Dear Mrs Slater Inquest Touching the Death of Anne Hawkes: Regulation 28 Preventing Future Deaths Report write further to your letter dated 2 April 2023 understand that following review of the evidence heard at the Inquest dealing with the circumstances of Mrs Hawkes' death, a number of matters were raised that were of sufficient concern to invoke your statutory duty under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. was disappointed to hear that you were in a position whereby you did not receive sufficient assurance through the evidence you heard. We take such matters seriously and we are truly sorry that this happened whilst Mrs Hawkes was in our care. would like to repeat our deepest condolences to her family and friends_ In order to fully respond to the concerns you raised, we have carefully reviewed the evidence presented at the time of the Inquest and my response below will provide you with the necessary assurance that we have addressed the concerns raised: For ease of reference will address your concerns in the order presented as follows:
1. The delayed cardiology referral whilst Mrs Hawkes was on the orthopaedic ward led to suboptimal management of her cardiac failure which in turn is implicated in her death: There is no procedure in place at the Trust for Clinicians to automatically refer in-patients with known cardiac failure to cardiology for expert management understand that you heard evidence that there was a recognition that it is practice to refer in-patients with known heart failure to cardiology and the heart failure specialist nursing service for advice and management and there is an expectation of both medical chhief Executive, The Rotherham NHS Foundation Trust very hope good

and nursing staff to use their clinical judgement and recognise when patients require referral to the heart failure service. In addition, you heard evidence that there is no automatic referral of in-patients with known cardiac failure to cardiology for management: In the first instance, think it is important to highlight that all patients with heart failure have on their record within Meditech which appears as a 'pop up' whenever a user logs onto the patient's records. Mrs Hawkes had such a on her record and would like to reiterate our apology to Mrs Hawkes' family for the delay in referring her to cardiology for specialist heart failure management understand that during the Inquest; it was discussed at length that a crucial aspect of heart failure management is fluid balance with the view of preventing fluid overload and to monitor this, patient's weight in an important consideration: It was recognised and accepted at the Inquest that Hawkes' admission weight was not accurate. Since this incident, additional prompts have been incorporated into Meditech to direct clinicians to complete daily weights for patients with heart failure. More specifically, the prompts have been made to the Inpatient Admission Summary (a checklist completed for every patient irrespective of where are admitted to), the Trauma & Orthopaedic Admission, Trauma & Orthopaedic Femoral Fracture Admission and Nursing Admission Checklist PCS Assessment: This prompt will direct clinicians to answer the question of whether the patient has a past medical history of heart failure. If the answer is 'yes' (as will be the case for patients with heart failure) this will trigger a Daily Weight Monitoring assessment: If the patient's weight has increased by more than 3kg since admission; a pop-up message will appear on the system prompting a referral to the Heart Failure Specialist Nursing Team_ For your ease of reference have attached, at Appendix 1 document which outlines the process: The aforementioned process is in addition to clinicians recognising other signs and symptoms of heart failure which also prompt referral to cardiologylheart failure service_ Furthermore, orthopaedic inpatients are also reviewed by an orthogeriatrician during the ward round where specialist input and guidance can be sought as to the medical management of the patient: acknowledge that you have highlighted there is no automatic referral for in-patients with known cardiac failure_ It should be acknowledged that not all patients with known heart failure mandate a referral to the Heart Failure Service, unless there are signs of decompensation (including shortness of breath, decreasing oxygen saturations and tachycardia) andlor fluid overload (visible oedema andlor changes in body weight): We have carefully considered this and concluded that automatic referral would place a disproportionate amount of additional pressure on the service which ultimately would not prove beneficial for patients_ There are several ways, for both medical and nursing staff to refer patients to other specialities and this includes the cardiology and the Heart Failure Specialist Nursing Service. These include completing the electronic Inpatient Referral Form which is inbuilt into the Trust's electronic patient record system, Meditech: Referrals can also be made via telephone requesting to speak to a clinician or Consultant in that relevant speciality. Chlef Executive; The Rotherham NHS Foundation Trust flag flag Mrs they Friday

2. The lack of communication between the services within the Trust (surgery, cardiology and tissue viability) led to delayed and incohesive approach to the wound management On this occasion; it was recognised at the Inquest that the communication between orthopaedics, cardiology and our Tissue Viability Nurse services (TVN) could have been improved upon However; this is not a reflection on the overall communication with the TVN service_ Green, Tissue Viability Nurse, gave evidence that there exists a good working relationship between the surgical teams and the TVN service. It was acknowledged that TVN could have been contacted earlier when Mrs Hawkes was on Ward A1 when her wound started to break down and for this we reiterate our apology. Since this incident; collaborative work has begun between the TVN service and the Trust's Quality Governance Team to communicate the referral criteria for the Service to the whole Trust and repeat awareness of the Trust's TVN Service. hope the above provides you with the assurance that the Trust has taken your concerns seriously and please do not hesitate to contact me in the event can be of further assistance to you at this time_