Jude Augustus Gordon

From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall POCI810786 London SWIA 2NS Mr D Coutts-Wood Tel: 020 7210 3000 Assistant Coroner Mb-sofs@dhgsi-govuk The Medico-Legal Centre Watery Street Sheffield S3 ZET 2 0 NOv 2003 Je M _ Cowlj Thank you for your letter following the inquest into the sad death of Jude Augustus Gordon. In your report you state that Mr Gordon died from cardio respiratory failure; with Ankylosing Spondylitis significant contributory factor Following a sudden deterioration in his condition, although the deterioration was recognised by staff, the need to attend to that problem was not acted upon and subsequently the level of treatment was not increased. You raise two areas of concern relating to early warning scoring systems and in conclusion recommend that a) national early warning scoring system be introduced; and, b) consideration be given to the introduction of computerised systems that lead to automatic refcrral to the relevant senior doctor; In relation to yOur first area of concern; work is already being taken forward. In July 2012 a report entitled National early warning score (NEWS); standardising the assessment of acute-illness severity in the NHS; was published by the Royal College of Physicians The multi-disciplinary working party on the report was chaired by Professor_ Professor of Medicine at University College, London. This report advocates the use of a NEWS to assist in standardising assessment of the severity of acute illness. To support this clinical observation, charts and e- learning materials were produced by a collaborative project funded by the Royal College of Physicians, the Royal College of Nursing, the National Outreach Forum and NHS Training for Innovation:
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There is however as yet no national requirement for this approach to be followed, although the report strongly encouraged Trusts to do so voluntarily to ensure a consistent and high-standard approach: Furthermore, the Patient Safety Domain of NHS England is developing work to identify and implement actions to prevent deterioration ofpatients whose conditions are amenable to treatment_ One of the outputs ofthis programme is likely to be guidance to staff about best practice, supported by material to develop and improve front linc clinician skills in this arca Your second recommendation relates to computerised systems linked to the EWS score You ask if consideration is given to the introduction of computerised systems that lead to automatic referral to the relevant senior doctor: The operational in a Birmingham Trust depends on patient observations recorded in the Patient Information Communication System (PICS), the Trust'$ rules-based clinical information; prescribing and administration system. As observations are entered an early warning score is generated, Depending on the score generated and the settings programmed, an automatic message can be sent to designated nursing and medical staff: Currently, NHS England has no plans to computerised EWS systems more widely across more than 150 NHS acute trusts and foundation trusts_ This is because development of an electronic system such as this relies on the individual Trust's IT infiastructure, which is not standard across the NHS. For Trust to develop an electronic EWS it would need to have the required IT' capability. It is not something that is simple to implement and deploy across the wider NHS. This may explain why it appears to be operational at present only in the Birmingham Trust: Secondly, both electronic systems and paper based systems are reliant on local clinical observations and require observations to be recorded and entered properly before an alert could be generated to a senior clinician: The early warning should be considered not as a substitute for; but an aid to, clinical decision making, based on the clinical judgement of the responsible clinician. AlI forms of early warning system depend on accuracy in completion, calculation of the relevant score and trigger settings, and (subsequently) staff escalating to the appropriate senior clinician; this latter point is well understood in the Sheffield Hospitals Early Warning Score documentation: being system being drug require each system system

Department of Health Therefore, regardless of the in use, whether local 0r national, I believe effectiveness will always be predominantly governed by locally tailored staff training and updating; [ hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Gordon's death to my attention. kz 6~v) JEREMY HUNT system