Dear Miss Hamilton-Deeley The late Mrs Frances Gibb Thank you for your Regulation 28 report of 10 December 2019, and for sending your Record of Inquest:. May begin my expressing my sympathy and condolences to the family of Mrs Gibb at this difficult time_ We cannot agree that lessons have not been learnt in relation to NEWS within the Trust During his evidence at the inquest, described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well: roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making) Level 9A ward, the on which Mrs Gibb was a patient, introduced the system in October 2019 and, as stated in his evidence, it is used effectively by all clinical staff. The Matron for Abdominal Medicine and Surgery has conducted a review and can confirm that: 100% of the staff on Level 9A have been trained to use Patientrack: 2 The system automatically calculates the NEWS score and prompts staff with regard to the frequency of required observations defined by the previous observations results 35 Monitors at the Nurse Stations give Team Leaders visibility of the NEWS scores of all the patients live I-Pads are taken on the Ward Rounds so doctors have up to date NEWS scores at all times_
5. This system also incorporates the Sepsis 6 Tool and other triggers to prompt staff if patients score in one parameter: 6_ Both nurses who cared for Mrs Gibb engaged in an After Action Review (AAR) with the Ward Matron and have reflected a deal on Mrs Gibb's care have learnt and acknowledged where we could have done better: The nurse who was caring for Mrs Gibb when she deteriorated recognises that she should have out a MET call at
21.00 hours due to sudden change in Mrs Gibb's NEWS score The ward the the They great put the

Mrs Gibb was reviewed by a doctor at that time she deteriorated and the staff prioritised Mrs Gibb back to bed believing that this may have been a vasovagal episode in the chair. She needed to be hoisted back to bed as she was too unwell to stand and the MET call was put out as soon as Mrs Gibb was safely returned to bed as her NEWS score did not improve_ 8 The case has been discussed (anonymously) at Matron led teaching sessions for all the staff on Level 9A ward to ensure the important learning points have been shared widely. We also now hold an AAR after all MET calls to ensure any learning is identified and shared, and that any issues are resolved. A robust governance process has been in place in the Surgical Division to ensure shared learning:
10.All new staff to the ward have received training on both NEWS and the importance of escalation of care.
11. We have increased the number of Band 6 Nurses on night shifts on Level 9A ward from 1 to 2 so the junior staff have more support with clinically deteriorating patients
12. The Trust now has a Critical Care Outreach service 24 hours a (this began on 22 July 2019) and Patientrack can also be viewed remotely by the Critical Outreach team_ Patientrack has greatly improved the process in the Trust for recording and acting on patients' observations as now the respiratory rate, heart rate, blood pressure, oxygen saturations, inspired oxygen, temperature, conscious level and pain score are entered directly onto |-Pads. The system automatically calculates the NEWS score and then prompts a Lowl Medium/ High" response which must be acknowledged by the staff caring for the patient: If a patient requires review, response is escalated via the hospital bleep system to the appropriate person: If a patient has a high NEWS score or more) the Patientrack prompt requires staff to consider whether a MET call is required. All clinical staff can log in and access Patientrack on any computer throughout the Trust: The latest NEWS score is also displayed within PANDA: You are welcome to visit Level 9A ward to see the system in use. Miss Stone, Head of Medico- legal Service would be happy to arrange this for you: Additional support The Critical Care Outreach team (CCOT) provide a 24 hour service at the Royal Sussex County Hospital (as well as the Princess Royal Hospital) and provide additional support to ward areas as part of the Medical Emergency Response Team (MET) CCOT lead ACUTE course teaching for trained nursing staff and contribute learning on acute patient deterioration to the nurse induction programme and the annual clinical updates Radiology As confirmed inl statement for the inquest; the initial CT report missed an embolus lodged in ihe superior mesenteric which was not causing radiological bowel changes at the time_ Iconfirmed that this was not an easy diagnosis to make and having shown the scans to some of his Consultant Radiological colleagues not all of them identified embolus on the imaging: As acknowledged by in his statement for the inquest; perception errors such as these unfortunately do occur in the field of radiology and any misses are discussed by the team in regular discrepancy meetings. did not state that he was under any particular pressure when he reported Mrs Gibb's scan, and he could not recall any particular interruption or distraction that night: However; the Chief of Service for the Central Clinical Services Division has reviewed the case and has shared it within the Division for learning can confirm that junior radiologists working overnight have access on site to Consultant Radiologists up to 9pm with telephone contact available overnight 9pm-8am, The team have been reminded of this and that must seek assistance from a Consultant whenever need extra support: The actions department have taken include: 2 of 3 being put day the artery the from they they the Page

AII Radiologists including trainees have been reminded to look specifically at the SMA when the request is for a queried ischemic bowel 2 The Protocol has changed so the reconstructions are thinner in two plains to enable better visualisation of the region_ 3_ All overnight scans are reviewed by a Consultant the following morning for those reported by pre Fellowship of the Royal College of Radiologists (FRCR) Part 2b trainees overnight: scans reported by post FRCR Part 2b trainees can be reviewed the following morning by a Consultant at the trainee's discretion 5_ Mrs Gibb's case has been re-presented in our REAL (Radiology Events and Learning through case review) meeting: Thank you again for raising your concerns following the inquest We do listen , and we do act and make improvements to the systems in place at the Trust