Alexander Blewitt
PFD Report
All Responded
Ref: 2023-0207
All 1 response received
· Deadline: 18 Aug 2023
Coroner's Concerns (AI summary)
The coroner notes concerns about the lack of reliable recording of intravenous fluids in the emergency department, missed points during triage, and a failure to record a major presenting symptom by the treating doctor; the Incident Investigation Report was also found to be of a poor standard.
View full coroner's concerns
[1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department. That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of Inquest 8 months later, was unable to demonstrate that the Trust had remedied that. [2] Despite the 8 month interval between Mr Blewitt's death and the Inquest the issues of concern had not been brought to the attention of hospital authorities. [3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself. [4] I was concerned that the treating doctor made a contemporaneous note on the 9th July 2022 at Mr Blewitt's first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence, which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit. [5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
Responses
Action Planned
The hospital is implementing mandatory training for ED staff on referral note review, accurate medication documentation, and sepsis protocols. The Chief Nurse and Medical Director will write to all registered ED staff to emphasize key issues from the case. (AI summary)
The hospital is implementing mandatory training for ED staff on referral note review, accurate medication documentation, and sepsis protocols. The Chief Nurse and Medical Director will write to all registered ED staff to emphasize key issues from the case. (AI summary)
View full response
Dear Dr Cummings Regulation 28 Report following an Inquest into the death of Mr Alexander Blewitt I am writing following receipt of a Regulation 28 Report dated 06 June, subsequent to the Inquest which you concluded on 21 March 2023. Mr Blewitt attended the hospital for the first time on 09 July 2022, having been referred from the Urgent Care Centre (UCC, the out of hours service for primary care in MK). He was discharged home with a working diagnosis (ongoing urinary tract infection) which was incorrect. Mr Blewitt then returned to the Emergency Department (ED) on 11 July 2022 and once a diagnosis was made, went to theatre for a laparotomy. Mr Blewitt suffered a cardiac arrest at the induction of anaesthesia and sadly died post- operatively on the ICU. He had been found to have pus in all four quadrants on laparotomy, following a bowel perforation. You raise several specific issues in your Regulation 28 Report. I summarise these issues as follows:
• Lack of attention to the referral note from the UCC - inaccurate transcription by the triage nurse and failure of the doctor to seek out the original.
• A failure on the part of the assessing doctor on 09 July to record change in bowel habit as a prominent presenting symptom in his contemporaneous record, leading to an implied concern about the accuracy of the record and his subsequent evidence.
• Lack of reliable recording of IV fluid administration in the ED - you note that the author of the internal Serious Incident Report had been unable to demonstrate any remedy to this issue since the incident.
• A potential contributory factor (fluid prescriptions 'disappearing' from the electronic prescription chart) had not been raised to hospital authorities between the date of the incident and the date of the Inquest.
T eMK CARE COMMUNICATE. COU. CONTRIBUTE. r,•t:kj Milton Keynes University Hospital NHS Foundation Trust
• A Serious Incident Report which you felt to be of an unacceptable standard (in part as it noted the poor documentation of fluid prescription but did not explore further). Prescription of Fluids in the Emergency Department and documentation of the same The narrative around the prescription of intravenous fluids in the Serious Incident Report, Inquest statements and verbal evidence seems to have been complex and nuanced at best, contradictory at worst. Intravenous fluids should be managed as any medicine in the hospital, prescribed (by a doctor I non-medical prescriber) and administered (typically by a nurse, occasionally by a doctor or operating department practitioner). Since we have been using our electronic patient record (an Oracle Gerner product, branded locally as eCare), both of these steps should take place within eCare. eCare has been the primary record system in the Emergency Department since May 2018. It has been the primary record system in the theatre environment since September 2021. As with paper records, it remains possible for medicines to be given by verbal order. This should occur only rarely when urgency is paramount, and it should subsequently / retrospectively be recorded very clearly in the record. As a rule of thumb, I would not expect the doctor (in the context of the Emergency Department) to leave the vicinity ofthe patient without completing the prescription. It may be that intravenous fluids may be more prone to administration without prescription than other medicines as a series of fluids may be administered in quick succession in a dynamic environment and - perhaps - on account of an erroneous view that fluids have less potential for harm than other medicines. During the course of Mr Blewitt's Inquest, views were offered in relation to the prescribing of intravenous fluids within eCare. It seems that there may have been a lack of understanding, and perhaps some misunderstanding, of the technical position and the impact that this might have had on practice and record keeping. Several years ago, we became aware that prescriptions for intravenous fluids would 'expire' if they had not been administered (commenced) prior to the time at which a prescription should have been completed. For example, if a 1000ml bag of intravenous saline was prescribed at 16:03 to run over 12 hours, the prescription would expire (and As a teaching hospital. we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your core. or you may be asked to
participate in a clinical trial. Please speak ta your doctor or nurse if you hove ony concerns.
heMKWa r,•1:k1 CJ. COMMUNICATE. Milton Keynes CC CONTRIBUTE. University Hospital NHS Foundation Trust disappear from view as a medicine awaiting administration) at 04:02 the next morning. It would still be visible in the record ('greyed out'), with details of the prescriber and the time of prescription but it will be marked as 'completed but not given'. This is a feature of the Oracle Gerner product internationally and has some benefits / advantages. Ordinarily, this issue does not have a negative impact on workflows and clinical care. However, it is more likely to be problematic in a fast-moving dynamic environment such as the Emergency Department where fluid prescriptions may be administered over relatively short periods of time (i.e., over one hour rather than over 12 hours). Of note, fluid prescribing is undertaken differently in the USA (Oracle Gerner's base) and in the UK: in the USA fluids are ordered at a rate (e.g., 100ml/h) to run indefinitely/ until stopped, whilst in the UK fluids are ordered as a fixed volume to run over a defined and discrete period (e.g., 1000ml over 8 hours, then stop). This issue was raised with Oracle Gerner and we developed a distinct 'short infusion' order. In this scenario, the prescription remains a planned administration and does not 'grey out' on the chart at the expected time of completion The 'short infusion' order remains visible as due until it is administered, or when the patient is discharged from the clinical encounter. It does not expire at a timepoint related to the time of prescription and/or the calculated time of completion of administration. It has been specifically designed for use when prescribing fluids for infusion over a short duration (i.e., an hour or less). If doctors in ED prescribe fluids where there is a risk that they may not be started in an appropriate timeframe, or where a number of fluid options are laid out (e.g., depending upon an awaited laboratory result), these short infusions will be more suitable. They have also been included in a sepsis 'PowerPlan' (an electronic 'care bundle') intended to guide practitioners through the required orders for managing sepsis. The orders look as shown overleaf. A training video was also developed for staff around the short infusion workflow. In Mr Blewitt's case, documentation around fluid administration is poor but it does not seem that this specific eGare related issue - which I think was introduced into evidence at the Inquest - was relevant. At 21 :28 on 11 July, a 4-hourly bag of fluid was prescribed although it was never recorded on eGare as started (the prescription 'timed out' at 01 :37 the next day, so it As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your core, or you may be asked to participate in a clinical trial. Please speak lo your doctor or nurse if you hove any concerns.
TheMK r~1:kj CAR COMMUNICATE. Milton Keynes CC CONTRIBUTE. University Hospital NHS Foundation Trust remained on the chart available to be given until well after the patient left ED). Of note, antibiotics had been given at 18:55. Following the cardiac arrest, a retrospective entry was made by the anaesthetist describing the 5 litres of fluid given in the anaesthetic room. One entry that evening (by surgical staff) stated that the patient had received 2 litres of fluids in the ED. It remains possible, although it clearly cannot be demonstrated in the record, that Mr Blewitt did indeed have two litres of intravenous fluid in the ED. Indeed, he could have received more or less (which is clearly not a satisfactory position). It seems likely that members of staff visiting ED and reviewing Mr Blewitt (for example the two surgeons and the anaesthetist between 21 :39 and 22:15) would have commented had intravenous fluids not been in progress at the time of review, given the clinical scenario which had by that point emerged. Quality of Incident Investigation Report It appears that the specific issue of the intricacies of electronic prescribing surprised witnesses at the Inquest and in their efforts to provide answers for you, a confused picture emerged. At its core, all ED clinicians should be aware that: As a teaching hospital. we conduct education and research to improve healthcare for our patients. During your visit students may be involved in your care, or you may be asked to participate in a clinical trial. Please speak lo your doctor or nurse if you have any concerns.
TheM ,~1:bj CJ.. COMMUNICATE. Milton Keynes a CONTRIBUTE. University Hospital NHS Foundation Trust
1. Upon suspicion of sepsis, time-critical treatment (including fluids) should be commenced as soon as possible. The Royal College of Emergency Medicine's standard is that 75% of patients should be in receipt of fluids within 1 h of arrival, 100% within 4h.
2. High quality record keeping is key to the delivery of effective clinical care and is a professional responsibility for regulated healthcare professionals. This includes accurate documentation of patient history, examination, investigation and plan. Accurate prescribing, and documentation of administration of medicines, is essential. Incident Investigation Reports are reviewed through a weekly meeting (Serious Incident Review Group, SIRG) where there is some consistency of senior membership. This report was signed off by that group. The two key deficiencies which you infer were: acceptance of the diagnostic approach taken on 09 July; and identification of the issue of poor documentation on 11 July without further exploration of root causes or learning. Whilst I would accept both criticisms to a degree, I do not think they are as clear cut as your Regulation 28 Report implies. The 09 July presentation was not typical for peritonitis, although there were also several elements which cast some doubt over the putative diagnosis of urinary tract infection. I note that the episode was subsequently considered - and not criticised - through a morbidity and mortality meeting which aims to facilitate an objective and arms-length review for learning. The role of clinicians involved in Mr Blewitt's presentation on 09 July You criticise the failure of the triage nurse and the assessing doctor to take proper account of the written notes from the UCC. It is not now possible to establish with certainty whether Mr Blewitt tried unsuccessfully to bring the note to the attention ofthe assessing doctor, or whether he assumed (quite reasonably) that all important elements would have been entered into eCare at triage and be available to the doctor. I agree that it is important for a doctor to make all appropriate efforts to understand the views of other professionals who have assessed a patient and referred them on. The fact of onward referral from the UCC should have made the doctor ask himself what it was about Mr Blewitt's presentation which rendered him outside the scope of the UCC to manage: the doctor should have been As a teaching hospital, we conduct education ond research to improve healthcare for our
patients. During your visit students may be involved in your care, or yoo may be asked to participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns.
TheM CJ COMMUNICATE. CC CONTRIBUTE. r~t:kj Milton Keynes University Hospital NHS Foundation Trust curious as to whether the UCC felt further tests were necessary, or whether there was such diagnostic uncertainty that a second opinion was effectively being sought. You suggest in your Regulation 28 Report that the doctor's contemporaneous record was not entirely satisfactory, particularly given his view at Inquest that bowel symptoms were not present. The contemporaneous record by the doctor on eCare states: Lower abdominal pain associated with urinary frequency ... exacerbation of supra public pain. There is no comment in relation to bowel habit in either this document or the discharge summary. The ED triage note on eCare had also focused on sudden abdominal pain in the suprapubic area and stated, 'sent to ED due to level ofpain with no clear cause', without reference to bowel habit. On review (in the writing of this letter) of the records from the urgent care centre, reference to bowel habit was as follows: 'Abx have given him diarrhoea - stool was loose prior'. The UCC record very much focuses on pain rather than bowel habit. The statement prepared for the Inquest, finalised approximately 5 weeks after the clinical contact, states: On further questioning, Mr Blewitt did not have any nausea, vomiting or change in bowel habit. As shown above, there is no contemporaneous reference to bowel habit within the notes against which to reference his comment in relation to responses to further questioning. The doctor may have been basing this on his usual practice when taking a history from a patient with abdominal pain. I shall meet with the doctor in question to further understand his perspective on both elements. Clearly, a distinction may emerge between having inaccurately recorded the history given and having been insufficiently thorough in eliciting an accurate history. There are I am sure other potential explanations. From reviewing entries from three clinicians (UCC and MKUH ED) on 09 July 2022, it is not clear to me that As a teaching hospital. we conducteducation and research ta Improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to
participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns.
TheM CAAL COMMUNICATE. CC CONTRIBUTE.
r.!1:kj Milton Keynes University Hospital NHS Foundation Trust changes in bowel habit were felt to be particularly prominent at that time: pain was the over-riding symptom. I am sure - given that you have shared your Regulation 28 Report with colleagues at the General Medical Council (GMC) - that I will discuss the case with the GMC Employer Liaison Adviser in due course. Indeed, the doctor will likely seek to report himself formally to the GMC on the basis of paragraph 75 of Good Medical Practice: I would ask you to reflect on how this criticism could have been shared in parallel with your Regulation 28 Report - potentially in writing to me as Responsible Officer. The doctor now finds himself in a rather grey position in relation to paragraph 75 some ten weeks after the Inquest (and having not himself been a recipient of the Regulation 28 Report). We have made advances over the last year or so in relation to the visibility of electronic patient records between different providers and IT systems involved in a patient's pathway. Specifically, through use of the Health Information Exchange (HIE), it is possible for clinicians at MKUH to see selected content from the primary care record in SystmOne. This content includes read-only access to clinical notes from the UCC. By the same token, selected eCare content is available to colleagues using SystmOne. Sepsis work more broadly You will be aware that the Trust is transitioning from the reactive 'root cause analysis' investigation of clinical incidents to the new national Patient Safety Incident Response Framework (PSIRF). PSIRF will afford us more discretion going forward in targeting our governance efforts to those areas where they have the greatest opportunity to make a positive impact for future patient care. In reviewing our historic incident profile, we have determined that we should focus our efforts on a couple of areas relevant to this Regulation 28 Report, namely: Robust clinical triage on presentation to the ED including timely management of sepsis where indicated. Recognition of, and response to, deteriorating patients - including escalation - in the inpatient environment (where sepsis may well be the driver of that deterioration). Asa teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to participate in a clinical trial. Please speak to your doctor or nurse iiyou have any concerns.
TheMK ,~1:kj CAI< COMMUNICATE. M ilton Keynes COt CONTRIBUTE. University Hospital NHS Foundation Trust Notwithstanding this planned focus, it is noteworthy that our in-hospital mortality rate for patients with a coded diagnosis of sepsis across 2022/23 was 15.9% (lower than both the prior year and the national average). Sepsis is included as a priority within our 2023 Quality Account (due to be laid before Parliament in June 2023) and we have set up a 'Sepsis Quality Improvement (QI) Group' under the chairmanship of an Associate Medical Director who also happens to work as a Consultant within ED. The Sepsis QI Group will use quality improvement methodologies to provide assurance on current performance and to drive further improvement in areas contained within the relevant NICE quality statements, including: Use of standardised physiological monitoring (NEWS2) Senior review and timely antibiotics for patients screening positive for sepsis Appropriate and timely fluid management Escalation of care to a high dependency environment where appropriate Effective antimicrobial stewardship We are also working to improve the way in which we capture learning from the work of our Medical Examiners and the Structured Judgement Review (SJR) process, including in relation to deaths involving sepsis. Other Actions The Chief Nurse and I will be writing to all registered staff in the ED to highlight the key elements of Mr Blewitt's case, and to remind them of the issues referenced in this letter: Importance of reviewing notes I letters from referring colleagues (where applicable), and the HIE functionality within eCare in respect of patients referred on by UCC. Requirement for all medicines, including intravenous fluids, to be prescribed correctly in eCare and for their administration to be documented. Only in very rare circumstances should documentation occur in parallel with / after administration, and this too must be recorded clearly within the record. The specific issue of the 'short infusion' order for fluids in ED, with signposting of the available video resources and an emphasis on the sepsis PowerPlan. As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to participate in a clinical trial. Please speak to your doctor or nurse ifyou hove any concerns.
TheMK CA,, COMMUNICATt. CC CONTRIBUTt. t~1:kj Milton Keynes University Hospital NHS Foundation Trust Value of the 'sepsis 6' interventions, with a particular emphasis on timeliness of antibiotics and intravenous fluids. I trust that this response is helpful. rely,
Medical Director / Deputy Chief Executive Copies , Chief Executive, Milton Keynes University Hospital , Medical Director, BLMK Integrated Care Board Relationship Manager, CQC Employer Liaison Officer, GMC As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your core, or you may be asked to
participate in a clinical trial. Please speak to your doctor or nurse ifyou hove any concerns.
• Lack of attention to the referral note from the UCC - inaccurate transcription by the triage nurse and failure of the doctor to seek out the original.
• A failure on the part of the assessing doctor on 09 July to record change in bowel habit as a prominent presenting symptom in his contemporaneous record, leading to an implied concern about the accuracy of the record and his subsequent evidence.
• Lack of reliable recording of IV fluid administration in the ED - you note that the author of the internal Serious Incident Report had been unable to demonstrate any remedy to this issue since the incident.
• A potential contributory factor (fluid prescriptions 'disappearing' from the electronic prescription chart) had not been raised to hospital authorities between the date of the incident and the date of the Inquest.
T eMK CARE COMMUNICATE. COU. CONTRIBUTE. r,•t:kj Milton Keynes University Hospital NHS Foundation Trust
• A Serious Incident Report which you felt to be of an unacceptable standard (in part as it noted the poor documentation of fluid prescription but did not explore further). Prescription of Fluids in the Emergency Department and documentation of the same The narrative around the prescription of intravenous fluids in the Serious Incident Report, Inquest statements and verbal evidence seems to have been complex and nuanced at best, contradictory at worst. Intravenous fluids should be managed as any medicine in the hospital, prescribed (by a doctor I non-medical prescriber) and administered (typically by a nurse, occasionally by a doctor or operating department practitioner). Since we have been using our electronic patient record (an Oracle Gerner product, branded locally as eCare), both of these steps should take place within eCare. eCare has been the primary record system in the Emergency Department since May 2018. It has been the primary record system in the theatre environment since September 2021. As with paper records, it remains possible for medicines to be given by verbal order. This should occur only rarely when urgency is paramount, and it should subsequently / retrospectively be recorded very clearly in the record. As a rule of thumb, I would not expect the doctor (in the context of the Emergency Department) to leave the vicinity ofthe patient without completing the prescription. It may be that intravenous fluids may be more prone to administration without prescription than other medicines as a series of fluids may be administered in quick succession in a dynamic environment and - perhaps - on account of an erroneous view that fluids have less potential for harm than other medicines. During the course of Mr Blewitt's Inquest, views were offered in relation to the prescribing of intravenous fluids within eCare. It seems that there may have been a lack of understanding, and perhaps some misunderstanding, of the technical position and the impact that this might have had on practice and record keeping. Several years ago, we became aware that prescriptions for intravenous fluids would 'expire' if they had not been administered (commenced) prior to the time at which a prescription should have been completed. For example, if a 1000ml bag of intravenous saline was prescribed at 16:03 to run over 12 hours, the prescription would expire (and As a teaching hospital. we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your core. or you may be asked to
participate in a clinical trial. Please speak ta your doctor or nurse if you hove ony concerns.
heMKWa r,•1:k1 CJ. COMMUNICATE. Milton Keynes CC CONTRIBUTE. University Hospital NHS Foundation Trust disappear from view as a medicine awaiting administration) at 04:02 the next morning. It would still be visible in the record ('greyed out'), with details of the prescriber and the time of prescription but it will be marked as 'completed but not given'. This is a feature of the Oracle Gerner product internationally and has some benefits / advantages. Ordinarily, this issue does not have a negative impact on workflows and clinical care. However, it is more likely to be problematic in a fast-moving dynamic environment such as the Emergency Department where fluid prescriptions may be administered over relatively short periods of time (i.e., over one hour rather than over 12 hours). Of note, fluid prescribing is undertaken differently in the USA (Oracle Gerner's base) and in the UK: in the USA fluids are ordered at a rate (e.g., 100ml/h) to run indefinitely/ until stopped, whilst in the UK fluids are ordered as a fixed volume to run over a defined and discrete period (e.g., 1000ml over 8 hours, then stop). This issue was raised with Oracle Gerner and we developed a distinct 'short infusion' order. In this scenario, the prescription remains a planned administration and does not 'grey out' on the chart at the expected time of completion The 'short infusion' order remains visible as due until it is administered, or when the patient is discharged from the clinical encounter. It does not expire at a timepoint related to the time of prescription and/or the calculated time of completion of administration. It has been specifically designed for use when prescribing fluids for infusion over a short duration (i.e., an hour or less). If doctors in ED prescribe fluids where there is a risk that they may not be started in an appropriate timeframe, or where a number of fluid options are laid out (e.g., depending upon an awaited laboratory result), these short infusions will be more suitable. They have also been included in a sepsis 'PowerPlan' (an electronic 'care bundle') intended to guide practitioners through the required orders for managing sepsis. The orders look as shown overleaf. A training video was also developed for staff around the short infusion workflow. In Mr Blewitt's case, documentation around fluid administration is poor but it does not seem that this specific eGare related issue - which I think was introduced into evidence at the Inquest - was relevant. At 21 :28 on 11 July, a 4-hourly bag of fluid was prescribed although it was never recorded on eGare as started (the prescription 'timed out' at 01 :37 the next day, so it As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your core, or you may be asked to participate in a clinical trial. Please speak lo your doctor or nurse if you hove any concerns.
TheMK r~1:kj CAR COMMUNICATE. Milton Keynes CC CONTRIBUTE. University Hospital NHS Foundation Trust remained on the chart available to be given until well after the patient left ED). Of note, antibiotics had been given at 18:55. Following the cardiac arrest, a retrospective entry was made by the anaesthetist describing the 5 litres of fluid given in the anaesthetic room. One entry that evening (by surgical staff) stated that the patient had received 2 litres of fluids in the ED. It remains possible, although it clearly cannot be demonstrated in the record, that Mr Blewitt did indeed have two litres of intravenous fluid in the ED. Indeed, he could have received more or less (which is clearly not a satisfactory position). It seems likely that members of staff visiting ED and reviewing Mr Blewitt (for example the two surgeons and the anaesthetist between 21 :39 and 22:15) would have commented had intravenous fluids not been in progress at the time of review, given the clinical scenario which had by that point emerged. Quality of Incident Investigation Report It appears that the specific issue of the intricacies of electronic prescribing surprised witnesses at the Inquest and in their efforts to provide answers for you, a confused picture emerged. At its core, all ED clinicians should be aware that: As a teaching hospital. we conduct education and research to improve healthcare for our patients. During your visit students may be involved in your care, or you may be asked to participate in a clinical trial. Please speak lo your doctor or nurse if you have any concerns.
TheM ,~1:bj CJ.. COMMUNICATE. Milton Keynes a CONTRIBUTE. University Hospital NHS Foundation Trust
1. Upon suspicion of sepsis, time-critical treatment (including fluids) should be commenced as soon as possible. The Royal College of Emergency Medicine's standard is that 75% of patients should be in receipt of fluids within 1 h of arrival, 100% within 4h.
2. High quality record keeping is key to the delivery of effective clinical care and is a professional responsibility for regulated healthcare professionals. This includes accurate documentation of patient history, examination, investigation and plan. Accurate prescribing, and documentation of administration of medicines, is essential. Incident Investigation Reports are reviewed through a weekly meeting (Serious Incident Review Group, SIRG) where there is some consistency of senior membership. This report was signed off by that group. The two key deficiencies which you infer were: acceptance of the diagnostic approach taken on 09 July; and identification of the issue of poor documentation on 11 July without further exploration of root causes or learning. Whilst I would accept both criticisms to a degree, I do not think they are as clear cut as your Regulation 28 Report implies. The 09 July presentation was not typical for peritonitis, although there were also several elements which cast some doubt over the putative diagnosis of urinary tract infection. I note that the episode was subsequently considered - and not criticised - through a morbidity and mortality meeting which aims to facilitate an objective and arms-length review for learning. The role of clinicians involved in Mr Blewitt's presentation on 09 July You criticise the failure of the triage nurse and the assessing doctor to take proper account of the written notes from the UCC. It is not now possible to establish with certainty whether Mr Blewitt tried unsuccessfully to bring the note to the attention ofthe assessing doctor, or whether he assumed (quite reasonably) that all important elements would have been entered into eCare at triage and be available to the doctor. I agree that it is important for a doctor to make all appropriate efforts to understand the views of other professionals who have assessed a patient and referred them on. The fact of onward referral from the UCC should have made the doctor ask himself what it was about Mr Blewitt's presentation which rendered him outside the scope of the UCC to manage: the doctor should have been As a teaching hospital, we conduct education ond research to improve healthcare for our
patients. During your visit students may be involved in your care, or yoo may be asked to participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns.
TheM CJ COMMUNICATE. CC CONTRIBUTE. r~t:kj Milton Keynes University Hospital NHS Foundation Trust curious as to whether the UCC felt further tests were necessary, or whether there was such diagnostic uncertainty that a second opinion was effectively being sought. You suggest in your Regulation 28 Report that the doctor's contemporaneous record was not entirely satisfactory, particularly given his view at Inquest that bowel symptoms were not present. The contemporaneous record by the doctor on eCare states: Lower abdominal pain associated with urinary frequency ... exacerbation of supra public pain. There is no comment in relation to bowel habit in either this document or the discharge summary. The ED triage note on eCare had also focused on sudden abdominal pain in the suprapubic area and stated, 'sent to ED due to level ofpain with no clear cause', without reference to bowel habit. On review (in the writing of this letter) of the records from the urgent care centre, reference to bowel habit was as follows: 'Abx have given him diarrhoea - stool was loose prior'. The UCC record very much focuses on pain rather than bowel habit. The statement prepared for the Inquest, finalised approximately 5 weeks after the clinical contact, states: On further questioning, Mr Blewitt did not have any nausea, vomiting or change in bowel habit. As shown above, there is no contemporaneous reference to bowel habit within the notes against which to reference his comment in relation to responses to further questioning. The doctor may have been basing this on his usual practice when taking a history from a patient with abdominal pain. I shall meet with the doctor in question to further understand his perspective on both elements. Clearly, a distinction may emerge between having inaccurately recorded the history given and having been insufficiently thorough in eliciting an accurate history. There are I am sure other potential explanations. From reviewing entries from three clinicians (UCC and MKUH ED) on 09 July 2022, it is not clear to me that As a teaching hospital. we conducteducation and research ta Improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to
participate in a clinical trial. Please speak to your doctor or nurse if you have any concerns.
TheM CAAL COMMUNICATE. CC CONTRIBUTE.
r.!1:kj Milton Keynes University Hospital NHS Foundation Trust changes in bowel habit were felt to be particularly prominent at that time: pain was the over-riding symptom. I am sure - given that you have shared your Regulation 28 Report with colleagues at the General Medical Council (GMC) - that I will discuss the case with the GMC Employer Liaison Adviser in due course. Indeed, the doctor will likely seek to report himself formally to the GMC on the basis of paragraph 75 of Good Medical Practice: I would ask you to reflect on how this criticism could have been shared in parallel with your Regulation 28 Report - potentially in writing to me as Responsible Officer. The doctor now finds himself in a rather grey position in relation to paragraph 75 some ten weeks after the Inquest (and having not himself been a recipient of the Regulation 28 Report). We have made advances over the last year or so in relation to the visibility of electronic patient records between different providers and IT systems involved in a patient's pathway. Specifically, through use of the Health Information Exchange (HIE), it is possible for clinicians at MKUH to see selected content from the primary care record in SystmOne. This content includes read-only access to clinical notes from the UCC. By the same token, selected eCare content is available to colleagues using SystmOne. Sepsis work more broadly You will be aware that the Trust is transitioning from the reactive 'root cause analysis' investigation of clinical incidents to the new national Patient Safety Incident Response Framework (PSIRF). PSIRF will afford us more discretion going forward in targeting our governance efforts to those areas where they have the greatest opportunity to make a positive impact for future patient care. In reviewing our historic incident profile, we have determined that we should focus our efforts on a couple of areas relevant to this Regulation 28 Report, namely: Robust clinical triage on presentation to the ED including timely management of sepsis where indicated. Recognition of, and response to, deteriorating patients - including escalation - in the inpatient environment (where sepsis may well be the driver of that deterioration). Asa teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to participate in a clinical trial. Please speak to your doctor or nurse iiyou have any concerns.
TheMK ,~1:kj CAI< COMMUNICATE. M ilton Keynes COt CONTRIBUTE. University Hospital NHS Foundation Trust Notwithstanding this planned focus, it is noteworthy that our in-hospital mortality rate for patients with a coded diagnosis of sepsis across 2022/23 was 15.9% (lower than both the prior year and the national average). Sepsis is included as a priority within our 2023 Quality Account (due to be laid before Parliament in June 2023) and we have set up a 'Sepsis Quality Improvement (QI) Group' under the chairmanship of an Associate Medical Director who also happens to work as a Consultant within ED. The Sepsis QI Group will use quality improvement methodologies to provide assurance on current performance and to drive further improvement in areas contained within the relevant NICE quality statements, including: Use of standardised physiological monitoring (NEWS2) Senior review and timely antibiotics for patients screening positive for sepsis Appropriate and timely fluid management Escalation of care to a high dependency environment where appropriate Effective antimicrobial stewardship We are also working to improve the way in which we capture learning from the work of our Medical Examiners and the Structured Judgement Review (SJR) process, including in relation to deaths involving sepsis. Other Actions The Chief Nurse and I will be writing to all registered staff in the ED to highlight the key elements of Mr Blewitt's case, and to remind them of the issues referenced in this letter: Importance of reviewing notes I letters from referring colleagues (where applicable), and the HIE functionality within eCare in respect of patients referred on by UCC. Requirement for all medicines, including intravenous fluids, to be prescribed correctly in eCare and for their administration to be documented. Only in very rare circumstances should documentation occur in parallel with / after administration, and this too must be recorded clearly within the record. The specific issue of the 'short infusion' order for fluids in ED, with signposting of the available video resources and an emphasis on the sepsis PowerPlan. As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your care, or you may be asked to participate in a clinical trial. Please speak to your doctor or nurse ifyou hove any concerns.
TheMK CA,, COMMUNICATt. CC CONTRIBUTt. t~1:kj Milton Keynes University Hospital NHS Foundation Trust Value of the 'sepsis 6' interventions, with a particular emphasis on timeliness of antibiotics and intravenous fluids. I trust that this response is helpful. rely,
Medical Director / Deputy Chief Executive Copies , Chief Executive, Milton Keynes University Hospital , Medical Director, BLMK Integrated Care Board Relationship Manager, CQC Employer Liaison Officer, GMC As a teaching hospital, we conduct education and research to improve healthcare for our
patients. During your visit students may be involved in your core, or you may be asked to
participate in a clinical trial. Please speak to your doctor or nurse ifyou hove any concerns.
Sent To
Response Status
Linked responses
1 of 1
56-Day Deadline
18 Aug 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 20 July 2022 I commenced an investigation into the death of Alexander Shone BLEWITT aged 48. The investigation concluded at the end of the inquest on 21 March 2023. The conclusion of the inquest was that: Alexander Shone Blewitt died at the Milton Keynes University Hospital on the 11th July 2022. He had attended on the 9th July 2022 after visiting the nearby Urgent Care Centre (UCC) and being referred to ED by the GP there. He was provided with a printout of his consultation with her. She was worried about him. That communication detailed his complaint of loose stools and abdominal pain. The triage nurse did not record the content of the UCC letter accurately and took that letter from Mr Blewitt. He later saw the ED doctor who did not see or read the UCC letter or attempt to source it. The ED doctor did not record any questions relating to bowel habit on his contemporaneous note, but sometime subsequent to Mr Blewitt's death wrote a statement in which he identified that he had and that there were no bowel complaints. This was despite several days of being faecally incontinent at home and highlighting this to the UCC doctor. The ED doctor sent him home with a diagnosis of a possible resistant or recurrent urinary tract infection even though the MSU taken by his GP a few days earlier and available to the UCC doctor showed no growth. Mr Blewitt, even though he was sent home with a diagnosis of a possible resistant urinary tract infection on the 9th July 2022, was told to continue the original antibiotics his GP had started him on and then to start the new ones the next day. Mr Blewitt spent a difficult two days with faecal incontinence and abdominal pain before returning on the 11th July 2022 to the ED. At this visit a possible acute abdomen was diagnosed and CT scanning confirmed this. He was taken to theatre and suffered a cardiac arrest before surgery and died the next day on ITU. It emerged in evidence that there were no reliable records of any fluid resuscitation in the ED available for examination. This is because the computerised system records the prescription of IV fluids but unless the prescription is signed, that prescribed item is erased. The best information I received was that he had received two litres of an unknown fluid at some point during his time in the ED. It seems that doctors were not as a routine signing the prescriptions and so no reliable record was retained. I was told that doctors had been reminded on the need to sign prescriptions but no audit of this had been carried out since Mr Blewitt's death.
Circumstances of the Death
Alexander Shone Blewitt died at the Milton Keynes University Hospital on the 11th July 2022. He had attended on the 9th July 2022 after visiting the nearby Urgent Care Centre (UCC) and being referred to ED by the GP there. He was provided with a printout of his consultation with her. She was worried about him. That communication detailed his complaint of loose stools and abdominal pain. The triage nurse did not record the content of the UCC letter accurately and took that letter from Mr Blewitt. He later saw the ED doctor who did not see or read the UCC letter or attempt to source it. The ED doctor did not record any questions relating to bowel habit on his contemporaneous note, but sometime subsequent to Mr Blewitt's death wrote a statement in which he identified that he had and that there were no bowel complaints. This was despite several days of being faecally incontinent at home and highlighting this to the UCC doctor. The ED doctor sent him home with a diagnosis of a possible resistant or recurrent urinary tract infection even though the MSU taken by his GP a few days earlier and available to the UCC doctor showed no growth. Mr Blewitt, even though he was sent home with a diagnosis of a possible resistant urinary tract infection on the 9th July 2022, was told to continue the original antibiotics his GP had started him on and then to start the new ones the next day. Mr Blewitt spent a difficult two days with faecal incontinence and abdominal pain before returning on the 11th July 2022 to the ED. At this visit a possible acute abdomen was diagnosed and CT scanning confirmed this. He was taken to theatre and suffered a cardiac arrest before surgery and died the next day on ITU. It emerged in evidence that there were no reliable records of any fluid resuscitation in the ED available for examination. This is because the computerised system records the prescription of IV fluids but unless the prescription is signed, that prescribed item is erased. The best information I received was that he had received two litres of an unknown fluid at some point during his time in the ED. It seems that doctors were not as a routine signing the prescriptions and so no reliable record was retained. I was told that doctors had been reminded on the need to sign prescriptions but no audit of this had been carried out since Mr Blewitt's death.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Documentation of technical adviser advice
Scottish Hospitals Inquiry
No open learning culture
Complaint record keeping failures
Publish Guidance and Board Minutes
Infected Blood Inquiry
No open learning culture
Complaint record keeping failures
Learning and information from complaints
Mid Staffs Inquiry
No open learning culture
Complaint record keeping failures
Learning and information from complaints
Mid Staffs Inquiry
No open learning culture
Complaint record keeping failures
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.