Dear Mr Irvine, Following the recent inquest touching upon the death of Ms. Juliet Saunders, please find the Trust's response in relation to the Regulation 28 report that was issued on the 18th May 2021. The following actions have been implemented in relation to the matters of concerns:
1. The absence ofany support within the emergency department during weekends, in dealing with patients with a learning disability:
• The Learning Disability (LD) Team provides an advisory service to support clinical teams during the hours of 09:00 - 17:00, Monday to Friday. To increase the cover to include weekends would require an increase in the LD establishment. The Trust has recently attempted to recruit a Lead Learning Disabilities nurse, however following three attempts; it has not been possible to find candidates with suitable experience to fulfil the requirements of the role. In addition to this, there has been a reduction in student applications for the learning disability nursing cohorts nationally. However, the Trust will continue with its recruitment to the post and has again advertised for this position in July 2021. The Trust has also developed a learning Disability Career map to attract staff into the Trust. In addition, the LD team have looked at different ways in which support can be provided to staff within the emergency department (as well as across the Trust) to care for learning disability and autistic patients who attend the Trust at weekends, bank holidays and out of hours. These are listed below:
• The Creation of a Safeguarding Oncall Manual. Relevant information pertaining to Learning Disability, Safeguarding Children, Safeguarding Adults, and Mental Health Act/Deprivation of Liberty Safeguards is now available for all staff who participate on the oncall rota. This manual is an aid memoire to assist staff.
• A Learning Disability Checklist has been created for use in the Emergency Departments on both hospital sites. The checklist was implemented on the 28th June 2021 for a trial period of 3 months. \iiii KiNJQ:,..; ~:,. Qu••~n,11 ,1 •• C h111ity UCLPartners SMOKEFREE

• A programme of LO and Autism training sessions has been implemented for Bands 6 and 7 Emergency Department Staff, to enable cascade training to all staff within the department.
• The Learning Disability Team attend all of the Departmental Keep In Touch Days and deliver a 2 hour training session to reinforce the key areas to focus on when caring for patients with a Learning Disability in the Acute Care Setting.
• KIT days were/are due to be held on the following days: o 27/04/2021 o 21/05/2021 o 08/06/2021 o 30/06/2021 o 20/07/2021 o 10/09/2021 - 2 sessions o 11/09/2021 - 2 sessions
• The Learning Disability Team provides teaching during induction of new doctors to the department. The case has been shared with staff within ED at the team briefs.
• A review of the Learning Disabilities Core Skills Education and Training Framework (Health Education England, 2016) has been undertaken by the Lead Nurse, Learning Disabilities and the Director of Nursing, Patient Experience & Engagement and Safeguarding Director.
• The Trust has approved the implementation of mandatory LD training, dependent of staffs roles and responsibilities. There are three different tiers of training, and staff would complete these dependent on their role within the organisation, for example non facing clinical staff would complete a different tier to clinical staff.
• The LO Team has liaised with the Communications Department to ensure that all staff have the information, tools and supporting information available digitally via the Trust intranet site. A standalone Learning Disabilities and Autism page has been created to include all of the resources contained within the ward LO and Autism Resource Packs.
• A review ofthe information available via the external Trust website has also taken place to ensure that patients, visitors and their carers/relatives have access to up to date information.
• A policy for People with Learning Disabilities and Autism has been approved and circulated across the Trust.
• A Learning Disability & Autism five year Strategy has been produced and was launched Trust wide on the 22nd June 2021. This strategy includes seven key priorities, which are Patient centered care, reasonable adjustments, Workforce, Decision making, Training, Service user engagement and Transition for children to adult services.
2. The poor standard ofmedical record keeping and documentation within the emergency department and observation unit:
• There are routine nursing documentation audits in place which are completed monthly and a peer review process has now been established between both Emergency Departments.
• The department conduct the following documentation audits to identify areas requiring improvement and to provide assurance that our documentation is monitored and improvements sustained. All of the audits are completed monthly other than two which are done weekly:

• Monthly: o Deteriorating patient o Falls o Morphine o Sskin o Mental Health documentation
• Weekly o Sepsis o Discharge and Transfer checklist.
• A weekly task and finish group was set up which was set up led and chaired by the DDON with all Lead Nurses and Matrons attending. Part of its remit was to review our compliance on both sites. Part of its remit has been to review our discharge and transfer compliance on both sites; the Matrons have completed their own weekly audits. We were keen to improve our compliance and tackle our underlying issues and deliver sustained care to our patients.
• The minimum compliance for all audits is 80%. Currently the discharge and transfer audit is at 85%.When the audits started the baseline level of compliance was 10%, since then there has been a steady improvement weekly.
• A Senior Sister and the Practice Development Nurse (PDN) have provided training on documentation. They have been speaking to staff during handovers, training sessions and impromptu discussions.
• There is a plan in place for Consultants to deliver clinical notes reviews as part of their supervisor meetings, with the next meeting to be held in August 2021. The Trust acknowledges that there has been some capacity issues which have impacted on the supervisors meetings, due to the impact ofthe Covid pandemic. The process will be part of supervisor meetings and will now be officially part of the appraisal process. The ED Consultant Clinical Supervisors plan to review 10 records of their supervisees notes and providing them direct feedback about their document which is led by a dedicated ED Consultant.
3. The failure ofsystems within the department to allow for the supervision ofjunior doctors to ensure that complex cases are escalated to more experienced staff:
• A consultant is allocated in each area of the ED at Queen's during the day up to 21:00 at night. The Consultant works alongside the junior doctors and will review all patients as needed. After hours and if there is not enough Consultants to be physically in every area, we will allocate a tier one/senior middle grade Doctor to supervise the area at both sites. We have 24 hour Consultant cover at Queen's and 18 hour Consultant cover at KGH. Regular board rounds are done in each area and Consultants are present for reviews in between.
• There has been reinforcement with the junior staff that there can be no handovers between FY2 level doctors and any handover should be to a Tier 2 doctor at a minimum. There is a dedicated handover Standard Operating Procedure (SOP). We have now installed a new IT system called Care Flow which requires Consultant sign off for specific patients such as patients with learning disability, cardiac chest pain and all patients that were seen by junior Doctors; i.e. FY2 and SHO.

• No patient with LD can be discharged without Consultant sign off. The new Care flow system has been designed in such a way that an alert is raised and the Junior Doctor must come and consult a Senior Doctor before the patient can be discharged
• Generally complex patients fall under the following categories and all require Consultant presence or input before patients can be admitted or discharged: o Trauma calls in adult or children, a Consultant must be present o Cardiac arrest and peri-arrest adults and children, a Consultant must be present o High frequency users o Cardiac chest pain o Learning disability o Aggressive patients o All patients admitted via the resuscitation unit o All patients that were seen by junior Doctors i.e. FY2 and SHO's
• No patients are allowed to be moved to the observation ward or the EDU without Consultant sign off. This has always been in the SOP. In this case the SOP was not followed.
4. Consecutive failures by medical and radiology staff to recognize abnormal findings within an abdominal radiograph, impacted upon by diagnostic overshadowing:
• Radiology clinical leads are in discussion with ED department to remove plain abdominal radiographs in assessing patients presenting with acute abdominal pain due to issues with low specifity and sensitivity. This would be in line with the recent GIRFT report in radiology and are meeting with ED to progress this. The ED department will be using CT scans for acute abdominal pain and clinically obstructed abdomens instead as sensitivity and specificity are much higher. The department has had discussions with the Radiology department and we need to involve general surgery to complete a new guideline. This should be complete by mid-August and the next meeting is scheduled for next week (W/C 19 July 2021).
• There is ongoing training and this has been added to the teaching rotation. Teaching takes place every Thursday and is done virtually to accommodate staff that cannot be present on site.
5. A lack ofclinical curiosity, combined with diagnostic overshadowing meant that there was a reluctance to depart from a queried diagnosis of gastritis which led to the failure to diagnose an acute intestinal obstruction:
• There has been a teaching session based on this case which highlighted the need to discuss patients with a learning disability with a senior team due to the risk of diagnostic overshadowing. This was presented in the January 2021 Mortality meeting. This included reference to escalation and consideration of CT scan and specific reference to Cornelia de Lange syndrome.
• In July 2021 Junior Doctor teaching on mental health including learning disability has occurred. This has included the Lead Nurse for LD & Autism being a speaker. This lecture included LD issues including diagnostic overshadowing.
• The teaching program is in full rotation which means that all the subjects will be repeated over a six month period. Safeguarding and diagnostic overshadowing will be included in the induction pack at the end of July 2021.
6. A departure from established procedures to ensure the safety of transfers to ensure the safety of transfers out of the emergency department onto the observation unit:
• Queens's Hospital Observation Ward closed in April 2020.

• The Observation Ward at KGH will be closing at the end of August as soon as building work is complete at KGH at the end of August.
• There is a consultant sign offthat is required prior to a patient being transferred to the Observation Ward area.
• There has been a review of the discharge process from the Emergency Departments and a focus from the Matron and Lead Nurse team to ensure that the staff within the department are following the correct procedure. There is an on-going audit process with PDSA cycle ensuring that there is compliance.
7. The absence ofsafety-netting advice to patients leaving the hospital:
• A discharge leaflet has been designed in partnership with patients which provides information on discharge. This will be launched shortly once the final approval has been signed off and the leaflet has returned from the printers. In addition to the leaflet, the Emergency Department are trialing a Discharge Helpline this is planning to launch from Monday 12th July and will provide a number to call if they have any queries after discharge. There is a draft SOP for the 2 month pilot period.
• The initiative is trying to provide a safety net service whereby patients who are discharged or leave the hospital can get in touch with us and clarify any further questions they may have. The leaflet contains contact numbers to assist in safety netting. The telephone line will be launched on Monday 12th of July by our Nursing team, the SOP is for the discharge helpline in place and will be audited weekly to ensure efficacy and to make necessary adjustments. The SOP is for internal staff to follow procedure and have a document to refer to ifrequired.
8. Ineffective identification ofsignificant care delivery problems through the Trusts own Serious Incident Investigation process, leading to a finalised report ofpoor quality:
• The Trust commissioned an external thematic review in March 2021, into Serious Incidents {Sis) from the period of January 2019 to December 2020. The review involved a structured review of SI reports as well as a review of SI related policies and procedures at the Trust. This was in conjunction with a series of semi structured interviews with staff at all levels of the Trust as well as site visits during which more informal conversations with staff and patients took place. The final report has now been received by the Trust. This will enable the Trust to undertake a review of existing systems and processes, and the opportunity to plan positive actions as well as planning for the transition to the new national policy framework, particularly the new Patient Safety Incident Response Framework (PSIRF), set to be rolled out nationally from spring next year. During the Covid pandemic governance arrangements, including SI reports were placed on hold, to allow for clinical staff to be released to support ward areas. The pause is still in place (the declaration of Sis or Never Event continues) however the Trust is taking proactive steps to ensure reports are still being progressed in line with reporting requirements, which the Trust is awaiting guidance from NHSEI and the CCG.