Dear Mr Morris

Re: Inquest into the death of Christine Mary DICKINSON

Thank you for giving the Trust the opportunity to respond further to the concerns you raised regarding documentation practices for staff working in the Laurel Suite.

I have asked the Division of Medicine & Urgent Care to provide further information.

You have raised two issues for our consideration which I will respond to in turn.

1) During the course on the inquest, the court heard evidence that staff on the Laurel Unit previously used a variety of systems (including one system not routinely accessible by staff elsewhere in the hospital) to record the administration of Chemotherapy.

As gave evidence to you during the inquest, documentation was previously solely on paper which was then scanned in to our electronic storage system, called Evolve. This process changed in 2018 when the team used digital documentation in Advantis CDS.

The Trust has a range of digital systems to support the delivery of patient care, this is to remove the reliance of paper and make patient data more accessible to users (who all have the appropriate access). Some clinical systems have a Trust wide use, and some are specialist systems for specific areas of care.

Within the Laurel Suite, the team currently input clinical details for haematology patients into two digital systems. These are AdvantisCDS and iQemo. The team also have access to a range of other Trust systems to view additional information regarding their patients.

The detail of the three systems is noted below:

The Advantis Clinical Document System (AdvantisCDS) is the Trust’s central document management system. Information is inputted, created, shared or viewed in this system and include the following examples (all information created within the system is based on self- populated templates for hospital staff to complete):
- Real time clinical data recording (this is used by the Laurel Suite as stated in this particular case) – At the time Mrs Dickinson was attending, when a patient attended Laurel Suite, the nursing staff accessed AdvantisCDS and added in information throughout the patient’s attendance on an open templated document. When the day’s treatment was completed, the document was then finalised, closed and published on the day which enabled the information

to be available to anyone with AdvantisCDS access. Laurel Suite medical staff and pharmacists can also add to AdvantisCDS directly. Toxicity assessments are documented within the AdvantisCDS document.

Other AdvantisCDS documents include:
- Clinic outcome letters which are dictated by the medical staff and typed by the secretarial staff which are sent to General Practitioners (GPs) and the patient. These letters would include any information regarding a patient’s planned treatment and / or any changes in the chemotherapy to be delivered.
- Referral letters which include letters generated by Trust clinicians for referral of patients to other Trusts, scanned copies of GP referral letters and scanned copies from external consultant referrals.
- Discharge letters following a patient’s episodes of care.

iQemo is a specialist e-prescribing system which provides an end-to-end solution including storage of predefined chemotherapy regimes, prescribing, scheduling of drugs, dispensing, and administration recording. Only a small number of relevant staff have access to this system which includes the haematology medical team, Laurel Suite nurses, pharmacists and aseptics staff (staff who make and dispense the chemotherapy treatments). It should be noted that it is a national requirement, as per the 2013/2014 NHS standard Contract for Cancer: Chemotherapy (Adult) Service specification, that Systemic Anti-Cancer Therapies including chemotherapy are prescribed using an electronic prescribing system.
- The process for managing patient care using iQemo is that the doctor prescribes the necessary regime on iQemo, it is then reviewed by the pharmacist and the aseptics member of staff (who will be making up the chemotherapy). The medic then uses the ‘go ahead’ button to approve the administration of medication. iQemo is then used by two of the nursing staff to electronically ‘sign’ to say that medication has been administered.

As referenced by , the staff in Laurel Suite also view patient information in Evolve. Evolve is the Trust’s patient record scanning solution which is used to scan any paper records a patient may have. In the absence of an Electronic Patient Record (EPR) system, clinical information written on paper notes during an inpatient stay or outpatient appointment is then scanned into Evolve. This information can be viewed by all hospital staff (subject to appropriate access). Additionally, some key documents from AdvantisCDS are also sent into Evolve for example a patient’s Emergency Department attendance, test results or patient monitoring information. Laurel Suite staff used to record on paper a patient daily care record which was then scanned into Evolve. As stated above, this practice ceased in 2018, when the staff move to direct electronic recording into Advantis CDS.

In summary, Laurel Suite staff use two key digital systems to input data for patient care (Evolve is a record viewing only solution). However, the fact that a patient is on chemotherapy, details of what treatment they have received in the Laurel Suite and information with regards to the chemotherapy regime is available in AdvantisCDS within clinic letters and Laurel Suite attendance records. This means that should an emergency occur, the Emergency Department medical staff or ward staff if a patient was admitted, would be able to access the information they would need to make decision on care and / or be prompted to contact a haematologist on call should that be required for specialist input before a treatment decision would be made.

2) Whilst the Consultant Haematologist told the court the requirement to use a single method of recording administration of Chemotherapy has been reinforced, in view of the above together with the fact that details pertaining to another patient entirely appear to have been entered into Mrs Dickinson’s record from September 2022, it is a matter of concern that no recent audit has been undertaken in respect of record- keeping on the Laurel Unit.

With regards to Mrs Dickinson's record being incorrect on 29/09/2023; this was incident reported on 17/04/2023 by Bethany Harrison (Laurel Suite Ward Manager) whilst staff were reviewing Mrs Dickinson’s records as part the Morbidity & Mortality process. This is our Datix incident form ID
96391. The incident description is: “On reviewing documentation for this patient it was noted on

29/09/2022 the documentation on Advantis written by the staff nurse treating the patient had included an entry incorrectly about another patient attending the same day for treatment.” And the immediate action taken: “The importance of documentation and ensuring the right patient is written for in the right notes has been reiterated to the nursing staff within the team on Laurel Suite.”

As informed you during her evidence for your enquiry, this incident happened with a member of staff who was new to the role at that time (29/09/2022). The team was spoken to regarding the recognised error some seven months earlier to which all have reflected upon. The Laurel Suite Ward Manager has confirmed that she is not aware that such an error has been identified at any other time and we can confirm that this has been confirmed by searching through the Datix incident system.

Matron has completed a documentation audit following Mrs Dickinson’s inquest. Twenty Laurel Suite patients’ records were randomly selected between March 2023 and August 2023. For all twenty records there was: relevant documentation on AdvantisCDS regarding the attendance, no incorrect patient details present and relevant information on iQemo relevant to the AdvantisCDS record.

To further assure you the following actions have also been taken:
- A monthly record keeping audit will be completed for Laurel Suite documentation and the results will be reviewed quarterly at the Division of Medicine’s Quality Group meeting.
- The team will be implementing a day case nursing admission documentation booklet for consistent documentation. This will be a proforma ‘live’ in AdvantisCDS for the nursing staff to add their information to which includes a question relating to any recent new diagnosis or hospital admission that may influence the decision to administer chemotherapy. This is currently in a pilot phase on paper with the intention to go electronic in the future. Whilst being piloted, at the end of each day the paper information is scanned in to AdvantisCDS so it is available on the day of administration. A copy of this template is included with this letter for your information.
- The team have purchased three additional computers on wheels (rather than desk based computers) so nurses are able to complete their documentation at the side of a patient rather than leaving them to work elsewhere. This allows for more timely contemporaneous recording, especially when patients require close observation.
- The Trust has established an electronic patient record (EPR) programme with the aim to procure and implement a single electronic patient solution to replace the majority of the Trust’s clinical systems. This programme is part of a national NHS digital initiative to ensure all Trusts have implemented such a solution by 2026 and associated funding has been made available to support Trusts. The Trust is working with Tameside Integrated Care NHS Trust and the Joint Outline Business Case is currently in the external approval process. Once final approval has been received, a formal joint procurement exercise will be launched. This is anticipated in Autumn 2023. It should be noted that the utilisation of iQemo will not be replaced under this procurement exercise due to its specialist nature. The consolidation of all other core Trust data into one solution will however deliver increased clinical safety benefits.

Once again, I would like to thank you for providing me with the opportunity to respond to your queries and provide this additional information. I trust that my response has been helpful to you. If there are any areas where I could provide further clarification, please do not hesitate to contact me.