Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – David Christopher Peter Lodge who died on 13 January 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 December 2024 concerning the death of David Christopher Peter Lodge on 13 January 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to David’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about David’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused David’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised concerns that no reasonable adjustments were made at the Emergency Department (ED) David was being treated at to assess David’s pain, given that he was not able to communicate verbally with medical professionals, that basic examinations were not carried out, and that NEWS2 scores above seven were not being appropriately escalated.

In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

17 March 2025

this with regional colleagues in due course. We are advised that the LeDeR review1 for David’s case is ongoing, with the panel scheduled for 20th March 2025.

Reasonable adjustments and basic examinations for people with learning disabilities

The issues raised about David’s care include diagnostic overshadowing, where the agitation would appear to have been attributed to his learning disability, for which reason sedative medication was administered, whereas the agitation may have been due to a physical cause such as pain or shortness of breath.

To ensure that learnings are taken, NHS England can disseminate the findings from the case of David through our network of contacts in health services. NHS England can inform the Medical Royal Colleges and the professional bodies for doctors of the lessons to be learned from the case, for dissemination to their members. The relevant professional bodies include the Royal College of Physicians (London), Royal College of Emergency Medicine, and Royal College of General Practitioners.

Staff training on the presentation of illness in people with learning disability is important in ensuring that illness is detected through careful clinical practice, which should involve reasonable adjustments during the assessment process to elicit the relevant clinical signs. The Health and Care Act 2022 introduced a statutory requirement that regulated service providers must ensure their staff receive learning disability and autism training appropriate to their role. The Oliver McGowan Mandatory Training is the standardised training that was developed for this purpose, and is the government’s preferred and recommended training for health and social care staff. All healthcare professionals are required to undertake some of the e-learning, regardless of where they work within the health system.

David was a vulnerable adult who was dependent on an elderly parent, with no other apparent social support. The welfare of vulnerable adults is largely the responsibility of local authorities and other community agencies, yet David and his father did not have contact with social care services for four days or more. A proactive system of support to David and his father could have alerted services to the perilous state that they were in. NHS England can emphasise to member agencies of Integrated Care Partnerships their important role in supporting and safeguarding vulnerable families.

NEWS2 Scores

NEWS2 is the latest version of the National Early Warning System, first produced in 2012 and updated in December 2017, which advocates a system to standardise the assessment and response to acute illness.

1 LeDeR reviews are undertaken to review the health and social care received by people with a learning disability and autistic people (aged four years and over) who have died, using a standardised review process. They are undertaken by Integrated Care Systems.

NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital. An aggregated score of above 7 is considered high clinical risk and should trigger an urgent or emergency response by a clinician or team with competence in the assessment and treatment of acutely ill patients, including recognising when the escalation of care to a critical care team is appropriate. The response team must also include staff with critical care skills, including airway management. In this case, where a NEWS score of 8 or 9 was recorded consistently for a number of hours, the appropriate response does not seem to have been taken. In January 2019, NHS England, in partnership with NHS Improvement, Health Education England and the Royal College of Physicians, published the NEWS2 resource pack. Developed with clinical input, the pack provides access to tools and resources which support planning and delivery of NEWS2 implementation and illustrates practical examples of how it is being implemented across the country. Learning from serious incidents

Your Report also raised the concern that no internal investigation or other form of serious incident investigation was undertaken.

As referenced above, NHS England has a significant learning disability mortality review (LeDeR) programme which outlines a clear expectation that “Integrated Care Systems (ICSs) will be responsible for ensuring that LeDeR reviews are completed of the health and social care received by people with a learning disability and autistic people (aged four years and over) who have died, using the standardised review process”. A LeDeR review is currently in progress to look at the care delivered to David. In addition, NHS England’s Patient Safety Incident Response Framework (PSIRF) guidance ‘Guide to responding proportionately to patient safety incidents’ clearly sets out in Appendix A the ‘events requiring a specific type of response as set out in policies and regulations’. For deaths of persons with learning disabilities, trusts should ‘refer for Learning Disability Mortality Review (LeDeR)’ and the guidance notes that ‘Locally led PSII [patient safety incident investigation] (or other response) may be required alongside the LeDeR’. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of David, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear HM Coroner (Mr Edward Steele, Assistant Coroner) Regulation 28 Report following the inquest into the death of Mr David Christopher Peter Lodge. We are sorry to hear about the death of Mr Lodge and we offer our sincere condolences to his family. We provide the formal response of the Care Quality Commission (CQC) to the Regulation 28 Preventing Future Deaths report made by HM Coroner (Mr Edward Steele, Assistant Coroner) following the inquest into the death of Mr Lodge. (‘the Regulation 28 Report’).

In the Regulation 28 Preventing Future Deaths report HM Coroner raised the following concerns:

1. Pain is not accurately assessed in people who are unable to communicate with words. The court heard evidence that Mr Lodge at no point was provided pain relief, despite requests from the attending family member who was speaking on his behalf.

2. Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department. The treating physicians in evidence agreed that there should have been a high index of suspicion of pneumonia in Mr Lodge’s case and that it is one of the leading causes of death for people with learning disabilities. The court heard evidence that Mr Lodge did not have a chest examination carried out on him due to him not presenting any signs of respiratory distress.

3. NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30-minute observations were not being followed.

4. Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. This regulation 28 report sets out the following matters of concern for CQC to address.

The trust’s last comprehensive inspection was in November 2022 and the report was published in March 2023. CQC rated the trust as “Requires Improvement”. A copy of the report can be found on our website - Trust - RWA Hull University Teaching Hospitals NHS Trust (23/03/2023) INS2-13905362001 (cqc.org.uk)

During this inspection serious concerns were identified in Urgent and Emergency Care (UEC) that led to the CQC subsequently issuing an urgent enforcement action – Section 31 of the Health and Social Care Act 2008. The Commission had reasonable cause to believe that any person will or may be exposed to the risk of harm arriving from the following:
• The identification and management of deteriorating patients.
• The inability to demonstrate that fundamental standards of care are being met.
• Management of patients waiting within the department. Immediate assurances were requested by the CQC that the trust had mitigated the risks identified by 4th of November 2022. Assurances were provided and accepted by the CQC. The trust was required to submit an action plan by the 8th of November 2022 to indicate actions taken and any further steps to be taken to mitigate immediate risks to patient safety as identified above. This action plan was submitted, and accepted, by CQC within the required timeframe. The trust also provided details of the longer-term actions required to ensure the improvements would become sustained and embedded. The CQC continues to closely monitor progress against all action plans to ensure sustained improvement through regular engagement with the trust.

In addition to inspection activity the CQC attends a monthly Quality Improvement Group (QIG) chaired by NHS England, where the trust presents monthly updates against the CQC action plans and key priority areas. The purpose of the QIG is to support planning, coordination and facilitate the sustained delivery of actions to mitigate and address the quality risks within the trust.

CQC first became aware of the death of Mr Lodge on receipt of the Regulation 28 Report on 23 December 2024.

CQC asked Hull University Teaching Hospitals NHS Trust to provide evidence of any action they had taken to date following the tragic death of Mr Lodge and we are waiting for their response.

CQC will continue to closely monitor information we receive about the service. Where CQC identifies that regulations are not being met, we will use our enforcement powers to require improvements to be made.

CQC will also check the provider’s compliance with the regulations on our next inspection of the service using our new single assessment framework methodology in accordance with the CQC regulatory remit. CQC will highlight any repeated or new breaches of regulation and ask them to make necessary improvements. CQC’s next inspection of the service is not yet confirmed, however we have adopted a more risk-based approach to inspections should CQC receive negative intelligence or have further concerns about the service we would carry out responsive inspections. CQC hope that this response addresses your concerns.

Dear Mr Steele,

Re: Hull University Teaching Hospitals NHS Trust response to the Regulation 28 Report issued by His Majesty’s Assistant Coroner, Mr Edward Steele, dated, 23 December 2024

Thank you for sharing your report with us regarding the sad passing of Mr Lodge. Having considered your report carefully the Trust wish to provide a detailed update regarding the work carried out by the Trust since January 2022 which will hopefully alleviate any concerns you may have regarding the risk of future deaths. We take the matters raised in your report seriously and we hope this letter is helpful in outlining how we are committed to learning.

The Trust wish to express their sincere condolences to David’s family for their loss of not only David but his father Mr Peter Lodge.

In formulating this response, we have sought opinion from a number of professionals within the Trust.

Hull University Teaching Hospitals NHS Trust (HUTH) along with North Lincolnshire and Goole NHS FT (NLAG) have recently joined forces to create NHS Humber Health Partnership which has brought a wealth of expertise together to create structure and improvements to patient safety. The creation of NHS Humber Health Partnership has created more structure than ever before. Various groups from HUTH such as the Resuscitation, Deteriorating Patients and Sepsis Steering Group and the NLAG Resuscitation Committee have come together to share their knowledge and experiences and created a route of escalation to the

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Quality and Safety Committee. NHS Humber Health Partnership follow the NHSE model of prevent, identify, escalate and respond.

Since the coming together of the two Trusts a number of key work streams have been created, some of which are addressed below, including education, Martha’s Rule, and patient engagement. NHS Humber Health Partnership believe that Patient engagement is vital. Feedback from patients and families is being obtained and the information gathered is being used to develop our improvement strategy which will feed in to our work around sepsis and deteriorating patients. The Partnership has seen the setup of the Patient Engagement Work stream which was a subsidiary group from the Resuscitation, Deteriorating Patient and Sepsis Steering Group.

In addition, the Dementia Volunteers have also been instrumental in helping to gather patient feedback and there is a plan in place for the volunteers to assist with gathering feedback from learning disability patients and their carers.

Caring for Patients with Learning Disabilities
1. A Mental Health, Learning Disabilities and Autism Steering Group was established in 2020 and held bi-monthly meetings chaired by the Assistant Chief Nurse. The group was made up of staff from all health groups, Training and Development, Patient Experience, Allied Health, Dementia Team, Mental Health Liaison Team, Learning Disabilities Liaison Nurse, Governance, Human Resources, Information Services and the Safeguarding Teams. The group reported to the Trust Patient Experience Sub Committee until the last meeting in July
2024. Governance arrangements have now changed within the new NHS Humber Health Partnership and there are now five Operational Groups including, Vulnerabilities, Midwifery, Children Safeguarding, Adult Safeguarding and Looked After Children and each group feeds in any concerns raised to the Strategic Safeguarding Board. Following the Coroners Inquest the case of David Lodge has been raised and escalated to the Strategic Safeguarding Board.

2. In June 2020, the Safeguarding Adults team in consultation with the Community Learning Disabilities team established a reasonable adjustment admission pathway for David (digitally stored on Lorenzo) to ensure his needs were considered and where possible met for all repeat attendances at Hull University Teaching Hospitals.

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3. From May 2021 to date, Hull Clinical Commissioning Group has commissioned one fulltime equivalent Learning Disability Liaison Nurse role, hosted by Humber Teaching Foundation Trust with an honorary contract within Hull University Teaching Hospitals NHS Trust. There are posters printed and displayed in the Emergency Department to make staff aware of this role and the poster includes contact details so the team are able to contact if support is required.

4. The Learning Disability Liaison Nurse is based within the Safeguarding Adults team and provides support to patients, carers and their relatives. The Liaison Nurse supports the Trust and its clinical staff providing expert specialist advice pertaining to Learning Disabilities; this includes structured judgement reviews, patient safety and safeguarding investigations.

5. Due to the innovative role, the learning disability liaison nurse straddles acute and secondary care so can work closely with family, carers and the community Learning Disability team to ensure care is person-centred.

6. In June 2022 Hull University Teaching Hospitals collaborated with the ICB and partners to produce a standardised health passport for people with a learning disability which are brought in by the individual or carer and scanned into the electronic patient record programme, Lorenzo, in case of repeat attendances.

7. These improvements have been embedded and are in use across adults and children services alongside training compliance reviews.

8. Fundamental Standards Safeguarding audits have been in place across the organisation since
2021. This audit reviews both service users feedback and clinicians’ knowledge of safeguarding. Compliance over 2022 and 2023 is seen in the table below.

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8/4/22 Emergency Care X 2 documents – v1.5 96% 28/4/22 AMU X 1 document – v1.5 91% 29/9/22 Emergency Care X 1 document – v1.5 92% 13/10/22 ED Majors X 1 document – v1.5 100% 8/9/22 AMU X 1 document – v1.5 91% 28/4/23 AMU X 1 document – v1.6 91% 19/6/23 Emergency Care X1 document – v1.6 100% 6/10/23 Emergency Care X1 document – v1 ED specific 99% 9/10/23 ED Majors X1 document – v1 ED specific 99%

9. In 2022, a virtual ward for learning disability and safeguarding was developed within the electronic nursing records. Once a learning disability diagnosis is recorded, an electronic flag for learning disabilities remains in place and is pulled through to future episodes of care within HUTH. This mechanism allows the adult safeguarding team and learning disability liaison nurse to identify patients quickly following their admission and then contact the wards (mon- fri) to provide specialist support and advice on reasonable adjustments and care.

10. In 2018/19 NHSE/NHSi introduced a national benchmarking exercise to audit the performance against the learning disability improvement standards across NHS organisations. These improvement standards reflect the strategic objectives and priorities in national publications, for example Transforming Care for People with Learning Disabilities and Learning Disability Mortality Review (LeDeR).

11. The Trust has completed this yearly audit and actioned findings. Learning from best practice saw the introduction of the Northeast and Cumbria Learning Disabilities Diamond Standard Acute Care Pathway in 2022/23 in the emergency department, planned admissions and outpatient attendances.

12. The Diamond Standard work supported immediate improvements within the emergency

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department by accommodating the individual with learning disabilities and/or autism into quieter areas or side rooms and aim to triage, treat and discharge or admit the individual rapidly to reduce waiting times and avoid distress.

13. As a Trust we are now rolling out, as of January 2025 the Oliver McGowan mandatory training on Learning Disability and Autism. The training is named after Oliver McGowan, whose death shone a light on the need for health and social care staff to have better training. The Health and Care Act 2022 introduced a statutory requirement that regulated service providers must ensure their staff receive learning disability and autism training appropriate to their role. The Trust provide the Government's preferred and recommended training for health and social care staff.

14. Oliver's Training also supports the NHS Long Term Workforce Plan ambition by upskilling the wider health and care workforce to provide appropriately adjusted care for people with a learning disability and autistic people to reduce health inequality. The Trusts aim in providing the training to all staff is to prevent avoidable deaths like Oliver’s from happening again.

15. The first phase of the training programme was rolled out to all staff within the ED department.

The matters of concern raised are addressed as follows:

A concern that pain is not being accurately assessed in people who are unable to communicate using words.

16. In 2001, Clinical Guideline 171, Guideline for Acute and Peri-Operative Pain Relief in Adult Patients provided clinicians with the Abbey Pain Scale and the DisDAT assessment tools for use in practice. The Abbey Pain Scale was developed for patients who cannot verbalise pain and the DisDAT tool is for patients with learning difficulties to support assessment of distress and discomfort.

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17. Compliance with Guideline 171 is completed by way of yearly audits undertaken by the Acute Pain Team.

18. The Acute Pain Team assess and provide advice to Clinicians and Nurses on referral in relation to effective pain management for patients during their hospital admission across the Trust. The team offer effective pain control to both surgical and medical inpatients.

19. The Acute Pain Team also provide training to doctors, nurses and other health professionals in effective pain management. The Clinicians and Nurses have access to online training and face to face training is also held at various times though out the year. Training sessions are provided at Induction for Junior Doctors which is mandatory and further mandatory training is provided at Junior Doctors 6 month turn round. The Junior Doctors also receive additional information pain assessment and pain control for their reference which they can take away with them following the training sessions.

20. The Acute Pain Team also provide specific training to Clinicians twice yearly and training is also provided to the ICU department on average twice yearly. Reference is made to the Abbey Pain Scale during all training sessions provided.

21. In addition to the training highlighted above, face to face bespoke training in pain assessment is delivered by the Acute Pain Team when requested by specific hospital departments.

22. There is an eLearning Pain Assessment module on HUTH’s training platform (HEY247). Up to December 2024 317 staff had completed this module, 36 of whom are based in the emergency department or acute assessment unit. On the 27 February 2025 it was agreed at the Learning and Organisational Steering Group meeting that the eLearning module for pain assessment will be mandated across the Trust for all registered Nurses.

23. Further work to improve the use of the Abbey Pain Scale by clinicians has been undertaken. This includes a Standard Operating Procedure, a ‘How to..’ guide and cascade training with targeted areas including the Emergency Department Clinical Nurse Educators.

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24. The role of the Clinical Nurse Educators is to provide knowledge and skills to the nursing team relevant to the urgent and emergency care service. The team keep abreast of changes in practice and responds through policy and guidance updates. They provide induction training to new starters and will support members of the team facing additional education needs.

25. In addition to the training provided, as outlined above, following the 2022 CQC inspection (published March 2023), the trust acknowledged that pain assessment was not consistently assessed for patients who were non-verbal and/or unable to use the visual pain assessment scale. In response the Acute Pain Team implemented an action plan to address the issues raised which included the following in addition to other action taken.

• Laminated posters regarding pain assessment and general management of pain and The Abbey Pain Assessment Tool (including QR codes for the SOP, the record chart and guide to opioid prescribing) were distributed to every ward and department across the Trust to be prominently displayed on the ward.

• An email was distributed to the Senior Executive Nursing Team, all Matron's, Band 7 and 6s across the Trust, instructing that the posters were displayed in staff rooms, work stations and anywhere that is visible for the clinical team to access.

• The Trust created and handed out credit card sized laminated guides which can be carried in ID badges regarding pain assessment tools and the basic analgesic ladder. The laminated guides were distributed to staff on the wards and at the Link Nurse meeting. A Link Nurse Meeting is a meeting which is held once per year and the last meeting was held in October 2024. Link Nurse’s have responsibility to upgrade their knowledge which is then disseminated to all staff and staff can refer to the Link Nurse with their particular questions. At this meeting work around pain assessment was the main focus along with training on the Abbey Pain Assessment tool.

• A blog was posted on the Trust intranet explaining pain assessment scales and the types of tools which are used in the Trust. The blog highlights the posters which have been distributed and how to use the QR codes to find information regarding the Abbey

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Pain Assessment Tool. There is also advice about completing the e-learning module available on the Trust intranet regarding Pain Assessment.

26. The Acute Pain Team continue to work with the ICU Department to ensure that appropriate assessment is conducted for all patients, including those ventilated or sedated, with the possibility of developing a QR code for the on-line Critical Care Pain Observation Tool (CPOT). CPOT tool is a tool for assessing pain in ventilated patients and is used in the ICU department which staff can access and use when assessing pain. An email was sent in May 2024 to all Critical Care Staff to remind staff of the CPOT tool in Level 3 care. In addition the CPOT observation tool was laminated and a copy is kept at each bedside for reference with additional guidance for staff to follow. The Pain Link Team went through the CPOT tool with each member of staff. In May 2022, the Trust introduced electronic recording as part of its move towards a paper light organisation. Nervecentre was introduced to record clinicians’ documentation and assessments. This included the recording of National Early Warning Score (NEWS). Within the NEWS module was the mandatory recording of the standard pain assessment. This is a verbal response by the patient who describes their experience of pain between zero (no pain) and three (severe pain).

27. In April 2024, Hull University Teaching Hospitals Acute Pain Team completed an audit to review progress regarding the assessment of pain. The results produced from the Emergency Department audit showed that pain was being assessed in 100% of cases. However the audit demonstrated awareness of the Abbey Pain Assessment tool remained low. This concern was escalated to the Chief Nurse, Corporate Patient Experience Committee. At the time there was no distinction in relation to which pain tool was being used and therefore further action was taken in November 2024 as indicated below in terms of changes on Nervecentre.

28. In response, the Acute Pain Team proceeded to complete two Quality Improvement Projects (QIP’s) on awareness and promoting the use of the Abbey Pain Tool.
a. QIP 1 – aimed at peri-operative staff within theatres, anaesthetics and the critical care service.
b. QIP 2 – aimed at medicine and care of the elderly teams

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29. Both QIPs included the Acute Pain Team attending induction training for new starters, teaching sessions, poster campaigns, drop-in sessions and attendance at governance meetings. Results have demonstrated a good increase in awareness across all staffing groups.

30. In November 2024, a stand-alone pain assessment measure section, not as part of the NEWS assessment, was introduced into Nervecentre in response to provide equitable pain assessment for all patients. Nervecentre was amended to enable clinicians to electronically record pain assessment when using an ‘alternative tool’, for example the Abbey Pain Assessment Tool or the Visual Pain Assessment Tool to ensure patients who require a reasonable adjustment to accurately assess their pain was accurately recorded.

31. A supporting Standard Operating Procedure was written along with a ‘How to..’ guide to support clinicians using the new standard pain assessment module to ensure clinicians are patient-focused by using the correct pain assessment tool for their patients communication/reasonable adjustment needs. In relation to the Abbey pain assessment there is a link to the presentation online and the documentation is available via the QR code.

32. Whilst it is too early to tell if this has resulted in a demonstrable improvement of clinician’s pain assessments, the Acute Pain and Digital Teams will continue to audit and monitor the progress and plan to convert the paper-based Abbey Pain Assessment Tool to an electronic version.

33. Further audit priorities are to include the quality of assessment and corresponding analgesic provision and evaluation. This will be led by the Lead Nurse for Vulnerabilities, supported by the Learning Disabilities Liaison Nurse.

A concern that basic examinations are not being carried out for learning disabled adults at risk of pneumonia in the Emergency Department.

34. The Emergency Department has adopted the Royal College of Emergency Medicine Learning Disabilities Toolkit, following the conclusion of the inquest.

35. Basic examinations, including a chest or respiratory system examination, are routinely carried out in the Emergency Department and are part of the routine physical examination of a patient that presents with symptoms or signs that require such assessment, including those who are

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at risk of pneumonia. Appropriate clinical examinations are carried out, as recommended and taught in clinical education. It is clinical judgment as to whether a patient requires a chest examination or other examination.

36. Basic examinations are undertaken on all patients and safe methods would be used to ensure that it is done effectively and appropriately across all groups of patients.

37. If examination of the chest is essential but not possible, the clinician would weigh the risks/benefits of sedating or restraining the patient in order to perform this. This would be if that particular examination is essential in the management of the patient. In situations where any examination or treatment is essential and the patient is agitated or disturbed, the Royal College of Emergency Medicine has published the Best Practice Guidance on Acute Behavioural Disturbance which provides necessary guidance. This guidance is utilised by clinicians in the Emergency Department.

38. The Emergency Department has not identified any evidence to suggest that basic examinations are not being carried out specifically in patients with learning disabilities. Nevertheless the Emergency Department and the Trust continually reflect on how the care and treatment can be improved for patients with learning disabilities.

A concern that NEWS2 scores above 7 are not appropriately escalated.

39. The Emergency Department follows the CP326: Recognition of the Deteriorating Adult Patient Policy. This is a Trust wide policy and is therefore also used outside of the Emergency Department.

40. The Policy has recently been reviewed and is in the final stages of the Trust Governance approval processes. It is expected that the updated policy will be signed off in May 2025. The policy has been updated to include the Trust NEWS2 Score Escalation Ladder which incorporates an additional step when assessing a patients NEWS2 score. The additional step takes in to account the family or carer’s views and concerns about a patient’s physical wellbeing, or any other abnormal parameters despite normal NEWS2 e.g, reduced urine output, deranged blood results, mottled limbs or just a gut feeling. If there is a concern raised,

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41. that would then result in an increased frequency of monitoring and observations would be rechecked after any interventions or every 15 minutes. If the Clinician doesn’t respond to concerns raised staff are directed to contact the Consultant in Charge.

42. The updated policy provides clear guidelines on the escalation process in terms of who to escalate to and what the response time should be. The response times will be in accordance with the National Guidelines.

43. The above policy update is also in line with ‘Martha’s Rule’, which is a major NHS England patient safety initiative providing patients and families with a way to seek an urgent review if their own or loved one’s condition deteriorates and they are concerned this is not being responded to. HUTH are not part of the NHS England Trust Pilot scheme which ends at the end of March 2024. However, the Trust have attended all of the NHS England conferences regarding Martha’s Rule and have adopted the nationally recognised patient wellness questionnaire which is being trialled within the Trust and which we are working hard to embed. The Trust have already seen some referral’s under Martha’s Rule to the Critical Care Outreach Team (CCOT). The Trust are committed to empowering patient, families, carers and staff, including Nurses and Juniors Doctors to ensure their concerns are listened to and acted upon. Martha’s Rule is also there to encourage and empower staff to have the ability to raise concerns outside of the official escalation channels.

44. In addition to and alongside the above policy update a separate Trust Standard Operating Procedure (SOP) to incorporate Martha’s Rule will be introduced. The wording of the SOP will follow NHS England’s recommendations. It is anticipated that if concerns are raised and no action is taken or the action taken is deemed insufficient the patient could be escalated directly to the critical care team for assessment. Under Martha’s Rule the patient or their family will not require the treating Doctors opinion to contact the Critical Care Outreach team.

45. In addition, as is already the case, if a patient’s care has been escalated to the Critical Care Outreach Team and then stepped down, due to an improvement in presentation, patients are always reminded that if they have any further concerns they can ask the nurse or switchboard to bleep the CCOT to re-escalate and they do not have to go through a Clinician to do this.

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46. Each time there is an escalation under Martha’s Rule a Trust DATIX will be raised to monitor trends, gather evidence of clinical incidences and highlight issues and concerns in Trust processes.

47. Training on the topic of deteriorating patients was provided to all staff until September 2024, however, the training had to be stalled due to unforeseen circumstances. The monthly training is due to resume in April 2025 in time for the updated policy roll out.

48. In addition to the monthly training outlined above the Nurses Training in Simulation and Sepsis team (NUT-S), have been running training sessions since 2022. The NUTS-S team was created off the back of the incident involving Mr Lodge which prompted the development of learning and the NUTS-S team have used Mr Lodge’s case as a simulated example within the training sessions. The training was developed by the Trust’s Deputy Director, Hull Institute of Learning and Simulation which began as a Pilot training session and was first delivered to the Nurses in the Acute Medicine Department and was later rolled out to include the Nursing Team within the Emergency Department and it is now Trust wide. The training covers different scenarios, however the structure and focus is always the same and includes a patient who shows signs of deterioration. The focus of the training is to assess, recognise deterioration and escalate and there is always a discussion around the human factors. The training is delivered by the Trust Approved Nurse Fellow in simulation. An example of the simulation training would include a patient with learning difficulties who is unable to express pain, with a NEWS2 sore of 7 and who is showing signs of deterioration. The NUTS-S team continues to run weekly training sessions which are Trust wide and can be department focused if there are specific issues identified regarding identifying deteriorating patients.

49. The aim of the Trust team is for the training to become mandatory and discussions are being held with the Trust in this regard. In 2024 the NUTS-S team began work on developing the training further with the aim of rolling out the training to multi professionals working in high risk areas and dealing with deteriorating patients and a business case has been presented to the Board for approval. The overall aim of the training is to improve patient safety.

50. A Task and Finish Group has also been set up to make sure education meets the needs of all staff groups including medical staff, nursing staff and Health Care Support Workers who come into contact with a deteriorating patient and also to cover learning outcomes relating to sepsis.

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51. In relation to Sepsis the Trust has carried out a substantial amount of work in the Acute Assessment Unit and the Emergency Department and data is collected on a daily basis relating to sepsis screening and the implementation of the correct management. Since the recent changes to NICE guidance the Trust have updated their policy and screening tools and created digital versions.

52. Over the last 18-24 months many changes have been implemented in the Emergency Department for incoming patients who need prompt treatment. The Emergency Department at present have 2 out of 8 bays within the initial assessment area which are earmarked for quick assessment and treatment. These are used, when capacity allows, for patients who are clinically unwell and may have a high NEWS. This allows for closer supervision and quick assessment of these patients.

53. The Emergency Department have also introduced an Escalation Clinician and Safety Nurse to support the escalation and management of patients that are deteriorating or have deteriorated. They are designated on every shift and their role would include responding to escalation, reviewing and treating patients. This is in addition to nursing staff escalating any patient with a high NEWS or those they have clinical concerns about. The role of the designated ‘Escalation Clinician’ is to respond to any escalating concerns as soon as possible.

54. The Emergency Department have also introduced a Sepsis Champion on every shift, a role performed by an F2 grade clinician, who will ensure that those identified with possible sepsis are treated appropriately.

55. At the streaming desk in the Emergency Department (walk-in area) there is always at least a band 6 nurse whose role is to escalate any clinical concerns immediately to the appropriate clinician if they identify any patient who is self-presenting and needs urgent review.

56. Patients with high NEWS in the Emergency Department are initially managed by the clinicians in the Emergency Department, with the support of or the direct involvement from registrars or consultants. If it is felt that their care would need the expertise and resources beyond the ED, the care is then escalated to the speciality teams and/or ICU as clinically required.

United by Compassion: Driving for Excellence.

Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust

57. In addition we have seen the introduction of the High Observation Bay (HOB) in AMU which is for higher acuity patients who are placed in the bay with a higher nursing ratio.

52. The Emergency Department continue to be under significant pressures due to capacity. All the above measures are in place to minimise the risk of NEWS scores not being appropriately escalated. The Trust will continue to monitor the effectiveness of the measures that have been implemented.

A concern that opportunities for learning from serious incidents are being lost.

53. Information of Davids death was provided by the emergency department to the Mental Capacity Act lead. No concerns were raised regarding omissions in care or treatment during the hours spent at Hull University Teaching Hospitals. A safeguarding concern was submitted to the relevant Local Authority for investigation due to the pathway of admission and prior knowledge of community safeguarding issues. Mr Lodge’s death was also reported to LeDeR who confirmed that a review of care would be completed at the conclusion of the inquest.

54. Serious Incidents are declared following a patient safety event whereby the severity of harm caused is determined to be moderate or higher. Harm was not deemed to have been caused by Hull University Teaching Hospitals therefore a serious incident was not declared.

55. However, since Mr Lodge’s death, Trust process and procedure has developed and going forward a Structured Judgement Review (SJR) is completed for all patient’s with identified learning disabilities and who sadly pass away while receiving care and treatment at the Trust. The SJR will be completed by the Vulnerabilities and Enhanced Care. The SJR will be completed despite the outcome of the initial clinical review of the care and treatment provided and despite the outcome of the decision from LeDeR in terms of their investigation.

56. The Trust hold Weekly Patient Safety Summit (WPSS) meetings to discuss patient safety concerns. Senior Clinical and Nursing staff as well as Clinical and Governance Leads from the Care Groups all attend this meeting.

57. Service condition 26 of the NHS Standard Contract requires any provider of services to the NHS to participate in the projects within the National Clinical Audit and Patient Outcomes

United by Compassion: Driving for Excellence.

Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust

58. Programme relevant to the Services. This includes the Learning Disabilities Mortality Review programme (LeDeR) of which NHS Humber Health Partnership is a member of the Humber Steering Group. Mr Lodge’s case was referred to LeDeR prior to the inquest and action was to be considered following the conclusion of the inquest. The Trust are aware that the LeDeR Panel Review Group are carrying out of full review of the care and treatment Mr Lodge received. The Panel Review Group meet every two weeks and the action plan ensuing from the review, which relates to the Trust will be monitored at the Panel Review meetings. The action plan across the ICB would be managed by the Humber Steering Group.

59. The Humber LeDeR Steering Group have developed learning briefings with good practice and areas for improvement presented from reviews that have occurred across the Humber region in both primary and secondary care. These briefings are shared at the internal Mental Health, Learning Disability & Autism Steering Group, internal End of Life Steering Group and with the Trusts mortality team manager. In addition, the briefings are made available on the Trust Learning Disabilities intranet website for staff to access.

60. Learning from the Humber LeDeR briefings that are directly related to the Trust are discussed, with subsequent improvement actions and implementation plans agreed and monitored at the Mental Health, Learning Disability & Autism Steering Group. . We trust this responds to the matters raised within the prevention of future deaths report.