Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Andrew Douglas Guillaume who died on 20 June 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 December 2023 concerning the death of Andrew Douglas Guillaume on 29 December
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Andrew’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Andrew’s care have been listened to and reflected upon. The matters of concern raised in your Report predominantly fall under the remit of the relevant Trusts, South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW). I note that you have addressed your Report to SWFT, but you may also wish to address your concerns to UHCW. NHS England has already been sighted on SWFT’s Root Cause Analysis Investigation Report, which we understand has been shared with the coroner and Andrew’s family. We note that lessons have been learned around communication, documentation and the problems encountered by SWFT in contacting UHCW. We welcome the report’s action plan which, in addition to the joint review references above, includes a review of UHCW referral mechanisms and circulation of a Trust-wide Safety Practice Alert with the priority telephone number for UHCW referrals. NHS England has also asked to be sighted on the Trust’s response to your Regulation 28 report so that we can, in addition, give it due consideration. I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

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

23 February 2024

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 Lakin Regulation 28 report – Mr Andrew Douglas Guillaume DoB 09/07/1971 DoD 20/06/2023 Thank you for your Regulation 28 report dated 29 December 2023 relating to the inquest of Mr Andrew Guillaume. I was sorry to read of your outstanding concerns at the conclusion of the inquest and hope that the following information will provide both you and Mr Guillaume’s family with further assurance of how seriously this matter is being taken by both NHS organisations involved in caring for Mr Guillaume. Following receipt of your Regulation 28 Report, the Trust arranged a meeting between senior staff and managers from UHCW and SWFT who it was felt could contribute to the points you raised. Attendees at the meeting included SWFT’s Chief Nursing Officer, Associate Chief Medical Officer for Governance, Consultants and General Managers for relevant specialities and UHCW’s Group Director of Nursing, Associate Director of Nursing, Quality and Patient Safety Lead, and Deputy Chief Medical Officers. The Group discussed a number of issues highlighted by Mr Guillaume’s case and also carefully considered the adequacy of the actions that had been jointly identified by the two organisations as part of the Serious Incident investigation that was referred to at the inquest. Details of the actions that had previously been agreed, and about which evidence was heard at the inquest, are set out below. These have been updated where appropriate, in particular, to reflect that the one action outstanding at the time of the inquest – that the learning be shared at the SWFT Grand Round meeting for medical staff – was completed in January.

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In addition to the work that had been carried out in response to the Serious incident (SI) Review, the meeting identified work streams/ themes which will be progressed by the two organisations. These include both short and longer term work to improve communications between SWFT and UHCW. Although many of these are still a work in progress I will, obviously, be happy to keep you updated. To address your concerns as they appear in your report:
1. The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions Reaching UHCW staff to request advice/transfers has been problematic for a number of years due to infrastructure issues. Following discussions at Executive level in 2022, a telephone number primarily intended for use by GPs to bypass UHCW’s Main Switchboard was shared by UHCW. This was as an interim solution whilst UHCW considered a more robust permanent solution. A solution agreed as part of the SI review was implemented in September 2023, namely for a list of direct numbers for cardiology wards and mobile ‘phone numbers for Cardiology Consultants to be provided to SWFT. The benefit would be that SWFT staff could make contact directly with the ward to establish which clinician was on call and then contact that person, thereby avoiding switchboard. In addition, the outcome of the meeting was that:
a. Long-term Technological Solutions
i. Technological solution to be developed to provide an alternative access to clinical teams (VOIP, Consultant Connect, WhatsApp, Teams). Initial discussion to be held with UHCW Director of IT around long term technology solutions to improve overall communication at UCHW (for example cloud based solutions, together with tele connection/messaging/email) and more specifically around improvements in systems for making referrals (getting a clinical conversation/ getting a bed).
b. Short-term Communication Pathways
ii. Whilst long-term solutions are being developed, SWFT/ UHCW to develop short term process for:
- How we do a clinical conversation better when seeking advice/ seeking beds/seeking conversations so it does not involve multiple people;
- How we create a referral pathway backwards and forwards between the organisations; and
- How we have a safety net when those do not work so we have an ability to escalate. (This may include: daily huddle between SWFT and UHCW to share patients needing transfer as two way, centrally held lists of patients requiring input from the other organisation, central oversight by site team at each organisation of patients requiring transfer to support front door, improved links between on-call managers).
iii. SWFT to send names of staff to be involved who understand systems to take part in discussion for action ii;
iv. Give SWFT switchboard contact details for UHCW’s site office – which will ensure one single point of access into the organisation. The site office is covered 24/7, should there be a need for escalation. This has now been actioned.
v. UHCW to complete work to collate information by specialty on how to contact teams on call into user-friendly and accessible form and share with SWFT

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c. Relationship Building
vi. Look at how registrar level staff can build relationships across the organisations to improve communication and team working
d. Specialty specific care pathway issues
vii. UHCW cardiothoracic/ cardiology to review contact details that can be provided to SWFT to support response to PFD
2. A previous incident in which a similar concern had been raised, had led to provision of an emergency GP phone number, that can be used by the clinical teams at South Warwickshire University NHS Foundation Trust (SWFT), which is manned 24 hours a day and is prioritised over other calls. The Cardiology team had not been aware of this, nor did they have the telephone number. As explained above, the sharing of the GP telephone number was only ever meant as an interim solution. This has been superseded by provision of direct numbers to reach the cardiology wards at UHCW and a list of Cardiology Consultant’s mobile ‘phone numbers whilst more robust short and longer-term technological solutions are developed.
3. Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023, as the referral had not been completed [and] 4. Had the referral been completed, the team at UHCW could have prioritised the patient’s transfer. The Trust recognises that it didn't pursue efforts to ensure that a consultant-to-consultant discussion took place between 7th and 9th June 2023. At least one attempt to call was made to the UHCW team but, as is made clear elsewhere in this response letter, difficulties in making contact with an appropriate clinician at UHCW hampered that communication and further attempts were not pursued rigorously enough. In reality, although Mr Guillaume's case was not discussed at MDT that day, an echocardiogram performed on the same day led to a recognition that a Transcatheter Aortic Valve Implantation (TAVI) procedure was not required and that a valve replacement would be a clinically more appropriate option. A referral for valve replacement surgery does not involve an MDT discussion and so a referral to UHCW's surgical team was made electronically that same evening. These points are highlighted on page 4 of the Trust's root cause analysis investigation document. In essence, there was a delay in making a referral for a TAVI procedure before the MDT meeting which the Trust recognises and for which it has apologised. This was in part due to difficulties in gaining access to UHCW colleagues and in part that an alternative temporary solution to aid communication was unknown to the consultant team. However, a cardiac investigation undertaken on the same day as the MDT highlighted that a different procedure was clinically more appropriate and referral for that occurred on the same day as the MDT meeting. It is believed that the short, and long, term plans described above to improve communication between the UHCW and SWFT consultant teams will mean that consultant­ to-consultant discussions will be able to be more speedily and effectively achieved in future. I hope that this provides you with the assurance that you require but if, having read this letter, you have outstanding concerns, please do not hesitate to contact me.

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Dear Mrs Lakin Re: Inquest into the death of Andrew Douglas Guillaume held 29th December 2023 Thank you for sharing the Regulation 28 report for the above patient. Whilst the Regulation 28 response is required from South Warwickshire University Hospitals (SWUFT) we have engaged with them by way of a tabletop review/learning event, having recognised that there were aspects of our processes that were identified in the report that required improvement. We have agreed to explore the technological options that may improve this however, in the interim we have agreed an escalation process that now provides a direct line of communication 24 hours, seven days per week. This arrangement has been confirmed with SWUFT following the tabletop review and we will also share this with the other Providers across the System. We hope this provides assurances, and I would like to assure you that we will continue to explore communication improvements as part of our digital plans.

Dear Ms Lakin,

Thank you for the Regulation 28 report to prevent future deaths of 29 December 2023 about the death of Andrew Douglas Guillaume. I am replying as Minister with responsibility for secondary care.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Guillaume’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. The report raises concerns about communication in relation to referrals for patient transfer between the Trusts mentioned in your report, and the consequences of that poor communication in the case of Mr Guillaume. The matters of concern raised are primarily for the Trusts to address, and I note both the South Warwickshire University NHS Foundation Trust (SWFT) and the University Hospitals Coventry and Warwickshire NHS Trust (UHCW) have addressed your concerns in detail in their responses. Local collaborations and working options are being explored to develop long term technological solution and short-term measures so this does not happen again. Several recommendations and actions have also been completed by the SWFT which address your concerns directly. I also note that NHS England has replied and are sighted on the issues you raised. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care. I hope this response is helpful. Thank you for bringing these concerns to my attention.