Dear Mr Ridley Re: Regulation 28 Report to prevent future deaths Joyce Violet Rumming (deceased) Thank you for your letter addressed to dated 6 June 2017 where you had detailed recommendations for the This letter sets out the Trust's response to your report: The Trust takes patient safety seriously and has clinical risk processes in place to investigate cases where a patient had or could have suffered harm and to identify areas of potential learning: In your letter you opined that you had shared the same concerns which were identified in the Trust's own investigation (Root Cause Analysis). In this letter will endeavour to set out summary of the progress the Trust has made with the recommended actions in the Trust's own investigation: Action One Handover _process_between _the ambulance service and the_Trust In October 2016, the ambulance service changed from a handwritten record detailing patient care to an electronic system. With all new documentation it takes time to embed, the Emergency Department staff are now familiar with the new ambulance documentation The Clinical Risk team had liaised with the local ambulance trust to see whether any changes can be made to the electronic system so that key information, such as allergies, is at the top of the handover document. Our local ambulance trust works with many acute hospitals in South West We have been advised that it is not possible to make Values Service Teamwork Ambition Respect Trust: the region. Our

this change as the electronic system cannot be tailored for each individual organisation which the ambulation trust works with. There is future plan to introduce a joint IT system between ambulance trusts and hospitals and we understand that a pilot is scheduled in the next couple of years: Action Two Review of documentation of_ allergies The majority of documentation in the Emergency Department is electronic_ On the electronic patient record system there is an alert section where drug allergies are to be noted. The alert notification tab is then flagged red on the patient's home page_ The Emergency Department continuously review their documentation and there are future plans to implement new clinical note. The clinical note is an electronic record with specific questions for the clinician to answer when assessing the patient: The new clinical note is planned to include patient allergies. Action Three Explore_the_interface between IT systems The IT infrastructure did not and still does not support sharing of information between the electronic patient medication system and the electronic patient record system: Actions two and four are to bridge this gap and ensure patient safety: The Trust plans to explore the IT infrastructure further in the future relating to the interface between the two systems: In addition to this the Emergency Department are being migrated onto the same server which the rest of the Trust uses. This will make it easier for Emergency Department staff to have access to the electronic patient medication record to look up any allergies and with the potential to prescribe medication using this system: Action Four Review the allergy alert system process policy The Medications Safety Group has developed six factsheets relating to patient medication allergies The factsheets are available to all staff and are located on the Trust intranet. The factsheets cover the assessment of an allergy, to document and share this information and how to treat the patient: The six factsheets are included with this letter for your information: The policy is currently being drafted however in the interim the factsheets provide adequate guidance on allergies hope that this provides you with assurance that the Trust has measures into place to improve systems around patient allergies. Our Values Service Teamwork Ambition Respect how put

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