Dear Ms Sutton,

Re: Victor Hutchens

We are writing in response to your request for the Trust to take action in relation to the frequency of care rounds. The frequency was reduced in Mr Hutchens care, in error, from hourly to four-hourly. The member of staff responsible for the error advised they were unaware of how the error occurred. You were concerned that with that being the case, the error could occur again and could cause or contribute to a future death.

The Trust would like to offer, once again, its sincere condolences to Mr Hutchens family for their loss. We take very seriously the concerns which you have raised.

Following further exploration of the issue, we have identified that the reduction in care rounding was made in error. This decision stemmed from a misunderstanding, where staff believed they were adjusting the frequency of patient observations rather than the care rounding schedule.

In response, we have undertaken a comprehensive education programme with the ward team to clarify the distinct purposes of care rounding and observation frequency, and to reinforce that neither should be reduced without appropriate clinical justification and oversight.

We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.

Please let us know if any further information is required.