Dear Mr Brownhill

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Mrs Kathryn Millard I am writing in response to your report dated 26 April 2022, concerning the care provided to Mrs Millard whilst at Medway NHS Foundation Trust. Your report highlighted three matters of concerns which are listed below. For clarity I will respond to each of your concerns in the order they are raised;

1. The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented. It is concerning that this treatment plan was not recorded properly in the deceased’s notes.

In relation to the concern of poor record keeping by the medical doctor, the Orthopaedic team have discussed the outcome of the Serious Incident Investigation report at the junior doctor’s grand round.

Medical doctors have been reminded of the importance and principles of effective healthcare record keeping, which is a minimum standard. The quality of records should meet the Generic Record Keeping Standard, General Medical Record keeping Standards (Royal Academy of Physicians) and Standards for the structure and content of patient records (Academy of Medical Royal Colleges).

The adherence to national and Trust standards will be audited on a monthly basis and the results of the audit will be shared at local and divisional governance board meetings to ensure compliance and improvement in practice.

Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY

2. The medical records indicated that at least one doctor had indicated that Mrs Millard should have anti-embolic stockings applied. However, the nursing staff gave evidence that they were not aware of this.

The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed.

Since the recipient of this letter, the team has again sent out safety message to all nursing staff as a reminder of the expected standard. Compliance with expected practice will be audited monthly, and monitored during ‘Ward Rounds’ and ‘Drug Rounds’ and lessons identified will be shared at ward meetings.

3. The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if anybody did in fact attend), did not make any entry into Mrs Millard’s medical records. It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing staff.

As you highlighted, the Trust was unable to ascertain if Mrs Millard was indeed assessed by a clinician on 12 May 2021 when her condition deteriorated as there is no record of this care taken place. This does not meet the standards we would expect and all staff have been reminded that all patient contacts are to be recorded in the patient medical record in line with national and Trust guidelines. An audit of healthcare record keeping (including compliance with relevant Trust policy) will take place on an annual basis Trust wide. In addition, compliance with the expected documentation standards are included in the Ward to Board Assurance and Accreditation Process, which will be rolling out from 27 June 2022. The results of such audits will be reported via the Trust’s Governance structures for Quality, including outcomes and exceptions. In addition, ongoing regular audits will be undertaken using the Trust ‘Gather’ reporting system by Care Groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.

The Trust is committed to learning and improving the standards and quality of our services and care to ensure the best possible experience and outcomes for our patients, their families and carers. I hope that my response, in addition to the included action plan provides assurance that we have taken your concerns seriously and responded to them to ensure we implement lessons identified.

Action Plan (KM) PFD REG 28 - 07.06.22 Service Trust wide Action Description What will be the final outcome? (include required KPIs or evidence of delivery) Executive Lead Care Group Action/ Work stream Lead Key milestones to be achieved Start date Due date Revised due date Completion date RAG Assurance Mechanisms Comment/narrative Risk Register number (if applicable) Surgical Services NO Share the outcome of the SI investigation report at M & M meetings. The aim is to raise clinician awareness around such incidents. Divisional Medical Director Orthopaedics The Prevention of Future death was received by the Trust in April. The outcome of the inquest and content of the PFD will be shared with the Surgical team, Care Group Meeting and Divisional Governance Board. Aug-21 N/A Jul-22 Complete - approved Minutes from relevant meetings that information has been shared to be submitted to the governance team. The PFD and action plan will also be discussed at the Divisional Governance Board for learning. N/A Surgical Services NO Change the 'Ward based structure to team based. This will allow hierarchical tree with responsibility on specific individuals attending. Changing the set up of the clinical team on the ward will allow the hierarchical tree with responsibility on certain individuals attending (either that person or their buddy) rather than the ghosting that happens with ward based cover. Divisional Medical Director Orthopaedics Completed Aug-21 N/A Nov-22 Complete - approved This is now embedded in practice. Ward-based structure has now been transitioned to team based structure. N/A Surgical Services NO Ensuring good record keeping. All Consultant ward rounds to be dictated and affixed into notes by respective secretary Consultant. Any advised given by the surgical doctors on Ward rounds must be documented and communicated to Nurses. Divisional Medical Director Orthopaedics

Service Manager None Aug-21 N/A Jan-22 Complete - approved An audit of documentation on EPR took place in January 2022. An action plan is being complied to address the issue identified and EPR documentation will be re-audited in the next two months (End of August). N/A Surgical Services NO Audit of Consultant ward rounds and post take to be undertaken. This is to review the completeness and thoroughness and effectiveness of documentation. Outcome is that there is continuity in patient care and high quality patient care is maintained. Divisional Medical Director Orthopaedics

Service Manager None Aug-21 N/A Jan-22 Complete - approved An audit of documentation on EPR took place in January 2022. An action plan is being complied to address the issue identified and EPR documentation will be re-audited in the next two months. N/A Surgical Services NO Nursing training towards routine TED application for all inpatients and its application should be the norm, unless contra-indicated eg DVT. Raised awareness and knowledge. Nursing should be aware of when patients require TED stocking and should liaise with clinicians if not prescribed. This should improve patient care and lead to better outcome for the patient. Director of Nursing Orthopaedics Head of Nursing & Matron Completed Aug-21 Aug-21 N/A Aug-21 Complete - approved Compliance with expected practice will be monitored during ‘Ward Rounds’ and ‘Drug Rounds’ and lessons learned will be shared at ward meetings. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed. N/A Surgical Services NO Audit of Nursing notes on completeness and handover - gaps noted on communication to medics / escalation/ failure to document the correct weight of the patient etc. This will ensure that all actions from the clinicians have been completed or escalated where needed. Outcome is that there is continuity in patient care and high quality patient care is maintained. Director of Nursing Orthopaedics Ward Manager & Matron The questions on the documentation audit Jun-22 Monthly N/A On track Compliance with expected practice and lessons learned will be shared at ward meetings, Care Group Meeting and Divisional Governance Board. Matron's documentation audit utilising 'Gather' is to commence from June. N/A