Derek Hare

Dear Mr Pollard, Re: Regulation 28: Report to Prevent Future Deaths following Inquest into the death of Derek Edward Hare (Deceased) write further to your letter dated 16"" March 2016 in relation to the Trusts response to your Regulation 28 Report issued following the Inquest; touching upon the death of Derek Edward Hare, on 13" January 2016. am very somy that you cause to contact me again and lhat you found the response given to point of your Regulation 28 Report unsatisfaclory: hope to be able lo address your concerns as set out in section 5 of your report, to your satisfaction in this lelter: With reference to why the response to your Regulation 28 Report typed on the 8" February look a month between typed and being sent to your office, am very for the confusion this caused and would like to assure you that this was a clerical error, and the letter should have been dated 28" February not the 8" February In response t0 1,you staled: It would appear that throughout his various admissions to the hospital, two completely separate sets of "notes were open and used. Thus when the doctor tried to refer t0 the notes in court, he could not do so and had to seek a short adjournment to find the relevant If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient: It was not a question of large case notes which run into two volumes, this was a situation where both sets of notes were apparenty open at the same time and doctors were therefore putting new notes into one or the other but not properly into one single document had being sOrry point being entry:

In respect of your concerns regarding the case notes recognise that staff entries into the records should be in one set of records which should be the current ones in use during the patient's admission This is the Trust's standard and expectation and has been reiterated to the ConsultantClinical Leads, Lead Clinicians and Senior Nurses in the_Clinical Divisions for dissemination to all staff and for discussion at their Clinical Governance and team meetings. As you have highlighted where it is necessary to provide two sets of notes for reference Io the previous history and continuity of care there is a risk that medical staff may enter their notes in the older set of notes This reiteration and reinforcement of the record keeping policy will minimise this. have sought further clarity as you suggested on the problems encountered at Mr Hare's Inquest in this regard and have liaised with Mr Siddiqui. As previously stated two large sets of case notes perlaining to the patient were made available for Inquest: Consultant Mr Siddiqui maintains that he was asked to clarify a date in response to a question raised by Mr Hare's relative. Mr Siddqui informs me that he found it necessary to Iook al the notes which were in a different volume of the case notes ad as such had (o manage both volumes at the Inquest: acknowledge that this was not ideal and further enquiries have informed me that it appears that one set of case notes has records filed up t0 the 27/05/15. This volume held some of the notes Mr Siddiqui had to access (these related to the surgical care) in response to your queslions: The other volume has records up to the patient's death on the 12/08/15. This contained medicine specialty notes and notes where the surgeons had been asked to review Mr Hare) which were also pertinent to the questions asked. am very sorry that Ihis resulted in you having to adjour the Inquest t0 give time for Mr Siddiqui to find the entry and for any inconvenience this caused YOu in respect of your HM Coronial Hearing: also recognise that this gave rise (0 your concerns in relation to the Trusts ability to provide high quality care for the patient 'hope you will find my actions in relation to the concerns you have raised satisfactory: would Iike t0 assure you that have taken your concerns serlously and hope that have addressed your concerns and reassured you of all that the Trust has already undertaken and is currently underlaking, in order to prevent the recurence of similar set of circumstances in the future: Should you have ay further questions arising from the contents of this letter, please do not hesitate t0 contact me_