Dear Dr Fox, Fax 0117 974 3203

INQUEST INTO THE DEATH OF MR ANTONIS HANNIDES RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I am writing in response to your Regulation 28 Report dated 11.11.19 following your Inquest into the death of Mr Antonis Hannides, who underwent hernia repair surgery at Spire Bristol Hospital ("the Hospital") on 21.03.19. MATTERS OF CONCERN
1. No formal system at Spire Bristol for seeing patients who re-attend unexpectedly after discharge.
2. No formal system at Spire Bristol for ensuring full and comprehensive record I Ii I I I keeping in accordance with GMC and NMC guidance.
3. No formal system for ensuring that consultants are informed immediately of any patient who re-attends unexpectedly after discharge. SPIRE'S RESPONSE FORMAL SYSTEMS IN PLACE AT SPIRE BRISTOL FOR PATIENTS WHO RE-ATTEND UNEXPECTEDLY AFTER DISCHARGE. It is anticipated that some patients who have undergone treatment at a Spire Hospital may contact the Hospital with enquiries about their care after discharge. As such, Spire Healthcare has an Admission and Discharge policy (in place at the time of Mr Hannindes' admission) which outlines a number of key steps that must take place as part of any patients' discharge planning process, to ensure that patients are supported after they leave hospital and are aware of how to seek advice if they have concerns. At the point of discharge, all patients will receive a detailed discharge summary (with a copy sent to their GP). The summary includes details of how the patient (or their Legal\50770630.1

carer) can get in contact with their Spire Hospital should they have any concerns regarding their recovery or discharge, together with relevant contact telephone numbers that provide 24 hour access to a qualified member of nursing staff. The policy also outlines a formal process nursing staff should follow in the event a patient (or their carer) contacts a Spire hospital with an enquiry about their care after discharge. All enquiries are first assessed by a nominated, qualified member of the Hospital nursing team, who will make an assessment (a triage) of the next steps required and depending upon the patient's clinical needs. Nursing staff are supported in their triage assessment by comprehensive guidance in the policy on appropriate sign-posting for medical assessment, including escalation to the Registered Medical Officer (RMO) and treating consultant, where appropriate. In light of the concerns raised at the Inquest, Spire Healthcare has updated its National Clinical Admission and Discharge policy (copy enclosed at Appendix A) to ensure that the existing triage process applies equally to patients who unexpectedly re-attend the hospital (as happened in Mr Hannindes' case). In such circumstances, the policy provides that the patient must be reviewed by an RMO. The patients' consultant must be informed of their attendance post-discharge and the RMO or nurse reviewing the patient must document that the consultant has been notified (and when), and whether advice has been sought from the consultant. Where advice was not specifically sought before providing care, for example as a result of minor concerns, the reasons for not doing so should also be documented. The policy requires that any patient that has attended the hospital must be contacted within 24 hours of attendance by the RMO and the follow up call must be documented in the patient's medical records. Post-discharge re-attendances will be reported onto Spire's incident management database to ensure the hospital tracking of the patient's outcome and any learning as a result Any patients who unexpectedly present to a hospital post-discharge with seriously concerning symptoms would be immediately escalated to the operating surgeon by the RMO for advice. In addition to the enhancing its National policy for handling in-person post-discharge enquiries, Spire Healthcare has also:­
1. Updated its RMO Handbook (copy enclosed at Appendix B) to emphasise the RMOs' key responsibilities, aligning these to the escalation requirements in the Admission and Discharge policy.
2. Been working together with its corporate provider of RMOs, NES Healthcare, on the dissemination of the learning from the sad events following Mr Hannindes' death. NES have provided all of their RMOs with a copy of "how to be an excellent RMO" on induction (copy enclosed at Appendix C). In addition to this the learnings from this case have been provided to all RMOs, across the Spire network, via a clinical update issued by NES on 5th December 2019 (copy enclosed at Appendix D). The update identified learning points including that:­ Lega!\50770630.1 Page2 of 5

1. A full clinical assessment should be undertaken of patients who re-attend unexpectedly following discharge and fully documented;
2. For patients who re-attend the Hospital unexpectedly following discharge there is a process in place and it should be documented to follow up with the patient
3. RMOs should always make good clinical notes in the patient care records. If the patient's medical records are not immediately available, a record of the examination should be made and placed within a temporary folder. All documentation should then be merged with the original medical records as · soon as possible.
4. RMOs should inform the Consultant of all patients who return to the Hospital for a review. The patient's consultant should be contacted immediately and the attendance documented.
5. If the patient's NEWS score is 7 or more, the patient must be reviewed by a Consultant and a detailed entry should be made in the clinical notes.
6. If the patient's Consultant is unavailable or if there is a delay, the RMO can arrange to transfer a deteriorating patient to an appropriate NHS Hospital. The Consultant should be kept informed.
7. Do not delay taking action with any deteriorating patient. FORMAL SYSTEMS AT SPIRE BRISTOL FOR ENSURING FULL AND COMPREHENSIVE RECORD KEEPING IN ACCORDANCE WITH GMC AND NMC GUIDANCE. All nursing and medical staff at Spire Bristol are subject to professional and contractual obligations to maintain good record keeping standards. Those obligations are detailed in Spire's Patient Records policy (which was in place at the time of Mr Hannindes' care, a copy of which is enclosed at Appendix E) and provides that "an entry should be made in the healthcare record whenever a patient is seen by a clinician or member of staff. All clinicians and healthcare professionals must make clear, accurate and contemporaneous records relating to their patients. The record must contain regular and timely progress notes, observations and consultation reports made by such professionals. In addition to Spire Healthcare's requirements, clinicians and healthcare professionals may formally be required to do so by their professional regulatory body." All RMOs practising at Spire are provided with a copy of Spire's RMO Handbook, and an induction pack (copy enclosed at appendix F) which outline further the obligations with regard to good medical record keeping and adherence to Spire's Patient Records policy. Spire Bristol undertake routine audits of record keeping standards at the hospital in keeping with the Spire Patient Records policy. An additional audit has been added to the local 2020 schedule that will focus specifically on the standard of documentation in the medical records where patients have re-attended the hospital following their discharge. All employed staff at Spire Bristol are required to complete mandatory on-line information governance training at induction and then on an annual basis as a reminder of their responsibilities to adhere to Spire's patient records policy and good medical record keeping practices. Similarly, as part of their mandatory training programme, and before starting with any Spire Hospital, all NES RMOs are required to Legal\50770630.1

also complete online training modules via the NES website, which includes record keeping standards and escalation to consultants Appendix G details the training that NES RMO's are required to complete. Evidence of completion is provided to the hospital prior to the RMO commencing their placement, which was received for the RMO concerned. As identified above, in light of the concerns raised at the inquest, Spire's Admission and Discharge policy and RMO Handbook have been updated to remind staff of the requirements and standards of good medical record keeping practices and explicitly how post-discharge enquiries should be recorded. This policy requires that any clinical encounter with the patient must be comprehensively documented in the patient's records by the clinical staff involved in the patients' care. In situations where the patient's notes are not immediately available, for example as a result of any out of hours query (or in Mr Hannindes' case as a result of an un-expected presentation to outpatients), then a temporary set of records will be created by the team involved in the care of the patient, and merged as soon as possible with the original patient records. At Spire Bristol there is a folder that is held on the ward for temporary records and the medical records department collect this daily and any temporary records are merged with the full patient record. Spire Bristol has undertaken a number of local actions to share learning from this case with respect to record keeping practices including:­
1. Shared learning sessions reiterated the process that should a patient re-attend the hospital, whether expected or unexpected, that a temporary file must be made and the assessment, findings, plan and advice given must be documented on clinical continuation sheet. This file must then be placed in the ward folder for collection and merging with the patient's medical records.
2. Shared learning sessions from the incident were provided to all clinical staff as a priority to reiterate the NMC standards of documentation ..
3. The RMO involved in Mr Hannindes' care has been asked to complete her own reflection of the case for her appraisal to be discussed with her supervisor. I hope that my response and the actions outlined therein provides assurance to HM Coroner and Mr Hannides' family that the Hospital have taken on board and acted upon the concerns which have been raised. Interim Hospital Director Spire Bristol Hospital Appendices Evidence of actions taken Legol\50770630.1 Page4of 5

Appendix A: Spire's Admission and Discharge policy Appendix B: Spire's RMO Handbook Appendix C: NES guidance on "how to be an excellent RMO" Appendix D: Clinical Update from NES to RMOs 5.12.19 Appendix E: Spire's Patient Records policy Appendix F: Spire RMO induction Appendix G: NES mandatory training for RMOs Legal\50770630.1

Dear Re: Telephone Follow Up Appointment As part of your ongoing care following your surgery at ......... Hospital you were to be contacted by telephone. On three separate occasions I have telephoned your number and have been unable to make contact with you. Your Consultant and GP have been made aware of this. From / / please contact your GP if you have any further queries. In the meantime, please contact me on the above number if you should wish to discuss this further. Yours sincerely {GP Letter} Dear Re: Patient Details The above named patient was to be followed up by telephone following their .............................. surgery at......... Hospital. I have been unable to contact this patient on three separate occasions, including the date and time we agreed with them. I have not made any further appointments and have sent a letter to the patient informing them of the above. From / / the patient has been advised to contact you if they have any further queries. Should you be aware of any changes in the patients circumstances or require any further information please do not hesitate to contact me on the above number.