Dianne Macrae

Dear Mrs Pember, 1 am writing in response to your letter dated 16 June 2017 regarding an inquest held on 17 and 18 May 2017 and the Regulation 28 report you enclosed. It was saddening to learn of the death of Mrs Macrae following elective spinal surgery but I thank you for sharing this Information with us. The College has followed your direction to consider what actions it could take to try to help to prevent future deaths of this kind. We have shared your letter with our colleagues In the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS) and discussed with them how best to do this. The Presidents of SBNS and BASS have jointly prepared a letter to send to their members, highlighting a number of learning points. I have enclosed a copy of this letter for you information.

Dear Madam In response to your Regulation 28 letter to prevent future deaths following the Inquest touching the life of DIanne Jane Macrae, notwithstanding your previous Indication that Woodland were not required to respond. For completeness, I can confirm the hospital has considered and taken action for each point of cause for concern you have raised, this includes but is not exclusive to the following action. The hospital has reflected on the case at Clinical Governance Committee, and will reiterate the findings and conclusion of the Inquest at the next Medical Advisory Committee, 20'^ September 2017. The case and the learning points were also discussed at the theatre team meeting, and will be included at a reflective learning session in the next three months, which is led by Matron. As standard practice now since this tragic outcome, if an anaesthetist or surgeon is re-called to the hospital, both Consultant Surgeon and Consultant Anaesthetist are asked to attend. The Senior Management Team (SMT) who provide on call support 24/7 are all very clear on this and ensure this happens as part of the escalation process for any deteriorating patient, or when a Consultant is asked to return to the hospital. The new Matron is in the process of establishing a multi-disciplinary deteriorating patient committee where cases are discussed, to establish learning from incidents and near misses, the findings will also be published in the new "Clinical Matters" staff and Consultant Newsletter. Ramsay Health Care UK Operations Limited Registered Office; 1 Hassett Street, Bedford. MK40 IHA Registered in England No. 1532937 People caring for people

• The spinal neuro surgeons and Consultant anaesthetists working at the hospital are very aware of this case and now have a high suspicion to exclude post-operative internal bleeding. The holistic learning from this case will be shared with all Consultants following the Medical Advisory Committee meeting on the 20*'' September 2017 via our Consultant Newsletter.
• A bed side Haemocue machine has been installed in recovery, to allow patient bedside testing of haemoglobin by recovery staff. This enables recovery staff to initiate this test as part of their observations to inform attending clinicians of the haemoglobin level in the instance of a deteriorating patient.
• An emergency skills drill was undertaken in recovery in May 2017, and a programme of such drills is being rolled out through the clinical areas involving Consultant Anaesthetists. The hospital would like to reiterate their condolences to the family of Dianne Jane Macrae, and confirm that the action in relation to the matters of concern that you have raised have been addressed as outlined above. If you require any further information please do not hesitate to contact me. Kind regards.