Gerald Werrett

Dear Mrs Voisin; Further to my letter of I1th August 2014,regarding the death of Mr G T Werrett the Regulation 28 Report; I have now investigated training and education aspects of chest drain insertion for anaesthetists Please note the following information together with a summary of appropriate actions taken or planned. Training and trainees chest drain insertion is covered at several stages of the anaesthesia training curriculum_ Initial insertion techniques are assessed at the basic level of training and management responsibilities for the procedure then progress through training; and across increasingly complex environments. Subsequent training and work-place based assessment advances to the longer term management of patients with chest drains and dealing with emergency patients and trauma situations. These areas of training are under annual review by our Training Committee and we will ensure particular attention is attached to correct site location at the next review. Further to general anaesthesia requirements for training in chest drain insertion; additional training and assessment takes place in several sub-specialty areas e.g. paediatrics, obstetrics and intensive care_ This may take place in the advanced or higher levels of training andlor subsequent to gaining to the Specialist Register of the GMC and progressing into sub-specialty interest areas. Career education for anaesthetists who are entered on the specialist register; or for those who opt-out of advanced training at the Specialty Doctor level, there is an ongoing need to maintain competence in all areas of clinical practice. This is a requirement of revalidation and necessary to maintain a licence to practice with the General Medical Council. This competence may be achieved by sub-specialty development, engagement on courses such as Advanced Life Support (ALS) o workplace experience coupled with attendance at events and conferences which are quality assessed and recognised for Continuous Professional Development (CPD) points by the College. Several past professional CPD events have been identified where the use of chest drains; particularly with the inclusion of chest ultrasound, has been covered. We can find no similar planned events in The RCoA: Advancing Patient Care and Promoting Safety Patron: HRH The Princess Royal REGISTERED CHARITY NO: 1013887 VAT REGISTRATIOM NO: GB 927 2364 18 REGISTERED CHARITY AN SCOTLAND NO:Sc037737 Storey and entry grade

our calendar for the immediate future; however; when this occurs we will highlight the need to emphasise further safe practice at insertion. In addition, we have also identified this is a frequent topic for events managed by colleagues at the Intensive Care Society and have highlighted to them a need to stress safe practice and double checking the correct site before insertion: Actions to highlight the issue to other providers of events anaesthesia CPD credit will be progressed through our safety network as below. General aspects The College was alerted to & specific chest drain insertion problem earlier this year which led to notification to our safety network in March 2014. The initial notification and subsequent alert were completely anonymised; however, from the detail you have provided we now believe this was the same incident you now highlight and our ongoing work with colleagues will focus on lessons to be learned and shared from this situation_ You would wish to be aware ofan alert issued by the National Patient Safety Agency (NPSA) in 2008 regarding chest drains (http ILwwwnrls npsa nhs uk/resources/?Entryld45_59882 and this is still a point of reference for anaesthetists and others in their safe use. Despite the closure of the NPSA we believe the responsibility for these alerts continues through the safety department within NHS England and we have advised them of this death, with anonymised detail, and requested they review the alert and consider its re-issue. Ihave reminded each of the directors in the College, with responsibility for training and education, about the need to continue to stress the importance of correct chest drain insertion techniques at all stages of professional development and beyond this into continuing practice. As stated in my previous letter; I have also issued an alert to our network of senior anaesthetists, risk managers and clinical directors (approximately 800 healthcare staff across the UK) about the need to check local policy and procedures to ensure ongoing vigilance where chest drains are to be used. Finally, through our Safe Anaesthesia Liaison Group we will now ask for reports related to chest drain insertion incidents to be forwarded to uS as soon as occur S we may monitor any incidence of problems more closely and take remedial action where necessary this provides reassurance of the gravity we attach to this incident and the steps we are taking to learn from it to avoid recurrence_

'o/14 From Rt Hon Norman Lamb MP Minister of State for Care and Support Department Department of Health of Health Richmond House 79 Whitehall London SWIA 2NS Mrs M Voisin HM Senior Coroner for Avon The Coroner's Court The Courthouse Old Weston Road Flax Bourton 2 9 SEP 2014 BS48 1UL Va Thank you for your letter to Jeremy Hunt about the death of Mr Werrett am saddened to hear of Mr Werrett's death, and offer my sincere condolences to his family: Your report details the events prior to Mr Werrett's death which included X-rays which were inverted and mislabelled, resulting in the drain being inserted on the wrong side of Mr Werrett's body: This resulted in an additional drain, which was found to have been a contributory factor in his death You listed a number of concerns about the insertion of these chest drains and the mistakes made in Mr Werret's care. These have, understand, been addressed by North Bristol NHS Trust_ However; have noted your suggestion that the safety check list and guideline that the Trust implemented since Mr Werrett's death might usefully be shared with other organisations in the NHS to prevent future deaths. The risks of inserting a chest drain on the wrong side are already to known to the NHS through patient safety incident reports received through the National Reporting and Learning System (NRLS): The NRLS is a database of patient safety incident reports submitted voluntarily by organisations across the NHS_ Trusts regularly upload incident reports from their local systems to the NRLS specifically for purposes of learning: Data is interrogated by national patient safety experts to spot trends, specific incidents of concern, or emerging risks to patient safety_ The WHO Surgical Safety Checklist was designed as a tool to improve the safety of surgery by reducing deaths and complications. The checklist specifically addresses has

Department of Health issues relating to wrong site surgery which includes the insertion of drains An NPSA Alert issued in 2009 recommended that the checklist should be adapted for local use. The alert can be found at httpILwww nrls npsa nhs_uklresources/?entryid45-59860. NHS England (NHSE) has recently established a Reference Group to take forward the recommendation made by the Surgical Never Events Taskforce in February
2014. This Taskforce was commissioned to examine and clarify the reasons for the persistence of these patient safety incidents, and to produce a report making recommendations on how they can be eradicated http Iwww england nhs uklourworklpatientsafetylnever-eventslsurgical: One of the key recommendations in this report is to develop National Standards for Operating Department Practice that will support all providers of NHS-funded care to develop and maintain their own more detailed standardised local procedures. The scope of the standards will cover all surgical procedures and not just those being undertaken in the operating theatre environment: Current timescale for the development of the standards is early 2015. Once the standards have been developed the next phase of this work will be to address how the standards should be implemented and this will include requirements for educators, commissioners and regulators. If North Bristol Healthcare NHS Trust would share the checklist it has developed with NHS England there be opportunity to include it as a resource for other Trusts to use or adapt when the standards are implemented: hope that this information is helpful and thank you for bringing the circumstances of Mr Werrett's death to our attention: Ap02 € NORMAN LAMB may

Dear Mrs Voisin, Regulation 28 Report Gerald Trevor Werrett Thank you for alerting us to the case of Mr Werrett in your report received on 5th August: The College shares your concerns, and will take the following actions: Highlight this case and the findings of the investigation the next Safety Newsflash to its members Share North Bristol NHS Trust's safety check list and guidelines on our website once received: Following this incident; the things we feel that should be reviewed locally are whether the environment supports the review of X-rays (e.g. availability of IT in the room where the procedure was carried out), if the doctor was trained in the use of ultrasound guidance for insertion of chest drains and whether ultrasound was available, in addition to the availability of rapid 24 hour reporting: The College is dedicated to reducing the risk of 'never events' and promoting safety in the workplace, through guidance and regular safety news updates; Thanks again for bringing our attention to this issue With kind regards Chair, Quality in Emergency Care Committee Excellence in Emergency Care Incorporated by Royal Charter; 2008 Registered Charity number 122689 The Flax key