Gary Bradshaw

Dear Mr Pollard Re; Bradshaw 15/03/1965 (Deceased) Thank you for letter, of the 15th 2014 , concerning the inquest of the above am grateful to you for highlighting your concerns on the Regulation 28 named: As always, I and for providing me with an opportunity to respond. 'Report to prevent deaths' I shall address each of your concerns in the order in which you raised them:
1. There was a considerable delay in the initial diagnosis that he was stones, between 2011 and March 2012. suffering with The report of the Ultrasound Scan, undertaken on 15" July 2011, stated that there were: "severa} echogenic foci in the lower pole of the right kidney: of these exhibit are likely to represent renal stones. The right is otherwise shadowing ad hydronephrosis. There is no scarring: normal: There is no As these stones were not causing ay obstruction were deemed to be 'incidental were not responsible for his pain_ It was felt important to follow findings' and period of time between the Ultrasound Scan and follow up the stones but by leaving there was up, this would assist in determining whether any significant change in the size of the stones which would influence their management: In order to try ad prevent further problems, such a Mr Bradshaw place to undertake calcium and urate blood test experienced, there is a policy in kidney stones If it has been a5 soon a possible following new diagnosis of their calcium discovered, whilst the patient is in hospital, that have stones and and urate levels are normal ad the plan has been explained to the patient will be seen in the outpatients' department at 6 months; however, if it already, then and the patient does not know have stones and the was an incidental outpatient appointment will be made to bloods have not been done, an early problems, check their bloods explain the presence of stones, give advice to minimise and explain the follow up. At the consultation in March 2012 both blood and urine tests were ordered only the urine tests were done and/or reported, thus his but apparently hypercalceamia hypercalciuria was seen but not At Mr Bradshaw's clinic attendance 'on 19th March 2012, serum urate and calcium levels; for a unknown requested staff to take blood for time the electronic order reason tne serum calcium was not requested at the was made and so after it was printed, a member of staff calcium) in handwritten format next to 'clinical information on the added '+CA' (plus of the case subsequently determined that;nWhen therrequesofothe wainteeceeedest form ; Investigation was received in the laboratory, the our Health: Our Priority: Gary your May future kidney May Two kidney they groin they they finding they his

staff there mistook the handwritten addition to mean 'plus cancer' (aS it was written next to the clinical information and not in the request column) and so the serum calcium was not determined . There are some tests that have not been set up on the electronic system due to there such high number of possible tests available. We have the frequently requested tests on and also some infrequently requested ones and continue to add on a regular basis. system advances also increase the variety of tests becoming available; therefore it has been accepted Technology that such tests can be added to electronic requests in handwritten format. However practice tests are on the system in their own right and as profiles. calcium and urate AIl staff have been reminded that; where the parameter exists for blood test to be ordered electronically, it must be ordered in that way: in exceptional circumstances should a blood test request; from within the Trust, be hand written. Exceptional circumstances are those such as an emergency, when electronic ordering is not readily available, or when blood test to be requested is not available to choose in electronic format: If a blood test must be requested in hand written form; then the test required should be written out in full and not abbreviated. All requests must be made in the requests box within tne form and not in the clinical details section.
3. The above blood tests were ordered but the patient was prescribed and administered Bendroflumathiazide before the results were known, something which the expert witness described as contraindicated accepted at inquest that he should not have prescribed Bendrofluamathiazide without knowing the serum calcium results and will not do so in the future; He had expected to review the results within a week and review his decision but unfortunately that did not happen as he expected. We now have systems in place to allow to electronically check all tests done in his name in the outpatients department
4. There was a misunderstanding or misreporting of the results to the GP as to whether the results related to blood or urine tests Onl4th June 2012 the pre-operative assessment nurse reviewed the bloods that had been ordered on 8th June 2012; however she only reviewed those bloods fadffelaxithid beerenrdteredhar These included Mr Bradshaw's Complete Blood Count; Liver Profile ad Urea and Electrolytes; the nurse then wrote to Mr Bradshaw's GP that same day, enclosing copies of the results, advising him that Mr Bradshaw had low platelet count and that some of his liver functions were also deranged: Although the nurse did not specifically mention the results pertaining to serum calcium in her letter; these results, titled 'total serum calcium 3.25 range 2.20
2.60' were at the very of the report that the nurse enclosed with her letter to the GP; it was clear that these results related to blood and not urine tests. Action All consultants have been given clear instruction that it is their responsibility to ensure that they follow up, or ensure that have systems in place to follow Up, any blood tests or ay other investigation that order.
5. Mr Bradshaw was discharged from the hospital on the June rather than being retained as an inpatient whilst full investigations were carried out; again a practice which the expert witness felt to be inappropriate: Mr Bradshaw presented to the ED with renal colic ad worsening of his kidney function; therefore the plan for that emergency admission was to control his pain and rule out tract obstruction secondary to the known stones aS a cause of worsening of his function. Mr Bradshaw had & urgent US scan of the urinary tract on the 26/6 and this showed the previously known kidney stones with no evidence of hydronephrosis The renal colic was controlled and Mr Bradshaw became symptomatically better; management plan for the kidney stones had been made_ The serum creatinine level was slightly elevated but he was known to be diabetic &d the US scan did not show any evidence of obstruction to his Mr Bradshaws blood sugar was elevated o admission; ordering being the Only the time. top they they 27th urinary kidney kidney kidneys.

however he was known diabetic on regular medications ad his spontaneously and it was at its lowest level on the ation; discharge blood sugar continued to drop Mer Bradshaws fitness for discharge was assessed by the fact that his pain septic, there was no evidence of urinary tract obstruction was controlled, he was not Tanagement plan GVdeace foruriaridnect Sbortesctiooweecessttating _ urgent intervention and he had missed opportunity for further diagnosis and treatment; been accepted that this was
6. During the subsequent admission on the 29th June no consideration Mr Bradshaw to an endocrine surgeon: was given to referring (has reviewed this question and states that all of his actions in care of Mr prepare him for_Surgery: Our Endocrine/ Parathyroid Bradshaw were to Hospital: had not discussed Surgeon_is at Manchester Royal Bradshaw would not be able urgent surgery with as he was well aware that Mr to have general anaesthetic_unti myocardial infarction had definitively excluded (we were awaiting an echocardiogram) lhad been with Cinacalcet which was also mentioned by the external considered possible treatment to previous experience with expert, but he had dismissed this option due patient with worsening of kidney injury secondary to precipitated by this medication. However in light of this case the trust guidance has been changed to indicate hypercalcaemia, the investigation and referral pathway should be that with acute severe completed within 72 hours. 7 Fluid balance charts were not kepty or kept properly on various patient stays: occasions the in- thconversation has been held with the ward manager of All with regard to the the fluid balance charts. The ward manager has reiterated poor documentation on contemporaneous record with her staff the importance of each time a patient has Oreelered anonseieportance % Gocumentingeach event a6 it happense |.ef has passed urine. completed consumed drink; IV fluids are completed or changed or a patient To monitor this ad ensure compliance, fluid balance charts are now reviewed hourly basis at each intentional rounding event (Intentional by the staff on two patient on the ward to ensure they have their rounding is where a nurse will visit every front and in reach of them and nurse call buzzer within reach, have all need in asks them if there is anything else require) The fluid balance charts are now also checked again just prior to handover ensure are up to date for the next shift team of staff. one shift to the next to
8. The hospital laboratory only up" blood results if the blood calcium 3 Smmol/L or more of serum calcium, The expert witness levels exceed levels of 3.Ommol/L and that this should be a national opined that this should occur at Theescalation of Gerum calcium tevelshaoove mmoltiovas introdsced 2014 into Trust processes in March
2. System %f escalation of patients from the wards to the ITU did not or alternatively did not seem to have worked as it seem to be in place wanted to send the patient to the ITU, should have done when the ward Sister There is a clear process for the escalation of patients from wards who transfer: If a member of staff is concerned regarding require Intensive Care input Care input is required then representation patients condition and believes that Intensive If it is agreed that such should be made to the clinical team after the patient. input is required then the team should make the referral in call Intensive Care team who will discuss and review the patient person to the on required:, our investigations we and make arrangements for transfer as this process; were unable to find any evidence that the Ward Sister followed This issue has been discussed with the Ward Sister, who has confirmed that and how to escalate concerns for patient; she is aware of her she is aware of the policy error and appropriate action been day the vomiting during they they they from they "flag The looking During has

taken to ensure she has learned this the policy and how to implement it; incident She also confirmed that her staff are aware of
10.Hospital notes and especially those in less than comprehensive and the ED (on the Advantis system) seem intothe computer but it efficient The emergency doctor featehe) to have been in her did not reveal the notes of the previous patient's "number" statement said that: admission; "I checked his Advantis under his case otemmary and requested his old hospital notes as I note number of _ that point: could find on The Advantis system has been checked to try to Whi Bradshaws details appear a5 eweecaso all hs reclrdte issues: if search is his F number which is his actual patient number. records under both the F number and and the number If the search is for the ] number then the J number records are shown. both the number records It is known that some patients historical issue back appeareover the years to have been given two that these, when to pre-electronic recording of notes) and €he hospital numbers (this is system and the recognised, are linked clearly: The safest way of works hard to ensure Number; if the Wey advocated by the Department of Healthvay for patient via the system is searched Mr Bradshaws to use the patient's NHS records) then both F number files and the NHS number (which is on of his J number are shown: ED 11,I was told that a new electronic and throughout the NHSectrould coteideof note_ is being introduced at highlighted to doctor that "kce corsiter it helpful in the systeng hatrodbaed iat {tockport blood/urine test results had been or she was prescribing drugs beforerthe which Electronic records have moved received. requested Emergencyeepasthaent Televeronic cecscderabpisince 2011 for example we now have administration) and Advantis record)i EPMA (Electronic prescribing ana Advantis ED (The at present to create Ward {waric efectronic records in its pilot stagenat of medication or rule for the circumstance is however not possible in {{Laboratorv-hedicaion Administration) It isounlikelyct e farsible f Cecabed
i.e. across disciplines The kind of advanced Electronic Patient Recoed the vast majority, if not all Trusts next few years may this level of decision the Trust is to implement this example when 'discussing capabilities support/configurability; therefore the Prestentiloirecluae and requirements with suppliers include
2. There seemed to have been the manual assesseeent rethodbjective interpretation of the EWS at the out: I would hope that this meghod I was told that an electronic version hospital by more objective can be sooner rather than later as it will is rolled assessment of the Early Scores; give far better and "Patientrack" is the electronic track and genterates a urgent alertron Doctors ad otneer_ system purchased by the Trust and this system has been piloted and evaluated clinicians of unwell and deteriorating atientsysteis Trust: Phase one of the rollout; which on one ward in Trust and is due to be rolled This being introduced will focus on the input of vital signs out across the on a ward by ward basis, with the alert only, has commenced and is to commence in January 2015. 'functionality activated in phasenerce planned ipettthat this response answers Your concerns mitted to improving the quality of carecwe todlipovidetierou with the assurance that the Trust give to all our patients. is from has discharge F**xrat nothing the dating Trust searching however using the the front files keeping flag recording flag looking have using being Warning the

Please do not hesitate to contact me if you have any further questions regarding this matter,