Dear Ms Lee Regulation 28 Report _ Mr_John Doyle Thank you for your email of 12 November 2024 enclosing Regulation 28 Report to Prevent Future Deaths which is addressed to a number of organisations which include University Hospitals Coventry and Warwickshire NHS Trust (UHCW) following the inquest into the death of Mr Doyle: As you are aware from the evidence of the medical witnesses at the inquest on 8 November 2024 the renal team at UHCW have been developing guidelines to assist George Eliot Hospital (GEH), non-renal specialist hospital, in the management of acutely unwell kidney transplant renal inpatients. are pleased to report that these guidelines have been finalised and agreed between the Trusts and we enclose a copy_ These guidelines have been shared and cascaded within the respective clinical teams which includes discussion as the Trust's Renal Quality Improvement and Patient Safety meeting (QIPS) Once ratified through the usual governance processes these guidelines will be placed on the Trust's intranet to be accessible to all staff. In addition both Trusts have agreed a Service Level Agreement (SLA) which means that a member of UHCW's renal team will attend GEH and review their renal inpatients on GEH request up to twice week: One of our senior Transplant Nephrologists has liaised with UK Kidney Association who are in agreement with the measures taken by UHCW and GEH in response to this report: We believe these combined measures address the concerns set out in your Report and will undoubtedly improve patient care and lead to better collaborative working Chief Executive Officer: Chair: We

Taking the concerns that you have raised in turn we respond as follows: Concern 1: Contacting Specialist Centres The SLA between the Trusts enables GEH to contact the UHCW renal team and request an on-site attendance_ This will mean that a UHCW nephrologist will attend to review renal patients where their input is required up to twice a week In addition, the current processes for GEH to contact specialist have been outlined in the guidelines, including conta the renal team and also the virology team: Concern 2: Information Sharing with Specialist Centres The SLA and guideline set up a clear framework to ensure good communication between the Trusts including timely investigation and treatment; Additionally, processes to document communication between renal department and other hospitals, "referapatient org" is being considered. Concern 3: Accessibility to Renal Care Guidelines The guidelines have been agreed with the relevant departments and shared with GEH: Both UHCW and GEH have worked closely to ensure the guidelines communicate the relevant information in an easily understandable manner, whilst ensuring the urgency is conveyed_ Guidelines have been cascaded within the respective clinical teams and will be placed on the UHCW intranet once have been through the governance process for ratification: Concern 4: Transfer Responsibility The SLA which provides that a renal specialist will attend GEH on request should help identify those patients requiring urgent transfer. UHCW will be responsible to accept all renal patients admitted to GEH, regardless of their parent hospital. In addition the internal processes to highlight which patients need urgent transfer have been changed (we now have a daily huddle at 11.30am with the UHCW Medicine Operational team where a renal doctor is present; so that interhospital transfers can be highlighted and appropriately prioritised). Concern 5: Decision-Making for Patient Location The SLA will support decision-making for patient location by ensuring face to face communication between senior medical staff from UHCW and GEH_ We anticipate that the guideline will also support this, in that investigations and results will be more timely available and reviewed_ Concern 6: Coordination Between Specialist and Non-Specialist Hospitals It is usually the case that a non-specialist hospital will contact the parent specialist hospital where that particular patient has been having their routine renal care_ However, following this Regulation 28_ UHCW will now be the primary specialist transfer centre for all renal patients admitted to GEH regardless of their parent specialist unit: The agreed shared guidelines and SLA will ensure closer working and improved patient care. Chief Executive Officer: Chair: cting they

Please do not hesitate to in contact should any further information be required.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – John Frederick Doyle who died on 30 December 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12 November 2024 concerning the death of John Frederick Doyle on 30 December 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to John’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about John’s care have been listened to and reflected upon.

Your report raises concerns about a lack of understanding and awareness from non- specialist medical staff as to when and how to contact specialist renal hospitals. You have also raised concerns around coordination and consistency of care provided to patients as they are transferred from non-specialist hospitals to renal hospitals, as well as the information which is being provided to patients about their care and the options available. Renal services are covered by NHS specialised commissioning services. A specialist Clinical Reference Group have developed service specifications that clearly define the standards of care expected from organisations providing specialist care for patients who undergo kidney transplantation, as well as patients with acute kidney injuries or those undergoing dialysis. Further information can be found here: NHS commissioning » Renal services. Renal medicine is a specialist service that is delegated to individual Integrated Care Boards. My regional colleagues in the Midlands have been sighted on your Report, and have shared it with Coventry and Warwickshire ICB, for the appropriate oversight. Getting It Right First Time (GIRFT) is a national NHS England programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change. The Renal Medicine GIRFT also highlights the importance of having clear pathways in place:

Medicine-Sept21k.pdf National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

7 January 2025

I note that your Report has also been sent to University Hospitals Coventry and Warwickshire NHS Trust (UHCW) and George Eliot Hospital NHS Trust (GEH). It is appropriate that the providers involved in John’s care respond to the Coroner regarding the concerns raised which relate to local arrangements and process. NHS England has asked to be sighted on their responses and will consider these in due course and whether any further actions are required from our Specialised Commissioning Teams. 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 John, 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 Mrs Lee, Re: Response to Regulation 28 Report to prevent future deaths following the inquest into the death of John Frederick Doyle. Following your email request received on 12th November 2024, the UK Kidney Association (UKKA; formerly the Renal Association) and the British Transplantation Society (BTS) have collaborated and produced the following recommendations in response to your concerns. Contacting off-site specialists and sharing information
• We recommend that all hospital switchboards, Emergency Departments and relevant personnel have a master copy of local specialist centre contact details so any query at any time can be appropriately directed.
• We recommend that all staff are advised of internal escalation routes. Relevant clinical colleagues should be aware of internal escalation routes to clarify whether off-site specialist input is required. We would expect this to be achieved by asking the Consultant responsible for the patient’s care or their deputy.
• We advise that electronic information sharing in real-time should be the gold standard for information sharing. In the case of kidney patients, we would expect to be informed about all patients admitted for care in another hospital or elsewhere in our own hospital who have chronic kidney disease stage 5 (CKD G5) or who are receiving dialysis treatment or who have a kidney transplant.
• We advise that Trusts review their processes to ensure that CMV results are available in a timely fashion. This involves considering the transport and turnaround of samples with prompt reporting in specialist virology laboratories as well as how to ensure that blood is taken in the correct blood tubes. Accessibility to Renal Care Guidelines
• As access to Guidelines could lead to a misunderstanding of the significance and urgency of required actions; the critical action in this case would be to contact the Specialist Centre.
• Whilst we acknowledge that being well-informed can help with communication and care delivery, in this case we would advise that care be delivered by a Specialist who should not necessarily need to refer to the Guidelines. Transfer of responsibility, care coordination and decision-making for patient location
• We recommend that when a Specialist Team is managing the care of a particular condition at a distance or on-site, they assume responsibility for recommending the best location for

The UK Kidney Association (UKKA) is a trading name of the Renal Association, a registered charity (no 800733) and a company limited by guarantee, registered in England and Wales under company number 2229663.

care delivery. This may require careful negotiation in cases where multiple conditions are being managed.
• We recommend that the responsible Specialist Team is from the local specialist renal centre rather than the renal centre usually caring for the patient. If necessary, local specialists can liaise directly with the relevant renal centre.

Action points for the UKKA and BTS Each organisation is to take the following actions.
1. Share recommendations with the kidney care and transplant communities.
2. Contact patient associations to assist with considering the role of patients and their carers in highlighting where their specialist care is undertaken/provided and who to contact.
3. Share with the Royal College of Physicians Patient Safety Committee.

As the UKKA and BTS do not have responsibility for the care of patients with other conditions who will be similarly at risk, we recommend that the Coroner considers how to escalate issues of specialist care provision in hospitals at a national level.

Dear Ms Lee

RE: REGULATION 28 REPORT – JOHN DOYLE

Further to your report dated the 12 November 2024, in accordance with paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009 and the regulations 28 and 29 of the Coroner’s (investigations) Regulations 2013, I offer the following response:-

As reported on the day of the inquest (8th November 2024) the University Hospitals of Coventry & Warwickshire (UHCW) were compiling guidelines to assist the George Eliot Hospital (GEH) should the Trust have an inpatient with similar health conditions in the future as there is no renal specialist service at the GEH.

The Trust has now received management guidelines from the Renal Team at UHCW and below is a table showing what actions the Trust has taken to embed the information received.

Description Action Taken New guidelines to be made easily accessible on the Trust’s intranet Guidelines have been developed and are currently going through the Trust’s ratification process prior to uploading on to the Trust’s intranet. Quick reference guidelines for management of acute unwell kidney transplant recipients have been produced (a laminated poster will be displayed in clinical areas) Posters have been shared for dissemination with the Directorate Governance Leads on the 12 December 2024. These will be discussed at the Directorate Governance Meeting. Guidelines to be discussed at the daily doctors briefing Information on the new guidelines and how to access them formed part of the daily brief for wards and departments from the 16 to the 20 December
2024. On the 17 December the guidelines and quick reference was e-mailed to all doctors and consultants. This will be reiterated at the Doctors Grand Round To be discussed at all Trust wide Governance meetings for them to share with all consultants/relevant members of staff Shared with all Directorate Governance Leads on the 12 December 2024 for dissemination.

Making staff aware of the referral process asking UHCW renal staff to visit a patient on the ward This is in the guidelines and is a consultant to consultant referral process. The process has been shared as per above.

Your concerns were:-

1. Contacting Specialist Centres Following the inquest on 8 November 2024, our Consultant Governance Lead for the Medicine Directorate has continued to liaise with the Consultant Renal Specialist at UHCW to develop robust joint clinical guidelines. GEH will take every case individually as they present and will also contact the appropriate Trust where the patient is receiving their renal care. As well as guidelines from UHCW a laminated quick reference guide has been produced which contains the emergency contact numbers for renal services at UHCW. This will be displayed across the Trust.

Patients who are pregnant with on-going renal conditions/transplant would be transferred to UHCW as part of the Maternal Medicine Pathway.

2. Information Sharing with Specialist Centres The guidelines (enclosure 1) illustrate the sample collection requirements, together with what to do if the results are positive and the telephone numbers to be used. Clinical staff will liaise at the earliest with the specialist centre as results dictate. This is documented on the enclosed guideline.

3. Accessibility to Renal Care and Guidelines The guidelines provided by UHCW will be available on the intranet once the Trust’s ratification process has been followed. Guidelines have already been shared with all Directorates to make sure that the relevant clinical staff are aware of the guidelines.

4. Transfer Responsibility Consultant to consultant clinical conversations will take place if there is a requirement to transfer the patient to the renal centre. There is a Service Level Agreement (SLA) in place for a renal specialist from UHCW to visit renal patients being cared for a GEH, twice a week. This patient familiarisation will assist in the timely transfer process should the patient need to be relocated to the specialist centre.

5. Decision Making For Patient Location There is a consultant to consultant referral process in place where decisions are made on the location based on the patients clinical need.

6. Co-Ordination Between Specialist and Non-Specialist Hospitals. The guidelines from UHCW are very clear on when they should be invoked and the quick reference guides will make it easier for GEH staff.

I hope this answers your outstanding concerns, but please do not hesitate to contact me if you require any clarification.

Dear Ms Lee Regulation 28 Report – Mr John Doyle Thank you for your email of 9 January 2025. In response to the additional points raised by the UK Kidney Association (UKKA) and the British Transplantation Society (BTS) in their letter dated 21 December 2024, we comment as below: Contacting off-site specialists and sharing information
• We recommend that all hospital switchboards, Emergency Departments and relevant personnel have a master copy of local specialist centre contact details so any query at any time can be appropriately directed. Whilst this is a question that is best answered by our local non specialist hospitals, we are aware that both South Warwickshire NHS Foundation Trust and George Eliot Hospital switchboards and their Emergency Departments have local specialist centre contact details.
• We recommend that all staff are advised of internal escalation routes. Relevant clinical colleagues should be aware of internal escalation routes to clarify whether off-site specialist input is required. We would expect this to be achieved by asking the Consultant responsible for the patient’s care or their deputy. We confirm that staff at UHCW are aware of internal escalation routes. The escalation of concerns is via the renal registrar and renal consultant. We confirm that UHCW has shared and agreed with George Eliot Hospitals the indications for referral to us as a specialist unit, and the routes for referral.
• We advise that electronic information sharing in real-time should be the gold standard for information sharing. In the case of kidney patients, we would expect to be informed about all patients admitted for care in another hospital or elsewhere in our own hospital who have chronic kidney disease stage 5 (CKD G5) or who are receiving dialysis treatment or who have a kidney transplant. University Hospital Clifford Bridge Road Walsgrave Coventry CV2 2DX Direct Line:

Chief Executive Officer:

Chair:

There is an established and effective process for referring patients who are receiving dialysis to their parent unit. UHCW has Service Level Agreements with George Eliot Hospital and with South Warwickshire Foundation Trust that UHCW will provide onsite Renal Consultant Specialist inpatient review at GEH and SWFT upon request up to twice a week. Additionally, UHCW has worked with UK Kidney Association and agreed to be the primary specialist transfer centre for all renal transplant patients admitted from referring hospitals regardless of their parent specialist unit.

Electronic patient sharing of blood test results in real-time exists for patients who are already known to UHCW Renal Department, whether admitted to GEH or SWFT. In addition, “referapatient.org” is being considered as a means of recording communication between referring centres and UHCW in real time.

• We advise that Trusts review their processes to ensure that CMV results are available in a timely fashion. This involves considering the transport and turnaround of samples with prompt reporting in specialist virology laboratories as well as how to ensure that blood is taken in the correct blood tubes. Following the sad death of Mr Doyle, UHCW Renal and Virology teams have reviewed processes. Guidelines have been developed which describe: the correct blood tubes, how to ensure urgent turnaround, who to contact, when, and how to escalate to These have been shared with GEH. Turnaround times for all pathology labs are published in CWPS Handbook V16 May 2024.pdf.

Accessibility to Renal Care Guidelines

• As access to Guidelines could lead to a misunderstanding of the significance and urgency of required actions; the critical action in this case would be to contact the Specialist Centre

We agree with the UKKA and Royal College response.

• Whilst we acknowledge that being well-informed can help with communication and care delivery, in this case we would advise that care be delivered by a Specialist who should not necessarily need to refer to the Guidelines.

We agree the UKKA and Royal College response. In addition to our established process of contacting the specialist team by phone, reinstating the SLAs ensures that referring centres can ask for specialist consultant review onsite. Both communications support early and appropriate treatment and transfer if needed.

Transfer of responsibility, care coordination and decision-making for patient location

• We recommend that when a Specialist Team is managing the care of a particular condition at a distance or on-site, they assume responsibility for recommending the best location for care delivery. This may require careful negotiation in cases where multiple conditions are being managed.

We accept the responsibility for recommending best location for all patients referred to Renal Services. Based on the clinical requirements patients could be transferred to UHCW or reviewed by the UHCW renal consultant at the local hospital and transferred over later if necessary.

• We recommend that the responsible Specialist Team is from the local specialist renal centre rather than the renal centre usually caring for the patient. If necessary, local specialists can liaise directly with the relevant renal centre.

Chief Executive Officer:

Chair:

It is usually the case that a non-specialist hospital will contact the parent specialist hospital where that patient has been receiving their routine renal care. However, as a result of this Regulation 28, UHCW will now be the primary specialist transfer centre for all renal patients admitted to peripheral hospitals regardless of their parent specialist unit. The agreed shared guidelines and SLA will ensure closer working and improved patient care.

Action points for the UKKA and BTS

Each organisation is to take the following actions.

1. Share recommendations with the kidney care and transplant communities.

2. Contact patient associations to assist with considering the role of patients and their carers in highlighting where their specialist care is undertaken/provided and who to contact.

3. Share with the Royal College of Physicians Patient Safety Committee. We note that the 3 points above are for consideration of the UKKA and the BTS and therefore make no comment.

Please do not hesitate to get in contact should any further information be required.

Dear Ms Lee RE: REGULATION 28 REPORT JOHN DOYLE Further to your e-mail dated the 9 January 2025, am writing to confirm that the Trust has considered the response from UK Kidney Association (UKKA) and the British Transplantation Society (BTS) and we believe that the Trust had covered everything in our original response, with 2 exceptions_ The first recommendation is ensuring switchboard have master copy of local specialist centre contact details and the Trust can confirm that this action has been taken 3 This recommendation is about notifying UKKA of all patients with chronic kidney stage 5 (CDK G5) or who are receiving dialysis treatment or who have kidney transplant: University Hospitals of Coventry & Warwickshire update UKKA as the specialist centre for this specialty The three action points at the end of the letter are for UKKA and BTS to undertake, however; confirm that the Trust has received and acknowledged them Please do not hesitate to contact me if | can be of further assistance_