Dear Mr Harris Inquest into the death of Katie Louise Horne - Regulation 28 report Thank you for the letter from your clerk of 31 August 2022, enclosing your Prevention of Future Deaths report. Firstly, I wish to convey my deepest condolences to Katie's family on her tragic death. I am acutely aware that my response will not bring Katie back, or lessen the pain that Katie's parents feel, however, I hope they can take some small comfort in how seriously we have taken her death and the improvements that we have made. Although the delays at the Princess Royal Hospital did not cause Katie's tragic death from covid, I can assure you that Katie's case received senior oversight prior to the inquest as part of the complaint investigation and discussion at our serious incident review group, and it continues to do so. My response below summarises the actions we have taken, and the improvements we have made. The Chief of Service for the Division of Medicine confirms that the Acute Medicine service at the Princess Royal Hospital was set up in early March 2020 in response to the covid pandemic. As such, the service was predominantly run by a locum Consultant. However, we now provide, at a minimum, a substantive acute physician and geriatrician at the Princess Royal Hospital site every weekday, and the weekends the care and management is provided by the substantive general physicians. Ambulatory care, instead of running out of a small room next to the Emergency Department, as it was in March 2020, is now situated in a large area connected to the Acute Medical ward, with its own dedicated nursing, administrative, and medical staff. This shares the same clinical governance and standard operating procedures as the main ambulatory care area at the Royal Sussex County Hospital in Brighton. On§LQfthe~keystandard~operating procedu,res now in place is that any patient whose problem is not resofvable-withJnJWQ visifaJo Jhe emer§ency aml5T.ilatory care Llni( must be-referred to the ap_12roj)riate specialist service - this rufe was operaUonalat the Royal Sussex County Hospital in March 2020, bufff liad not at

that time been set up at the Princess Royal Hospital. I can assure you that it is in place and regularly reviewed by the Division to ensure it is working. Our Lead Consultant for Acute Medicine & Same Day Emergency Care has confirmed the following important changes we have made:
1. The Acute Medicine team now manage the rapid access medical unit (RAMU). A business case has been submitted for additional administration support for RAMU at the Princess Royal Hospital, in line with our service at the Royal Sussex County Hospital.
2. We now have a virtual environment which allows for the tracking of outstanding patient investigations, including blood test results.
3. We have established a Gastroenterology 'hot clinic' (urgent new presentation clinic), which ensures referral of all jaundice patients after their initial assessment and ultrasound scan. This 'hot clinic' is run by the Gastroenterology Registrars with Consultant support. Our Lead Consultant Gastroenterologisthc1s gonfirmed thatther~ar~ sp~c::ialiststaff available ?_aays .9. we,~l(fo contaafc>r advice. Furthermore, we now have a digital enhanced cordless technology (DECT) 'phone (in addition to the normal bleeps and mobile telephones) which the Gastroenterology Registrars carry to ensure they are contactable. The Gastroenterology Bleep number/DECT 'phone number is in the directory on the Induction app which all junior doctors are provided with. I can confirm that it is extremely unlikely there would be a similar delay in the future, as after initial assessment, the patient is now referred to Gastroenterology 'hot clinic' with their autoimmune profile pending. The Gastroenterology 'hot clinic' team arrange appropriate assessment, likely in person, at the Emergency Ambulatory Care Unit (EACU) at the Royal Sussex County Hospital, and they ensure that all the relevant test results are available from the laboratory. To ensure wider learning and sharing of the changes and improvements we have made, the c::ase has_p~E:l!J.PI.esented(anonymously)atour monthly Patient Safety Group which has a wTcTe attendance of staff from all our hospitals. ·····. Our services were under extreme pressure in March 2020 due to the first wave of the global covid pandemic. I hope the changes we have made since, set out in this response, provide you with assurance and confidence in our service. We strive to continually learn and improve the services we provide to our patients. My thoughts are with Katie's family and friends.