Pennine Acute Hospitals NHS Trust
NHS / Health Body
Action Taken
The Trust drafted a new Thrombolysis Policy, circulated it on the Trust Intranet, and provided training sessions to Critical Care staff. They are also developing a training presentation and reviewing the Adult Critical Care Operational Policy. (AI summary)
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Dear Mrs. Hashmi, Re: Inquest touching the death of Mr James McManus 19 February 2015 Please find the Trust response to the recent Regulation 28: report to prevent future deaths, served to the Trust on 13 March 2015. You commented in your conclusion and also expressed in your concerns about the lack of knowledge, application and implementation of key protocols by Trust staff, in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of blood loss. On your advice, the Trust has taken action to prevent future deaths as documented below. This work has been led by Vascular Surgeon and Clinical Lead for Anaesthetics. New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology Consultants. The session dates were held on the following dates, 14th and 27 October 2014 and on l0hl and 24th November 2014.
• Development of a training presentation incorporating the policies and guidelines regarding Thrombolysis and management of associated bleeding risks. This presentation will take place on 22 May 2015, during the Clinical Governance Audit session, attendance is mandatory for all levels of medical staff. , Vascular Surgeon and Clinical Lead for Anaesthetics will lead on this presentation. Prior to the audit day the Directorate Manager for Vascular Surgery will ensure that all levels of vascular medical staff receive copies of the policies to be discussed.
• Development of a training presentation incorporating Clinical Record Keeping. Presentations will be delivered on the Clinical Governance Audit sessions. The Directorate Manager for Vascular Surgery is arranging this as a matter of priority, with an expected completion date of September
2015. Staff will be advised that all discussions, multidisciplinary meetings that are held and decisions made regarding patient management plans are to be clearly documented as a permanent record in the patient’s case notes.
• Review of Adult Critical Care Operational Policy - this will incorporate a mechanism that enables a senior member of a referring Consultants Team, to liaise with the consultant Intensivist when the consultant surgeon is unavailable (i.e. if they are scrubbed in theatre.) This will include Vascular and Anaesthetic consultants and representatives from the Divisions of Surgery, Medicine and Women and Children’s. The Directorate Manager is arranging this meeting with and the intention is that this will be completed by July 2015.
• Development of training regarding the improvement of communication pathways between clinicians and specialities. Presentations will be delivered on the Clinical Governance Audit Sessions and Directorate meetings during 2015. The final target date for completing these presentations will be December 2015 with the Directorate Manager arranging these as a matter of high priority. In order to confirm that all actions are implemented the Senior Directorate Manager will have overall responsibility for ensuring the completion of the actions within the assigned dates. This will include spot checks on the quality of health records with support from the clinical audit team. I would wish to offer sincere condolences on behalf of the Trust and myself to Mr McManus’ family. I am attaching the key policies in appendix 1. If there is any further information that you require please do not hesitate to contact me.
• Development of a training presentation incorporating the policies and guidelines regarding Thrombolysis and management of associated bleeding risks. This presentation will take place on 22 May 2015, during the Clinical Governance Audit session, attendance is mandatory for all levels of medical staff. , Vascular Surgeon and Clinical Lead for Anaesthetics will lead on this presentation. Prior to the audit day the Directorate Manager for Vascular Surgery will ensure that all levels of vascular medical staff receive copies of the policies to be discussed.
• Development of a training presentation incorporating Clinical Record Keeping. Presentations will be delivered on the Clinical Governance Audit sessions. The Directorate Manager for Vascular Surgery is arranging this as a matter of priority, with an expected completion date of September
2015. Staff will be advised that all discussions, multidisciplinary meetings that are held and decisions made regarding patient management plans are to be clearly documented as a permanent record in the patient’s case notes.
• Review of Adult Critical Care Operational Policy - this will incorporate a mechanism that enables a senior member of a referring Consultants Team, to liaise with the consultant Intensivist when the consultant surgeon is unavailable (i.e. if they are scrubbed in theatre.) This will include Vascular and Anaesthetic consultants and representatives from the Divisions of Surgery, Medicine and Women and Children’s. The Directorate Manager is arranging this meeting with and the intention is that this will be completed by July 2015.
• Development of training regarding the improvement of communication pathways between clinicians and specialities. Presentations will be delivered on the Clinical Governance Audit Sessions and Directorate meetings during 2015. The final target date for completing these presentations will be December 2015 with the Directorate Manager arranging these as a matter of high priority. In order to confirm that all actions are implemented the Senior Directorate Manager will have overall responsibility for ensuring the completion of the actions within the assigned dates. This will include spot checks on the quality of health records with support from the clinical audit team. I would wish to offer sincere condolences on behalf of the Trust and myself to Mr McManus’ family. I am attaching the key policies in appendix 1. If there is any further information that you require please do not hesitate to contact me.