Dear Ms Knight Thank you for your letter of 19 December 2022 received on 29 December 2022, in which you have shared the Regulation 28 with associated actions for improvement following the inquest into the sad death of Ms YDR aged 68 who passed away on 14 January 2021. I note that whilst the conclusion was narrative it is your view that some actions could be taken by the Health Board to minimise the risk of future deaths in similar circumstances. From your findings it became evident that the family of the deceased had not been (_ suitably alerted to the signs and symptoms of sepsis and if they had been made aware of the "red flags" they may have contacted staff sooner. In order to review the pathway of communication we have held several multidisciplinary meetings to consider the communication provided and to discuss where improvements could be made. I note that Abbott will respond to you under separate cover. the Health Board and Abbott have worked together to consider the most appropriate improvements across the communication pathway as people move through their journey of care. The eCORFLO booklet (Information for patients, relatives and carers, Gastrostomy feeding tube, Percutaneous Endoscopic Gastrostomy) the patient is given at time of the procedure has been updated to reference to sepsis (attached as Appendix One). People will also be given an additional information sheet if an early discharge occurs (attached as Appendix Two). The booklet and information sheet are in use. 6wrdd lec:hyd Pnfysgol Caerdydd ~·, FtQi yw enw gweith~OI Bw vrdd lechyd U.al Psify'9ol CatrdyOd a'r lllro Drd1ff and Vale University Health Board i1, th• opcratianal name of C:Jrdiff and Vale Unlve,,ity Local Healtll 8~rd C,oesawir y 9wtd<1~lh yn G~ neuSao$1H1P ~n tiY"(J(Jwn yn cJlfa.lhr8'bu, chi yn elChdelol,U llHth Nifydd gohebu _yn Gymmog ynaou unfhywo«J, , ,,.Bo.d~fc:on-.~nc.,,, W.,rih o,r Engli.sh. W• w•~'""Wit....oommurwc.e,~ it1 )'OINCIIOsM '•~-c«r..~nc• Ht Wfflll wilrrotWedlO. O.lay

In addition, we are considering suitable generic information to be given both at time of procedure and later in the community we are considering the SEPSIS awareness credit card size information. This will then be able to be used across wider areas, it gives simple clear information and is a highly visible card. We care for approximately 450 enterally fed patients within the UHB (not all with gastrostomies) so dietetics would purchase these so they could be issued at initial discharge as well as in the community when needed. Adult Symptom Cards IThe UK Sepsis Trust The patient can keep this with them and there is evidence that alert cards work quite effectively. We will in addition ensure a sepsis card is also given to children and their parents. We will use the Paediatric Symptom Cards I The UK Sepsis Trust to promote awareness of the signs and symptoms of children who are developing sepsis. We r will commence use of the cards as soon as possible. We will advise the other Welsh health board dietetic teams of actions taken in response to the Regulation 28 for their consideration as an all Wales approach would be helpful. In summary Cardiff and Vale UHB will update the current patient information provided to new patients with Percutaneous Endoscopic Gastrostomy to include the signs of sepsis. This updated information will be provided to patients and their family/carers by Cardiff and Vale UHB. The Abbott Nurse Advisors team will carry a supply of this updated literature and ensure that any new patients they see have this information. If they do not, the Abbot Nurse Advisor will supply this. I hope that this information is helpful and offers the assurance you are seeking regarding the improvements instigated to ensure patients and their families in similar circumstances to Ms R will be provided with the relevant information to consider the signs of sepsis at the earliest opportunity.

Dear Ms Knight Abbott responseto Regulation 28 Report (ref: 323219) dated 13December 2022 (the "Regulation 28 Report") For clarity, the Abbott Nurse Advisor team is employed by CHASE and, on behalfofAbbott Laboratories Limited (Abbott), their role is to fulfil an enteral feeding nursing service. as part ofan NHS Contract Specification. Abbott currently holds an enteral feeding contract with Cardiff and Vale University Health Board (Cardiffand Vale UHB). In accordance with the existing contract specification between Abbott and Cardiff and Vale UHB, the Abbott Nurse Advisors (the ANAs) are only permitted to issue patient information as authorised by Cardiffand Vale UHB. Abbott and Cardiffand Vale UHB reviewed how the requirements ofthe Regulation 28 Report can be met and the following has been agreed between the parties on 3 February 2023: Cardiffand Vale UHB have updated their current patient information provided to new patients with PEGs to include the signs ofsepsis. Document updated 30 January
2023.

C This updated information will be provided to patients and their family/carers by Cardiffand Vale UHB from 6 February 2023. The ANA team will carry a supply ofthis updated literature and ensure that any new patients they see have this information. If they do not, the ANA will supply this. We anticipate that this will be implemented by the ANA team by 1 March 2023 (upon receipt from Cardiff and Vale UHB). Cardiffand Vale UHB will purchase Adult and Paediatric Symptom Cards (cards with the symptoms ofsepsis). This information will be given to any patients who presentwith signs of an infection with copies shared with relevant family members/carers. The ANA team will carry a supply ofthese cards (to be initially provided by Cardiff and Vale UHB) and ensure that they are shared ifany patients present with signs ofan infection. Adult and Paediatric Symptom Cards ordered byCardiffand Vale UHB on3 February 2023. We anticipate that this will be implemented by the ANA team by 1 March 2023 (upon receipt from Cardiffand Vale UHB).