Sandwell West Bimingham Hospitals NHS Trust
NHS / Health Body
Action Taken
Recording 'do not resuscitate' orders on a specific computer system, with disciplinary action for deviation, became a requirement on August 1st. A safety summit was held, and a presentation was created to track service changes monthly. (AI summary)
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Dear Mr Siddique
Response to the Regulation 28 Report – the late Mrs Lily Townsend
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 12 June 2017, in respect of the late Lily Townsend. I should extend again the condolences of the Trust to Mrs Townsend’s family, to whom I am copying this letter.
The important issues you raise have been taken very seriously within the Trust. I attach a presentation by the relevant clinical team which sets out their promises to us about how they will change their service. This is being tracked each month by the Clinical Group Management team using a data scorecard (also attached).
The consultant body within orthopaedics, geriatric medicine and anaesthetics attended, with other professionals, a Safety Summit which I chaired. Here we discussed the issues which had given rise to your report, and the planned actions. The summit was also attended by our medical and nursing directors, and the non-executive chair of our Quality and Safety Committee. The Trust's Board are fully involved with the improvement required.
One issue you notified me about relates to our practice around high risk patients, where a ‘do not resuscitate order’ may be relevant. Since August 1st, recording such orders on a specific computer system within the Trust has become a requirement underpinned by disciplinary
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action for deviation. This allows us to ensure the quality of each order is assessed. I should be clear that our audit data to date attests to good quality decision making and involvement but we are striving for excellence.
I anticipate the majority of the actions in the plan being complete by the end of October and will write to you again in November to update you on the status of our work.
Do contact me, or my colleague should this documentation give rise to questions or concerns.
Response to the Regulation 28 Report – the late Mrs Lily Townsend
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 12 June 2017, in respect of the late Lily Townsend. I should extend again the condolences of the Trust to Mrs Townsend’s family, to whom I am copying this letter.
The important issues you raise have been taken very seriously within the Trust. I attach a presentation by the relevant clinical team which sets out their promises to us about how they will change their service. This is being tracked each month by the Clinical Group Management team using a data scorecard (also attached).
The consultant body within orthopaedics, geriatric medicine and anaesthetics attended, with other professionals, a Safety Summit which I chaired. Here we discussed the issues which had given rise to your report, and the planned actions. The summit was also attended by our medical and nursing directors, and the non-executive chair of our Quality and Safety Committee. The Trust's Board are fully involved with the improvement required.
One issue you notified me about relates to our practice around high risk patients, where a ‘do not resuscitate order’ may be relevant. Since August 1st, recording such orders on a specific computer system within the Trust has become a requirement underpinned by disciplinary
2 | P a g e
action for deviation. This allows us to ensure the quality of each order is assessed. I should be clear that our audit data to date attests to good quality decision making and involvement but we are striving for excellence.
I anticipate the majority of the actions in the plan being complete by the end of October and will write to you again in November to update you on the status of our work.
Do contact me, or my colleague should this documentation give rise to questions or concerns.