Dear Mr Cohen

Re: North Cumbria Integrated Care NHS Foundation Trust’s (“the Trust”) Regulation 28 Response concerning the Inquest into the death of Ms Gillian Austin

I write following the inquest that you resumed on 08/08/2024 into the death of Ms Gillian Austin at the Coroner’s Court in Cockermouth. You concluded that Ms Austin sadly died on 18/06/2023 at the Cumberland Infirmary in Carlisle with a medical cause of death as:

1a Urosepsis and Acute Kidney Injury II Right cerebral Infarct

A Narrative Conclusion was recorded, together with a finding of Neglect.

During the inquest, you commended the excellent work the Trust had undertaken in improving fluid balance management and were reassured that your duty to issue a Regulation 28 Report in this regard was not triggered. The Trust remains committed to ensuring that staff understand that the assessment and management of patients’ fluid and electrolyte needs is absolutely fundamental to providing good patient care. Healthcare professionals need to consider this as part of every review to reduce the potential serious impact of inadequate fluid balance on all our patients. An urgent patient safety alert was therefore issued to all Trust staff on 30/08/2024 that as a minimum requirement, the following group of adult patients all have a Fluid Balance Chart completed, reviewed and acted upon as needed:

• All non-elective inpatients
• Elective patients who have a length of stay >24 hours
• Patients who have an alteration in their NEWS score

The cessation of this monitoring should only occur following a documented clinical decision. The Nursing Directorate will be monitoring compliance with this notice. In addition to the urgent patient safety alert, a Trust wide improvement plan for fluid/hydration is being launched.

Notwithstanding this, the Trust’s written witness evidence set out that one Consultant (Consultant A) covered 25 patients on 14/06/2023 during Ms Austin’s admission, during a period of industrial action, and that due to the industrial action, Ms Austin did not receive any medical input on 14/06/2023. The inquest also heard that another Consultant (Consultant B) who was rostered to ensure medical cover on the ward on 14/06/2023, may not have been on duty in line with the rota. You were concerned that the Trust’s planning which seeks to ensure safe levels of cover during periods of industrial action, was insufficient to meet the need, and

that this may lead to future deaths if action is not taken by the Trust. Your statutory duty to issue a Regulation 28 Report to the Trust was therefore engaged.

I was extremely saddened to learn of the circumstances surrounding Ms Austin’s death and on behalf of the Trust, I wish to extend my sincere condolences to her family and friends.

I am grateful to you for raising your concerns to me. It is imperative to the Trust that safety issues are identified and rectified to ensure our services are safe and effective. Please accept this letter as the Trust’s formal response to the Regulation 28 Report.

To ensure a thorough review of Ms Austin’s care and the concerns raised within the Regulation 28 Report, the Trust has reviewed the following:

 The Trust’s witness evidence to the inquest  Ms Austin’s medical records  WebV nursing documentation  ICE system for requesting bloods and reviewing results  Collaborative (formerly known as Care Groups) industrial action strike plan  Trust industrial action strike plan  Industrial action logs  June 2023 staffing rota, including industrial action confirmed staffing plans  Review of quarterly weekend staffing at that time, in order to obtain an average indication of weekend staffing

Preparation for industrial action

The Trust would like to offer assurance of the planning process undertaken before the proposed industrial action on 14/06/2023 to 16/06/2023, which includes utilising the framework for managing industrial action. The priorities were to maintain patient safety and access to services, and to identify the level of service disruption and risk. An initial planning meeting was undertaken on 25/05/2023 which informed all Senior Managers and Clinical Directors of the confirmed industrial action and the impact that the Trust would be required to navigate, namely the lack of Foundation Doctor in training availability during this period. Staff from across the Trust were contacted to ask if they would be able to support and Consultants from other services, including in the community were available to be redeployed to other areas. There were offers of clinical skills updates if required, to ensure that individuals working outside their usual clinical area were confident. The key services that were required to be maintained were identified and risk assessments were undertaken for services that needed to be cancelled, in order to free up medical and support staff to work in other areas.

Daily meetings were subsequently held for a two week period up to 13/06/2023, to effectively plan for this period of disruption. Planning meetings were chaired by the Resilience Team with attendance including Executive Directors, a senior member of the Medical Directorate team, Care Group Senior Managers, Support Team managers, People Services and Communications. Rotas were reviewed by each Care Group, with contingency plans in place to ensure service continuity; namely that Consultants were covering designated ward areas with the support of multi-disciplinary team (MDT) members such as Advanced Clinical Practitioners (ACPs), and Specialist Nurses. ACPs are highly trained individuals, in this instance, from a nursing background and have developed skills to allow them to offer clinical support in expanded roles. ACPs are deployed across various settings within the Trust within the composite workforce model and are able to work autonomously, utilising advanced practice and skills to support patients with complex clinical needs.

The planning was agreed with a collaborative approach across all services, including the Executive Medical Director and Executive Chief Nurse. It was understood that due to the

predicted impact of the industrial action, medical cover during this time would not be at usual weekday levels, but was representative of usual weekend cover.

A daily situational report was expected to be completed which updated the Trust on the staff group affected, number of team members striking, actions taken short of a strike, and the impact on the service, for example any delays to diagnosis, treatment or discharge. A risk assessment was also completed to support with risk identification and mitigation plans. All Care Groups were represented at the below meetings, whereby escalations, updates and situational reports were provided by all affected Care Groups:

Situational updates during the period of Industrial Action were provided on:

14/06/2023 Tactical Co-ordination Group 08:15 and 13:00

Strategic Co-ordination Group 10:00 and 16:00 15/06/2023 Tactical Co-ordination Group 08:15 and 13:00

Strategic Co-ordination Group 10:00 and 16:00 16/06/2023 Tactical Co-ordination Group 08:15 and 13:00

Strategic Co-ordination Group 10:00 and 16:00

During this period of industrial action, as would be expected, there was reduced medical cover available, however, this was reflected throughout the medical wards and the Collaborative can confirm that no other incidents, other than the case of Ms Austin, were reported at this time, during the period of industrial action.

To support with any escalations that may have required attention during the industrial action period, Operational Managers were assigned to dedicated areas and tasked to liaise with the ward teams (this would include the Consultants, ACPs, Specialist Nurses, and other members of the MDT covering the wards) on a daily basis, and to escalate any unresolved concerns raised through the Tactical Co-ordination Group. The rota for this has been reviewed and we can confirm that no concerns were raised from any of the Elm A team during this period of industrial action.

Following the period of Industrial Action, a debrief was led by the Resilience Team, during which all Care Groups had the opportunity to share any learning from the period. No concerns were escalated to the debrief regarding the planned staffing mitigation plan. Had escalations been made to the Tactical Co-ordination Group and/or during the debrief, this would have been acted upon.

Detailed staffing plans for the Stroke Unit

Specifically focussing on the provision of stroke care during the industrial action, as an overview, the Stroke Unit at the Cumberland Infirmary comprises a 10 bedded Hyper Acute Stroke Unit (HASU) and a 33 bedded Stroke Rehabilitation ward (Elm A). Both units are staffed separately due to the acuity of the patient cohort. Although staffed separately, the HASU is located within the same footprint as Elm A and staff are able to move between the departments as required.

The usual medical staffing for the HASU from Monday to Friday is:

 1 Consultant 09:00 – 17:00  Minimum of 2 Advanced Clinical Practitioners (ACPs)/Trainee ACPs 09:00 – 17:00  1 Foundation Doctor in training also covering Elm A and Elm C (Elderly Care ward) 17:00 – 21:00  1 Foundation Doctor in training also covering Elm A, Elm C and Larch C (Elderly Care wards) 21:00 – 09:00

The usual staffing for Elm A ward from Monday to Friday is:

 1 Consultant 09.00 to 17.00  1 Specialist Trainee Doctor Year 3 09.00 to 17.00  4 to 6 Foundation Doctors in training 09:00 – 17:00  1 Foundation Doctor in training also covering HASU and Elm C (17:00 – 21:00)  1 Foundation Doctor in training also covering HASU, Elm C and Larch C (Elderly Care wards) 21:00 – 09:00

The usual weekend cover for Elm A and HASU (combined) is:

 1 Consultant 09.00 – 15.00, based on HASU but available for Elm A should there be an escalation which requires expert decision maker review  1 Foundation Doctor in training on Elm A  2 ACPs on HASU

During the period of industrial action (Wednesday 14/06/2023 to Friday 16/06/2023), it is recorded that approximately 78% of Foundation Doctors in training rostered to work on a specialist medical ward at the Cumberland Infirmary opted to take strike action, as is their right. During the same period, 100% of the Foundation Doctors in training rostered to work on Elm A between the hours of 09:00 and 21:00 took strike action. As a result, medical cover on Elm A during this period did not fully replicate the rota compared to when there are resident doctors present.

An alternative rota was comprised of the composite workforce of individuals skilled and trained in the care of stroke patients. The rota was agreed at the Trust tactical planning meeting and was felt to be safe. The ward had Consultant cover between the hours of 09:00 – 21:00 on all days of the industrial action, therefore the Trust was assured of senior medical oversight, supported by Specialist Nurses and ACPs.

There were no concerns regarding staffing levels overnight (21:00 – 09:00). To note, other support services available to support if required or escalated to included wrap around services of Phlebotomy, Critical Care and the Hospital at Night Team.

The staffing during the period of industrial action was as follows:

Wednesday 14/06/2023 09:00 – 17:00

 Consultant A on Elm A (Stroke Rehabilitation patients)  Consultant B – carrying out an outpatient clinic for urgent patients (morning only)  Consultant C on Elm A (Neuro Rehabilitation patients)  Consultant D on HASU with 1 Trainee ACP HASU  Consultants A and C were supported by two Trainee ACPs, a nursing team, and Consultant B was available if required  The ACPs on duty during the strike period were in training, therefore were not qualified to work independently or carry out the full range of duties expected of a qualified ACP, however were under the supervision of a Consultant.

Consultant B was on site on 14/06/2023 and was undertaking an urgent clinic in the morning assessing acute neurovascular cases who are required to be seen within 24 hours of symptom onset. All other non-urgent clinics within stroke were cancelled in order to ensure Consultants were available for ward cover. However, Consultant B was available to support the ward teams if concerns had been escalated. We have been unable to evidence any escalations made on this day that would have necessitated Consultant B to attend the ward to provide support.

Between the hours of 17:00 and 21:00, Consultant D was on site providing medical cover to patients on Elm A and HASU.

Thursday 15/06/2023 09:00 – 17:00

 Consultant A on Elm A (Stroke Rehabilitation patients)  Consultant C on Elm A (Neuro Rehabilitation patients)  Consultants A and C were supported by 1 Trainee Advanced Clinical Practitioner (ACP) and 1 Advanced Nurse Specialist in the afternoon (available if required in the morning) and a nursing team  Consultant D on HASU with 2 Trainee ACPs

Between the hours of 17:00 and 21:00, Consultant C was on site providing medical cover to patients on Elm A and HASU.

Friday 16/06/2023 09:00 – 17:00

 Consultant A on Elm A (Stroke Rehabilitation patients)  Consultant A was supported by 1 Trainee ACP and 1 Advanced Nurse Specialist in the afternoon (available in the morning) if required and a nursing team  Consultant D on HASU with 2 Trainee ACPs

Between the hours of 17:00 and 21:00, Consultant A was on site providing medical cover to patients on Elm A and HASU.

For overnight provision throughout the period of industrial action, Elm A and HASU were covered by 1 Foundation doctor in training and 1 contactable Medical Registrar (Specialist Trainee). In total, overnight provision across the 8 medical wards was 2 junior doctors and 1 Consultant, which was greater than in normal circumstances when no industrial action was ongoing. Usual overnight provision across the 8 medical wards is 2 Foundation doctors in training and 1 contactable Medical Registrar.

The staffing plans were devised with the operational teams working closely with the senior clinical staff to determine what cover was needed. The Emergency Care and Medicine Care Group’s (subsequently known as a Collaborative) confirmed the staffing plan, detailing the staff rosters for 14 to 17/06/2023, was submitted to the Resilience Team, Associate Medical Director and Associate Director of Operations on Monday 05/06/2023. To note, the plan initially detailed just 1 Consultant working on Elm A on 14/06/2023, however, as documented, the Care Group were able to provide 2 Consultants on this day.

The staffing plan was discussed throughout the tactical planning meetings, led by the Resilience Team with attendance by a number of senior clinical and non-clinical managers in the weeks before industrial action took place. Whilst it was recognised that medical staffing across all of the medical wards was anticipated to be significantly impacted by the industrial action, all wards were covered by at least 1 Consultant during the core hours of 09:00 – 17:00 (with usual out of hours Consultant cover in place) and some mitigations from other staff groups (i.e specialist nurses and ACPs). This was not deemed to be unsafe.

Learning

The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:

1. The Ward Teams to embed extraordinary safety huddles twice daily during periods of industrial action to allow MDT members to attend and discuss concerns/escalations.
2. Operational Teams/Matrons to embed twice daily touch bases with each ward area, during periods of industrial action, to support and address any areas of concern/escalation.

Whilst the Trust already had robust systems in place for Operational Managers to visit areas affected by industrial action and groups for any concerns to be escalated to, the additional safety MDT huddles and twice daily visits from the Operational Teams/Matrons, provides an additional forum/opportunity for concerns/escalations to be made, and highlights the importance to the MDT of doing so.

In view of the Trust’s assurance that there is safe levels of cover during periods of industrial action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any missed opportunities within Ms Austin’s care. However, the Trust unreservedly acknowledges that there is a need to establish what the causal and/or contributory factors were in Ms Austin not receiving medical input and basic, fundamental observations and interventions during her hospital admission. The Trust will therefore carry out a review into this to identify any learning and take immediate action to embed the learning to prevent recurrence and ensure that the care we provide is safe, effective, and of a high quality.

Once again, thank you for bringing your concerns to my attention. I hope that the above provides assurance to you, Ms Austin’s family, and the public, that the Trust has taken them seriously and appropriate action is being taken.

I appreciate not all of the actions are yet implemented and I would be happy to provide updates on these in the future, should you require this. Please also let me know if you require clarity on any of the responses I have provided above.