Terence Millington

Dear Mr Dorries Re: Response to Regulation 28 Report to Prevent Future Deaths write further to your report dated 2 March 2017 , following the inquest into the death of Terence Millington: would firstly like to offer our condolences to Mr Millington's family along with our sincere regrets for the distressing circumstances surrounding his death: We take very seriously the findings of the report, which we have considered carefully: Our response to the specific Matters of Concern within the report is outlined below: In relation to the fact that the on-call senior doctor (the SpR) did not answer calls to her telephone , the consultant has discussed the incident with the doctor concerned. She was unable to offer any reason why the calls failed to wake other than she was very tired and in deep sleep: She is sincerely sorry and has reflected on and learnt from incident From April 2017 the local induction within ENT has included reference to the responsibility of non-resident on-call medical staff to remain contactable and, over the coming months, this is also to be incorporated within the central induction programme for medical staff. In addition, we are in the process of reviewing and amending the Trust's requirements for staff who are on call from home to ensure that both a primary and an alternative contact number are registered with switchboard_ We expect this to be completed by the end of July 2017_ In relation to the issue of contacting medical staff overnight and at weekends, it is important to note that increasing numbers of junior doctors, particularly in the more acute specialties, work resident shifts out of hours rather than being on-call from home_ For these doctors, problems relating to contact are not a concern as remain on site and in the relevant clinical area throughout the out of hours duty period: Sheffield Hospitals In hospital and in the community Charity proud to make a difference Chair: Tony Pedder OBE Chief Executive: Sir Andrew Cash OBE the her, the they

2 Regarding the issue of the next on-call doctor (the consultant) and the distance his home tothehospital_an investigation of the case of this specific consultant is being undertaken by the Trust's Medical Director _ The requirement is for on-call medical staff to be able to attend the hospital within 30 minutes and, whilst there are a number of consultants who live more than 30 minutes away from the hospital, they are required t0 make arrangements to stay locally at a location which meets the '30-minute requirement' when on call. 3_ In response to the issue of the availability of the two nasal packs, an emergency epistaxis bag for on-call medical staff who are required to attend patients elsewhere in Trust is now available on ward I1 at the Royal Hallamshire Hospital. The availability and the contents of the have been incorporated within the monthly health and safety checklist so that this will be regularly monitored: In order to ensure wider learning, the incident and the actions outlined above are to be presented at the Trust's Safety and Risk Management Board meeting on 24 2017 . Finally, hope that the above comments address the Matters of Concern within your report and would be happy to answer any outstanding queries.