any time In the previous four weeks. Thls wll enable the Consutlant conducting the Mortality Review to Identify whether there Is anything of significance from these previous presentations to be considered when revlewlng the care provided. In Mrs Forshaw's case; such a review would have Identified her attendance to A & E and her subsequent attendance at the Outpatient clinic in the 48 hours to her death. Consideration would therefore have been given to whether there was anything which could/should have been done at these presentations to have altered the outcome for Mrs Forshaw and the decision could then have been taken aS to whether this matter required further investigation and escalation through the governance procedures at the time of Mrs Forshaws death: I apologise that this did not happen and I hope that the improvements made to the mortality review process provide reassurance that any future deaths in the Accident & Emergency will now undergo a greater level of scrutiny to ensure that lessons can be learnt Wherever possible and improvements made to the care provided to patients. Continued action As noted above several changes have already been put in place following Mrs Forshaw's sad death and the following actions will be taken:- Emergency Care Staff are to be notified that calls should not be put through to the minors or majors area In the Accident & Emergency Department; Guidance has already been issued to staff to confirm that patients or relatives calling about a patients condition or treatment should be directed to their own GP, advised to call 111 or re-attend Accident & Emergency: Under no circumstances should treatment advice be given: prior
Nursing staff will continue to be notified at local induction sessions of the requirement to document in clinical notes any relevant care and treatment provided The Accident & Emergency weekly mortality review will now include a review of any hospital in or outpatlent attendances in the last four weeks prior to the final attendance, to consider any significant issues relevant to the patients care and treatment: The above actlons will be monitored via the Trusts Quality and Safety Committee which is chaired by a Non-Executive Director and attended by several members 0f the Executive team, including the Medical Director and Director of Nursing: hope the above response Is a testament to how seriously the Trust considers the concerns raised by Mrs Forshaws death; I @an reassure you that WWL has and will continue to learn lessons from Mrs Forshaws care and the Trust is constantly seeking to improve the service we offer to our patients Please can I pass my sincere condolences to Mrs Forshaw's family for thelr loss; If you have any comments or suggestions in relation to the proposed actions above; I would be only too pleased to hear from you: