Bryan Catanach
Action Taken
The Trust has refreshed communication processes for emergency patients, ring-fenced a spinal emergency bed, and expanded on-site spinal equipment with a central store, enhanced register, and pictorial training folder. They also updated their standard operating policy for CT scans under traction, while noting technological limitations. (AI summary)
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Dear Mr Cox
Re: Bryan Arnold Catanach Deceased Regulation 28: Report to prevent future deaths
I write as formal reply to the Regulation 28 notice served upon the Royal Orthopaedic Hospital NHS Foundation Trust on 1st December 2015, and in accordance with the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I respond to the matters of concern in the order in which they appear within your Regulation notice;
Difficulties with communication between various clinicians and hospital Trusts. The Trust has looked to progress improved communication routes and systems in preparedness for the receipt of an emergency/unscheduled patient. As was explained within your Court, ROH acts as a regional centre for a range of spinal emergencies. Broadly speaking two to three spinal emergencies are transferred into the ROH each week for emergency elective care. Following this court hearing, the Trust has refreshed and reaffirmed its receiving and first line management processes in preparedness for the arrival of such patients. The Trust robustly pursues the ring fencing of a single spinal emergency bed and this provides a guaranteed safe point of arrival for any inbound emergency patient. Should this bed be occupied and a further emergency referral be received, a process exists to receive the latest emergency patient within our HDU environment. You will recognise that by employing such a structure of escalation a higher state of safety is maintained.
The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham B31 2AP Telephone: 0121 685 4000 Facsimile: 0121 685 4100 ROH005
**Page 2** As is common place in many hospitals, the Trust maintains a consultant on-call rota for the receipt and management of emergency referrals. Historically this rota and others across similar specialist services has been provided by a single consultant surgeon over a 24 hour period. You may be familiar, but there exists a national emerging model to have a 'consultant of the week', within such a model the nominated receiving specialist provides on-call services for either 5 or 7 consecutive days. Based on learning from Mr Catanach's case the Trust has started to pilot 'a consultant of the week' model across spinal services. Whilst not fully embedded as an agreed model of future working, early output from the pilot is very favourable for longer term working.
Additional concerns over communications Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.
Future patients protected from fall by transfer to HDU at point of arrival As noted earlier within my letter rather than moving forward with Mr Newton-Ede's personal suggestion regarding potential direct admission to HDU, the Trust considered it both more clinically appropriate and an easier structure to maintain a position of standardised practice and quality to strengthen and reaffirm the use of the spinal emergency bed or HDU escalation bed. Working with a wider group of clinical colleagues the Trust has therefore consciously decided not to introduce a HDU only arrival model. I would however note no new concerns have been identified since the strengthening of this process.
Traction Equipment Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation. There exists an enhanced level of confidence by staff members in the recognition and application of traction equipment.
CT Scan under Traction The final point of concern raised with your Regulation 28 letter related to the technical inability of the Trust to undertake a CT diagnostic scan with a patient's traction weights in-situ. Due to the nature of equipment this is an issue that would exist at every site operating a CT scanner. Current technology does not allow for such examinations with weight equipment. Whilst I am unable to assure you as to any regularised mitigation for such examination; each case being considered on its
**Page 3** own merits, the basis of the examination is undertaken against a refreshed standard operating policy. I do offer you the assurance that as and when technology develops the Trust will review the opportunity for future service change in this regard.
I am grateful to you for highlighting the points with this Regulation 28 letter. I do hope my reply has provided you with the necessary assurance, both that organisational learning has been taken from these tragic events, and that our systems and processes have and continue to be developed in support of all of our future patients.
Should you require anything further, please do not hesitate to contact my office on 0121 685 4005.
Re: Bryan Arnold Catanach Deceased Regulation 28: Report to prevent future deaths
I write as formal reply to the Regulation 28 notice served upon the Royal Orthopaedic Hospital NHS Foundation Trust on 1st December 2015, and in accordance with the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I respond to the matters of concern in the order in which they appear within your Regulation notice;
Difficulties with communication between various clinicians and hospital Trusts. The Trust has looked to progress improved communication routes and systems in preparedness for the receipt of an emergency/unscheduled patient. As was explained within your Court, ROH acts as a regional centre for a range of spinal emergencies. Broadly speaking two to three spinal emergencies are transferred into the ROH each week for emergency elective care. Following this court hearing, the Trust has refreshed and reaffirmed its receiving and first line management processes in preparedness for the arrival of such patients. The Trust robustly pursues the ring fencing of a single spinal emergency bed and this provides a guaranteed safe point of arrival for any inbound emergency patient. Should this bed be occupied and a further emergency referral be received, a process exists to receive the latest emergency patient within our HDU environment. You will recognise that by employing such a structure of escalation a higher state of safety is maintained.
The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham B31 2AP Telephone: 0121 685 4000 Facsimile: 0121 685 4100 ROH005
**Page 2** As is common place in many hospitals, the Trust maintains a consultant on-call rota for the receipt and management of emergency referrals. Historically this rota and others across similar specialist services has been provided by a single consultant surgeon over a 24 hour period. You may be familiar, but there exists a national emerging model to have a 'consultant of the week', within such a model the nominated receiving specialist provides on-call services for either 5 or 7 consecutive days. Based on learning from Mr Catanach's case the Trust has started to pilot 'a consultant of the week' model across spinal services. Whilst not fully embedded as an agreed model of future working, early output from the pilot is very favourable for longer term working.
Additional concerns over communications Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.
Future patients protected from fall by transfer to HDU at point of arrival As noted earlier within my letter rather than moving forward with Mr Newton-Ede's personal suggestion regarding potential direct admission to HDU, the Trust considered it both more clinically appropriate and an easier structure to maintain a position of standardised practice and quality to strengthen and reaffirm the use of the spinal emergency bed or HDU escalation bed. Working with a wider group of clinical colleagues the Trust has therefore consciously decided not to introduce a HDU only arrival model. I would however note no new concerns have been identified since the strengthening of this process.
Traction Equipment Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation. There exists an enhanced level of confidence by staff members in the recognition and application of traction equipment.
CT Scan under Traction The final point of concern raised with your Regulation 28 letter related to the technical inability of the Trust to undertake a CT diagnostic scan with a patient's traction weights in-situ. Due to the nature of equipment this is an issue that would exist at every site operating a CT scanner. Current technology does not allow for such examinations with weight equipment. Whilst I am unable to assure you as to any regularised mitigation for such examination; each case being considered on its
**Page 3** own merits, the basis of the examination is undertaken against a refreshed standard operating policy. I do offer you the assurance that as and when technology develops the Trust will review the opportunity for future service change in this regard.
I am grateful to you for highlighting the points with this Regulation 28 letter. I do hope my reply has provided you with the necessary assurance, both that organisational learning has been taken from these tragic events, and that our systems and processes have and continue to be developed in support of all of our future patients.
Should you require anything further, please do not hesitate to contact my office on 0121 685 4005.