Stockport NHS Trust
NHS / Health Body
Action Taken
The Trust addressed the issue of a junior doctor performing the pre-operative assessment with the individual surgeon and discussed the case at a Morbidity & Mortality meeting. They reiterated the requirement for documenting equipment and materials used during surgery and are reviewing junior doctor rotas. (AI summary)
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Dear Mr Pollard, Re: Neil Thomas Westerman (Deceased) Thank you for your letter of 11mh March 2015, concerning the inquest of the above named. As always am grateful to you for highlighting your concerns on the Regulation 28 'Report to prevent future deaths and for providing me with an opportunity to respond. am able to address your areas of concern as follows: Aconcern_regarding the pre-operative assessment being_carried out_ bY a junior doctor and pot _the consultant who was to perform the operation_meaning the consultant was_ unaware of vital information This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation_ The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment The_operating_notes did not contain_details_of_the_equipment and materials_used during_the procedure: In this case this was an error; it is standard practice to document and record all relevant information for the related surgery, including the recording of equipment and the numbers Of items used, In this case there was clearly an omission to record such details and the requirement for vigilance in this respect has been reiterated across the Surgery and Critical Care Business Group: Despite_numbers being_in compliance_with set_quidelines_there were_too few junior doctors on duty to cover_the needs of the patients: We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week_ Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competence and skills to out many of the basic junior doctor roles_ The plan is to have these changes in place by the end of August 2015. hope that this response answers your concerns and provides you with assurance that the Trust is committed to improving the quality of care we give to all our patients Please do not hesitate to contact me if you have any further questions regarding this matter.