Dear HM Coroner Dr. Peter Harrowing Regulation 28 Report following the inquest into the death of Ms Madeleine Lawrence Thank you for raising the Regulation 28 report following the inquest into the death of Ms Madeline Lawrence. We have noted the matter of concern listed below. (2) The CQC should confirm that it is now satisfied that the trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff. We at the Care Quality Commission (CQC), have seen evidence of significant improvements at the trust and will continue to monitor this area. The CQC have contacted the provider North Bristol Trust to request written confirmation and evidence of the action they have taken to date, and intend to take, following the tragic death of Madeleine Lawrence. CQC also conducted an on-site assessment under the new single assessment framework on 22 January 2024 at Southmead Hospital with the focus on:
• learning culture
• systems, pathways and transitions and
• safe and effective staffing. At the on-site assessment we found staff working across all bandings in surgical and medical wards were clear on their knowledge and responsibilities for assessing and reporting patients’ NEWS2 scores. We attended nursing and medical handovers and ward safety huddles where we found patient escalation was discussed and managed appropriately. Staff were able to clearly demonstrate the escalation process for a deteriorating patient. Staff we spoke with reported they had attended recent NEWS2 training and showed clear professional ability to apply their learning. Staff reported they could override a low NEWS2 score with clinical judgement and escalate if they were concerned about a patient, however they were not able to override a high score. Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA

20240124_NBT_Regulation 28 Coroner response v4 On some of the wards we visited, the deteriorating patient training was highlighted as training of the month. There was easy to read information on wards for staff and weekly audits of NEWS2 compliance. The trust employed 250 internationally educated nurses last year and they had undertaken deteriorating patient training as part of their objective structured clinical examination (OSCE) preparation. The trust had created 335 senior healthcare support worker roles, with 70% having completed additional training in physiological measurement (observations) and caring for the deteriorating patient. There was a plan for this to be 100% by the end of April 2024. With regards to the ongoing training for new staff, the trust had instigated a new package entitled ‘Maddy’s Training’ which included the following subjects:
• deteriorating patient
• sepsis
• acute kidney injury
• NEWS2 This was being implemented trust wide but had not yet been fully launched. This was due to the national institute for health and care excellence (NICE) updating guidelines on suspected sepsis: recognition, diagnosis and early management (NG51) which was expected to be published in January 2024. The trust plan to amend the training to reflect the latest NICE guideline update before the launch. There were practice development nurses who were able to identify staff and refer them for further training when required. Junior doctors were on rotation every 4 months; therefore, deteriorating patient training was arranged for the intake of the new cohort. We were told bank staff had access to NEWS2 and deteriorating patient training and more explicit targets and ongoing monitoring arrangements had been established to strengthen this area. The Chief Nursing Officer had written to external agencies to reinforce the expectations of staff working at the trust. The trust had updated 3 key policies in response to patient deterioration. Acute kidney injury care had been approved in September 2023 and sepsis and NEWS2 had been approved in October 2023. We met with the senior leadership team. There was a business case for a 24 hour care rapid response team to augment ward care, with the addition of a critical care outreach service. This was progressing through the business planning process for 2024/25. A clinical lead for deteriorating patients had been appointed. They informed us that the learning from Madeline’s death had not only impacted this trust but had also been shared more widely with neighbouring trusts. The trust provided data on staff training compliance figures for sepsis, NEWS2 and management of deteriorating patients. This showed some improvement in training update compared to August 2023. Due to information migrating to a new electronic system and the implementation of revised training, the data supplied did not capture all the different methods staff received training. The trust plan to oversee the new training package with ongoing compliance versus a target percentage. We are therefore assured the trust has implemented

20240124_NBT_Regulation 28 Coroner response v4 measures to ensure ongoing training for new staff, although they are in the process of fully embedding this. CQC will monitor this position during ongoing engagement with the trust.