Dear Dr Cummings Regulation 28: Report to Prevent Future Deaths am writing to you following receipt of Regulation 28 report dated 28 March, subsequent to the Inquest held by you on 02 February into the death of Mr Nicholas Rousseau who died in October 2019. Mr Rousseau died from acute bowel ischaemia_ He had attended the Emergency Department at the hospital on two occasions in the week prior to his death_ On the first attendance, a venous blood gas had been taken which demonstrated that Mr Rousseau had blood lactate level of 3.9 mmolL The Regulation 28 report highlights conflicting accounts given by two senior members of the medical staff in relation to the importance that should have been placed upon this result and the actions, if any, that it should have prompted. Specifically, you assert that an elevated blood lactate level on presentation should have been repeated (referencing NICE Sepsis Risk Stratification Tools). Before coming to the substantive matter of blood lactate levels, would like to take this opportunity to extend my condolences and sympathies to Mr Rousseau's family. am conscious that any sense of divergence in view at Inquest, between HM Coroner and attending physicians will have added to the family's distress: am not clear from the Regulation 28 report whether you consider that an alternative course of action regarding the measurement of blood lactate might have afforded an opportunity to alter the subsequent clinical course and Mr Rousseau's untimely death: For avoidance of doubt; we do not consider this likely. teaching hospital; we conduct education and research lo Improve healthcare for our palients. During your visit students may be involved in your care; Or you may be asked {0 participale in clinical trial: Pleaso speak I0 your doctor or nurse if you have Cny concerns:

TheMK Way [S CARE COMMUNICTE Milton Keynes Collaborat, conRIBUTE University Hospital NHS Foundation Trust There are several pertinent points in relation to the issues that you raise: Ultimately it has been determined that Mr Rousseau died from ischaemic bowel and therefore it might be postulated that his presentations on 03 and 05 October were related: Mr Rousseau did not have risk factors for either acute or chronic mesenteric ischaemia: The predominant symptom on 03 October was vomiting and on 05 October; it was vomiting and diarrhoea with abdominal Had his blood lactate level been rechecked on 03 October, it seems likely (given the normal levels on 05 October) that it would have been improving: In the absence of abdominal pain, it is very unlikely that the attending physician would have considered that a CT scan of the abdomen would have been indicated, still less mesenteric angiogram: Whilst it is taught that ischaemic bowel can be a cause of elevated blood lactate levels, this is non-specific marker. Elevations in blood lactate level may also occur in association with dehydration. It is important to note that Mr Rousseau did not have sepsis at the time of either of his presentations to the Emergency Department: Whilst was not present at the Inquest and have not been privy to detailed account of discussions, wonder if clinical colleagues were surprised by granular discussion on 'blood lactate and sepsis guidelines' in relation to the case of a patient who was not thought to have had sepsis and who subsequently died from bowel ischaemia. The NICE guideline Sepsis: recognition, diagnosis, and early management (NG51, 13 September 2017) defines several_markers of high risk in those presenting with suspected sepsis ('high risk criteria ) These include: altered mental state; respiratory rate >25 per minute; systolic BP <9OmmHg; and, HR 130bpm. There are paired risk stratification tools (flowcharts) accompanying this guidance, to which you refer. The guideline notes that an elevated blood lactate level can be a marker of severity of sepsis and is associated with poor outcome: It is therefore an important test to be undertaken on patients presenting with suspected sepsis and can influence subsequent assessment, treatment;, and monitoring_ NICE guideline describes a lactate over 4mmolL as being of heightened concern in patient presenting with suspected sepsis A lactate of between 2 and 4mmol/L is regarded as an intermediate ievei: The NICE guideline does not make any specific reference to repeated or serial measurements other than implicitly if a person with suspected sepsis and any high-risk criteria fails to respond within an hour of initial treatment it is recommended that a consultant is teaching hospital; we conduct education and research 10 improve heoithcare for Our patilenls During your visit students may be involed in your care, Or you may be asked to nnrtirinnte in 0 cliniral tricl Please soeak t0 vour doctor or nurse if you have Ony concerns pain the The

TheMK WNay NHS] CARE COMMUNICATE Milton Keynes COLLABORATE CONTRIBUTE University Hospital NHS Foundation Trust alerted: A failure of the blood lactate to fall by >20% from the initial value over the first is specified as a marker of failure to respond_ Mr Rousseau presented on 03 October with a history of diarrhoea and vomiting: The clinical impression was oe of mild gastroenteritis associated with a slight tachycardia Mr Rousseau was not suspected of having sepsis on this attendance: His blood tests formed of baseline assessment of a patient presenting through the 'majors' pathway (as opposed to the ambulatory 'minors' pathway) with undifferentiated illness They were not triggered by a specific suspicion of sepsis Even if sepsis had been suspected, Mr Rousseau would have been presenting without any high-risk criteria, meeting just one 'moderate to high risk' criterion (tachycardia 91 to 130 beats per minute): In these circumstances, blood tests are' not mandated by guidelines. In the absence of high-risk criteria, the reference to a 20% reduction in an initial blood lactate does not arise_ Mr Rousseau was given intravenous fluids and monitored_ His vital signs were checked on two further occasions and were normal aside from persistence of tachycardia (improved from 114 to 103 bpm): He was then discharged. Approach to the identification and management of sepsis in the Emergency Department As above, it was not considered that Mr Rousseau was presenting with sepsis at the time of his attendances and therefore the relevance of compliance with sepsis guidelines is perhaps limited. However , we fully agree that the early recognition, assessment; and management of sepsis is a core function of an Emergency Department: In this regard, the Emergency Department: Maintains a local MKUH policy that is consistent with national guidance (including NG51): The current policy is due for scheduled review in November 2021. Operates an induction and weekly teaching programme, led by consultants; to ensure that each cohort of junior and middle grade medical staff is fully aware of the importance of this topic and the local management guidelines: Makes full use of the National Early Warning Score (NEWS) as part of the triage monitoring process in patients attending the department; Heavy investment in our IT infrastructure (Cerner eCare) means that measurement, calculation, and display is automated teaching hospital we conduct educalion and research to improve heallhcare for our palients. During your visit students may be involved in your care or yoU may be asked t0 parlicipale in clinical trinl Please speak I0 your doctor or nurse you have any concerns hour part

TheMKWay NHS CaRe COM'MUNICATE Milton Keynes Aborfie CONTRIBUTE University Hospital NHS Foundation Trust a model of Rapid Assessment and Triage (RAT) whereby 'majors' patients are seen by a more senior clinician at the outset of their time in the department; and appropriate investigations are ordered (and the results reviewed) promptly- Near patient testing (with its shorter turnaround time) is available and used. Participates in Royal College of Emergency Medicine (RCEM) national audits, including the audit on sepsis in 2016-17 . This audit examined performance in relation to 8 standards and the Trust performed at above the peer median: The profile of sepsis is also high across the wider Trust: Proposed Actions Whilst these actions are not specifically prompted by Mr Rousseau's case, the Trust will continue with existing measures as described above and: 1_ Ensure that the MKUH sepsis policy is updated for November 2021 2 Repeat an audit locally of the management of patients with suspected against the eight RCEM standards
3. Consider the case for the designation of a sepsis lead within the department with specific responsibilities for ensuring that the profile of sepsis rerains high: We shall also ensure that the Regulation 28 report, this response and a summary Of Mr Rousseau's case are discussed at an appropriate departmental forum in order to ensure that there is a wide understanding of the issues raised and that clinicians are reminded of the particular challenges in making positive diagnosis of bowel ischaemia hope that this response is helpful