Dear Mr Bridgman, I am writing to you further to the conclusion of the inquest into the death of Ms Audrey Newman on 22 August 2025, and in response to your request for assurance regarding the circumstances surrounding her care, specifically in the absence of a formal pathway or referral process to the anaesthetic team regarding Lumbar puncture procedure (LP) We would like to begin by expressing our sincere condolences to Ms Newman’s family. We recognise the distress caused by the events leading to her death and are committed to learning from this case to improve patient safety and care. Within adult medicine the number of lumbar punctures performed per week average between 10-15. The vast majority of these are done in a very timely manner i.e. within 12-24 hours, and within either the acute medical unit (AMU) or the medical same day emergency care unit (SDEC). Most lumbar punctures are done to exclude either a small brain bleed or meningitis. In rare cases they are done to exclude encephalitis or other more rare nervous system conditions. Very few LPs are done on the specialty medical wards as most would have been done within the first 24-72 hours of the admission on AMU or SDEC. The vast majority of LPs are done on AMU or SDEC and are successful in obtaining samples. On a few occasions the procedure is challenging. This is usually due either to the patient’s body

habitus (obese patients or those with spinal bone deformities) or in more rare cases because the patient is non-compliant or agitated. There is a process in place by which teams contact the anaesthetic team, in cases where the initial LP attempt failed. This involves contacting the anaesthetic senior doctor on call and once they agree to list the procedure by the anaesthetic team the patient is either transferred to theatre for the procedure to be performed or the anaesthetic team attend the ward to perform the procedure. The timeliness can vary and is dependent on other life-threatening emergencies that may need a much more urgent slot in theatre. Unfortunately, in Mrs Newman’s case despite the anaesthetic team being informed of the need for assistance in performing the procedure, there were delays, and as a result, we have enacted a program of work to tighten the process and prevent this from happening again. The details of this are outlined below:
1) In conjunction with the postgraduate department and some of the senior doctors within acute medicine, we have enacted a training program for all registrars working on the medical specialty wards to be signed off to perform lumbar punctures. The program involves signed off simulation sessions within the postgraduate department, then a supervised signed off procedure on a patient. Most registrars who have joined from overseas were competent in performing the procedure but required refresher training given the anxiety of joining a new healthcare system. This program is ongoing and I can report that all registrars have done the simulation sessions and the signing off for the live procedures is ongoing.
2) A meeting was arranged between senior members of the anaesthetic team and (Divisional Medical Director for Medicine and Urgent Care) to formalise the process of escalation of difficult LPs to the anaesthetic team:
• Training is being rolled out to all medical staff within the division of medicine to use the IT booking system for theatres (Theatreman) – this will allow any agreed procedure escalated to the anaesthetic team to be logged, giving visibility that a procedure is pending, and providing an audit trail. The lack of training in using this system was an issue as procedures would be agreed to be done by the anaesthetic team, but then there would be a delay in logging the procedure on Theatreman. It is important to note that this system would be very rarely used by staff in the medical division as they do not work in theatres which is why training was not part of the induction.
• The process of escalation to anaesthetics is being formulated into a flow chart that will be cascaded to all clinicians in the division of medicine and urgent care.

• Patients awaiting a lumbar puncture to exclude meningitis, encephalitis, or subarachnoid haemorrhage will not be transferred off the acute medical unit until the LP is performed successfully. If there is a need to escalate after failed attempts then this needs to be agreed and logged onto Theatreman before the patient is transferred to another medical ward.
• Patients awaiting a lumbar puncture will not be transferred off the unit on a Friday, Saturday or Sunday to avoid weekend related delays.

The elements above will prevent the delays that occurred in Mrs Newman’s case although one must note that to totally exclude encephalitis one would need a viral PCR which can take a number of days for the results to come back. We hope the information provided above offers assurance that Stockport NHS Foundation Trust has taken the findings of the inquest into Ms Audrey Newman’s care extremely seriously. We remain dedicated to continuous improvement in patient safety and care quality. Should you require any further information, please do not hesitate to contact me.