Dear Madam Lee, RE: Regulation 28 Prevention of Future Deaths Report: Jennifer Whinney I write in response to the inquest dated 17th November 2023 and the Regulation 28, Prevention of Future Deaths report to the trust dated 27th November 2023. I am sorry that the evidence of actions undertaken to reduce line infections at the Royal London Hospital (RLH) were not made available to you ahead of the inquest, but I understand was able to explain our actions during the inquest. I write further to this discussion to lay out the actions that our clinical teams are continuing to take at the RLH. I note from the feedback from the trusts legal team, that you had been informed in November 2022 that a Serious Incident (SI) investigation was to be completed. I apologise for the error in this information, it was never our intention to investigate this through the SI process and you were misinformed about this. Our staff had correctly reported it on our incident reporting system (Datix ID 399559) noting the various line infections and it has been investigated locally through that route. Ms Whinney was admitted to the RLH on the 12th July 2022 from Queens Hospital. Blood cultures were taken from her PICC line on the 12th July as part of her admission assessments. As your findings and conclusions have documented, these came back positive and were discussed with

Microbiology for treatment advice on 13th July. By the 15th July she was showing the clinical signs of infection. As a result of this timeline, it was not felt that a comprehensive SI investigation was required. However, the team did recognise that there was learning and improvements to be made. We are sorry that after this time, Ms Whinney continued to experience a recurrence of line infections during her admission. Despite not completing an SI report, the clinical team did investigate the events that affected Ms Whinney, identified the source of her infection, and took actions to make improvements to the care of all their patients. In the summer of 2022, prior to Ms Whinney’s death, the surgical nursing leadership team implemented an improvement programme for the management of lines. This included a number of workstreams including:
• Audit and performance - monitoring & feedback
• Training and education – aimed at both nurses and medical/ surgical professions
• Improving staffing & retention - including nursing and ward housekeepers
• Ward cleaning checklists The introduction of a multi-disciplinary Line Infection Meeting provided a forum to share learning across departments as well as the introduction and oversight of a robust action plan started in December 2022. This action plan continues to be monitored to this day with infection control practice being regularly audited across the wards. As a note of good practice, this meeting has now expanded to be the Surgical Infection Prevention and Control (IPC) and Harm Free Care Forum, it thus incorporates a number of other aspects that all contribute to improving our patients safety and promoting a positive experience for them whilst in our care. Below is the most recent section regarding the IPC action plan for reducing infections: Issue AIM Action Owner Staff involved Measure of success Line Infections To ensure particularly long line infections are clear of all known infections To monitor insertion and Line care on all wards - local audit Training initiated - planning OSCE several dates planned Data will be brought about how best and what to collect ANTT project to start Ward 3E All wards Nutrition team Nutrition audits IPC audits ANTT To ensure line infection are prevented, ensure all wards are above 85% To monitor insertion and Line care on all wards - Local Audit ANTT technique training being agreed 5/5s (old) audit started on all wards Ward 3E All wards Nutrition team Nutrition audits IPC audits

Nutrition Review of MUST scores ensure all wards above 85% To monitor compliance and actions across all wards Nutrition board Training MUST scores improving across all wards Symbiotix initiating on all wards - hostess will order - to look at who else needs training Matron All Wards Matron Nutrition audits IPC audits Staff Aim to achieve All staff are reminded about the All wards All Staff Symbiotic audit results compliance at least 90% uniform policy in daily safety briefing. Tendable audit with bare compliance with Ward manager to do spot checks on IPC quarterly audit below the Tendable audit. weekly results elbows Minimise transmission of infection in the ward. Noted during the strike the 3rd floor is very cold to bring to IPC board Compliance improving staff challenging poor practice High dust Aim to achieve Escalated to patient ambassadors who Ward Serco Tendable audit results and low dust at least 90% are responsible for cleaning. 10e IPC quarterly audit particularly compliance with Still not 100% = Discussed ways in results in bay areas Tendable audit. Aim to stay green for audit. changing the schedule - rotating which half starts at 07:00am so the whole ward is focused on 15 hours of funded cleaning is required extra on ward 3D Equipment Aim to achieve Housekeeper to check the store room Ward 3D All Staff Tendable audit results storage at least 90% daily. House IPC quarterly audit Orderliness compliance with NIC to check if staff allocated to do the Keeper results and storage Tendable audit. job has done the job (i.e., clean Aim to stay Review DSU cupboards - in place utility and green for audit. starting to use will feedback storage area) improvements Safety Aim to achieve Educate staff the importance of the All wards All Staff Tendable audit results mechanism at least 90% safety mechanism. Housekeeper IPC quarterly audit of sharps compliance with House keepers to check all the bays in results bins not Tendable audit. the morning. being used Aim to stay Repeat audit later this month - create Overfill green for audit. list of all non-safe sharps found in our sharps bin areas Patients Aim to achieve Not consistent, DSU improving, wards Ward Serco Tendable audit results areas clean at least 90% still highlighting concerns 10E/ IPC quarterly audit tidy. Chair compliance with Check on weekly basis by ward manager Matron results cushions and Tendable audit. Chairs and tables to be cleaned daily tables clean Aim to stay green for audit. flipped and cleaned underneath by ward hostess Met with hostess, supervisor and matron about key responsibilities and how to achieve this on each ward

Medication Management Aim to achieve at least 90% compliance with Tendable audit by IPC. Aim to stay green for audit. Moved IV medications into the locked medication cupboard. Drug prep area and storage shelving area to be included into the daily cleaning checklist. Medication trolley to be cleaned as required and checked daily NIC to check if daily temp record are complete on each shift. To ensure all drug trolleys are clean - rota implemented on wards Include pharmacist to this meeting All wards All staff Tendable audit results IPC quarterly audit results The work implemented by the nursing staff has resulted in improvements across the surgical wards with less line infections developing. This project has been presented at the RLH Senior Leadership Forum in June 2023 led by our Chief Executive. The lines themselves were put in place in our Interventional Radiology (IR) department. The IR service also have a quality improvement programme of work for reducing the risk of line infections and I attach their action plan for your information also. Issue Aim Action Owner Staff involved Measure of success Some staff not Staff Protocol discussed in safety huddles for Sister IR Team IR team fully compliant. observing bare following 2 weeks (documented in daily huddle below the bare the minutes). Radiographers and Clinicians elbows. elbow re-educated. Staff encouraged to protocol. challenge non-compliant members of team. Dusts observed Regular Regular damp dusting allocation for IR IPCC IR team Cleanliness maintained in procedure cleanliness staff and creation of cleaning record. Team and documented rooms maintained. Inappropriate Items stored Re organisation of equipment’s in the IR IPCC IR IPCC Items stored and mix appropriately. non-critical / low risk areas. Team Team appropriately. Access storage of Access for for Domestics to clean items and Domestics to all areas. equipment clean all making it areas. difficult to clean non­ critical / low risk areas

Rusted All old and Identify and replace trolleys/ gratnells Sister IR Nursing All old and rusted trolleys/ rusted that will need replacing. team trolleys/ gratnells gratnells trolleys/ replaced. gratnells replaced. Damaged All damaged Identify damaged procedure table Senior IR Team All damaged procedure procedure procedure cushion and pillows then replace. Radiograp table cushion and table cushion table cushion her pillows replaced. and pillows and pillows replaced. Inadequate All Creation of cleaning allocation and IR IPCC IR IPCC All equipment cleaned cleaning of equipment’s record for equipment’s. Team Team on a regular basis with some cleaned on a "I am clean labels". equipment regular basis (i.e., with "I am ultrasound clean labels". machine, etc. Task allocation Regular Identification of responsibility owner Senior IR Regular cleanliness for cleaning cleanliness and action maintained. Radiograp Radiograp maintained. equipment and maintained. her hers team surfaces ­ unclear responsibilities Doors of the All doors kept Action mentioned in the safety briefing Sister IR Nursing All doors kept closed at procedure closed at all and morning huddle for 2 weeks. Team all times. rooms are kept times. open when not in use Appropriate Protocol in Consult IPCC Team on creating a Sister IR Nursing Protocol in place and plan for place and put protocol/ management plan. team put into practice. management into practice. of visitors scrubbing in Donning area Donning Donning trolleys relocation for all Sister IR Team Donning trolleys prone for trolleys labs/rooms and inform all staff. relocated in all rooms. splash relocated in contamination all rooms. The divisions continue to report progress each month to the hospitals IPC Committee chaired by the Director of Nursing (who is also the hospitals Director of Infection Prevention and Control, DIPC) and this maintains oversight of the hospital acquired infections. In May and October 2023, the Clinical Lead Dietician and Lead Nutrition Clinical Nurse Specialist completed teaching sessions at forums with the multidisciplinary surgical staff (nursing and surgical professions). These sessions included teaching about practical tips to reduce Catheter Related Blood Stream Infections (CRBSI) and the Surgical Aseptic Non-Touch Technique

(Surgical ANTT) when managing surgical lines. Our Education Academy also runs an accredited surgical course for non-medical staff (nurses, midwives, and Allied Health Professionals) which includes training around line care, wound care and deteriorating patients. Furthermore, we have now updated our IPC statutory and mandatory training so that it is in line with the revised national standards. When all undergraduate medical students and junior doctors (Foundation year 1 and 2 trainees) join the trust, they undergo IV cannulation and venepuncture training which also includes ANTT training. This is part of their core teaching programme and again it follows trust guidelines. The Deputy Director of the Barts Health Education Academy is currently in the process of re- writing the ANTT policy with our microbiology and Infection Prevent and Control (IPC) teams. When launched, this multi-disciplinary policy will be embedded with training and competencies that adhere to national guidelines. It is anticipated that the final version of this policy will be ready by the end of January 2024. I hope this provides you with the assurance that we take line management and infection control very seriously and that we do have improvement work underway across the Royal London Hospital but I would be very happy to discuss or clarify any of the above points if you wished.

Dear Madam,

Regulation 28 Report on the death of Mrs Jennifer Ruth Whinney

Thank you for your Regulation 28 Report of 27 November 2023. The Trust has carefully considered the concerns raised in the learned Coroner’s report, and guidance has been sought from specialists within the Trust to address them.

The matters of concern identified in the Regulation 28 report are:

1. Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queen’s Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent.
2. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on.

Trust’s response:

1. A review of the process for sending patients notes accompanying them to external hospital visits has been undertaken and we have identified gaps in the governance of this. The policy has now been revised internally and the updated policy, was approved at the Policy Ratification Group that took place today, on 22 January 2024. The changes include both implicit responsibility of handing the patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. A copy of this policy is included with this response for His Majesty`s Coroner`s kind review.

2. As part of the review of transfer of health records it has been noted that medical letters detailing Name, Date of Birth, NHS number, presenting compliant, medical history, medication history and reason for referral with contact details of medical team requesting the transfer as a minimum data set should be sent with the patient and is included in the checklist detailed above.

3. The Trust is currently embarking upon its journey into digitisation of medical notes which should be completed in mid-late 2025. Once this is completed it is envisaged that the issue of medical notes being sent between hospital sites, that are also digitally enabled should be seamless; although it is recognised this is a lengthy timescale.

The Trust has taken the issues identified by the Learned Coroner very seriously and has taken positive action to address them.

I would be happy to meet to discuss this response if that would be helpful to HM Coroner.