Dear Ms Topping, RE Mr Clifford Crofts Regulation 28 Report to Prevent Future Deaths Please find below my responses to your concerns raised following the inquest into the death of Mr Crofts; The Trust's care plan no 94 RIG was not followed The Si report dated the 20 August 2015 (page 19) recommends that relevant staff members are aware of and understand the policies, guidance and supporting documentation which relate to the care of patients who have undergone enterostomies was informed this recommendation had not yet been put into effect: Several changes have been made to safeguard patients who have feeding enterostomies These procedures are not urgent and are no longer undertaken on Fridays (or at weekends): This enables the nutritional support Specialist Nurses to provide specific and directed training to ward areas each time one of these patients is present. The RIG care plan is commenced in radiology when the device is inserted and accompanies the patient to the ward area: The care plan has full details of the management of these devices and the complications which may result from their insertion or use_ The Care plans detailing the use of enterostomies and their complications are available on the Trust intranet via any workstation in the organisation and will be present in any ward where such a patient is an inpatient. A module has been produced for our on line training system for staff (Training Tracker) which covers many aspects of nutritional care including the use and complication of feeding enterostomies_ Our junior doctors are signposted to this system and its contents during their induction program prior to commencing clinical duties at the Trust. Patients first Personal responsibility Passion for excellence Pride in our team

Ashford and St:. Peter'$ Hospitals [HS NHS Foundatron Trust
2. There were considerable difficulties in escalating Mr Croft's care on 20 and 21 September 2014_ The Sl report recommends that the process by which care is escalated within and between specialties needs to be reviewed and clarified t0 ensure that patients receive timely attention. Again am not satisfied on the evidence have heard that this recommendation has been implemented. Difficulties with inter-specialty referral of inpatients have been identified in several Sl reports and a pilot scheme has been developed for use on labour ward which utilises a referral template based on SBAR principles. SBAR is a formal communication tool recommended by the NHS Institute for Innovation and Improvement which consists of standardised prompt questions within four sections (Situation, Background, Assessment and Recommendation), to ensure that staff are sharing concise and focused information: It allows staff to commuriicate assertively and effectively. This template requires the referring specialty to specify the level of response required (ie the grade of clinician to undertake the review) and the timescale for review: A formal process of escalation is described for occasions where the response to the referral is for any reason not adequate. If the pilot scheme is successful, use of the referral template will be rolled out across the organisation. 35 There were considerable difficulties obtaining _ a CT scan on Sunday, 21 September
2014. This was partly because it was not actioned at 16.00 when requested. 17*00 on the weekend the request had to be made by a Consultant to an outside provider Medica who read the scans when no-one is available at the hospital. It appears that junior doctors can now request CT scans and that a new arrangement is being put in place to obtain urgent CT scans in cases of suspected peritonitis: The Sl report recommends that guidance relating to CT scanning on the trust intranet should be reviewed to clarify the process for arranging investigations and be made available as part of the induction process for junior doctors and on the ward areas, for other staff to access was informed that this has not been actioned. There is a revised guidance document available for doctors who request CT scanning out of hours (Mon Fri 20.00 to 08.00 and Sat;, Sun & Bank holidays 17.00 to 09.00). Scans for patients on the following pathways no longer require a discussion with the Medica radiologist CT Heads for head injury, stroke or possible subarachnoid haemorrhage_ Trauma (other than isolated head injury) Quad CT for multiple injuries Cervical spine CT as per NICE guidelines. Acute abdomen pathway Patients first Personal responsibility Passion for excellence Pride in our team After yet

Ashford and St, Peter's Hospitals NHS NHS Foundatfon Tust For other CT scans requested out of hours a discussion with the Medica radiologist is required but direct consultant involvement is no longer necessary (except for paediatric head scans): The guidance is available both in full and abbreviated forms on the Trust intranet and junior doctors are signposted to the guidance as part of their induction process prior to commencing clinical duties_
4. During the course of evidence it became clear that the delay in attempts to escalate Mr Croft's care over the weekend was due in large part to staffing levels. Whilst heard that staffing levels at weekends have increased since 2014, it was not clear that the number of doctors at all levels of seniority available at weekends is sufficient to provide safe care to in patients at the hospital particularly at times when emergencies arise in A and E The Trust is committed to the provision of emergency care which does not vary with time of day or of week, as described in the Keogh Standards_ The timescale for compliance with the 10 Keogh Standards is the end of 2016/17 (financial year) We have recently adjusted the medical junior doctor rotas such that there is an extra doctor on the emergency medical take from 16.00 to 23.00 every day: In contrast to nursing practice; there is no guidance as to what constitutes 'safe staffing' for doctors This is an issue we are trying to address at Ashford and St Peter's and the Medical Director is leading a work-stream which is attempting to define, for each clinical area and each grade of doctor, the safe minimal level of medical staffing: It is likely the implementation of identified safe staffing levels for doctors will require the introduction of the new contracts for both junior doctors and consultants as at present there are significant restrictions on our ability to roster doctors to perform elective work within 'premium time' (19.00 to 07:00 weekdays and any time at weekends): Please do not hesitate to contact me if you require further details on any of these points.