Dear Ms Nadia Persuad 13th August 2019 RE: Mrs Shahida Begum Report to Prevent Future Deaths STEIS 210377 Followingreceipt of the Regulation 28 Report into the above patient, am writing on behalf of Barts Health NHS Trust to clarify the actions taken by the trust to prevent future deaths We revewed the report in meeting held July 2019, with representatives from the Emergency Department; GP Cooperative, Care Centre, Govemance team and CCG_ Action to Address;: #Itvas considered by myself (as Coroner) by an independent emergency medicine expert and a senior doctor Newham University Hospital that a safer system Iould be for the streamer to have the clinical observation available to them before see the patient" We rviewed the.initial assessment team functioning; to identify ways to address the above issue We also aimed to ensure there were no unintended negative consequences from pathway , such as an overall increase in assessment time, which could hawe changes to the other patient groups_ an adverse impact on Since this incident we have changed our procedures so that the vtal sign records are taken and made available to the streamer before the streaming decision is made_ We have also provded additional training for streamers and wil continue to do this on a ongoing basish@venaure poedmers 0f the importance of abnormal clinical observations when assessing the suitability are aware assessment in the urgent treatment centre: of patients for Yours sincerely {z_ Coro _ Professor Alistair Chesser Barts Health Chief Medical oficer GsABLEQ 4t Urgent from they LOuta Jve

90 T6/_5 WHS Newham GP Co-operative Ltd Newham General Hospital Glen Road, London E13 8SL Tel: No: 020-7511 4448 Fax No: 020-7474 7127 Nadia Persaud Senior Coroner RECEIVED Walthamstow Coroners Court 12 016 2019 Queens Road Walthamstow London E17 8QP Your reference NP/sc/9030
08.09.19 Dear Ms Persaud Re: Mrs Shaida Begum, reply to letter dated 18th June 2019 Thank you for your letter and detailed report. am in my capacity as Medical Director of the Newham GP Co Operative. Newham GP Co Operative provides out of hours medical services for GP Practices throughout Newham: It also provides Extended Hours GP services (booked GP appointments) at 4 HUB practices based in different locations throughout Newham (GP surgeries). The GP Co Op also holds a sub-contract from the Barts Health NHS Trust to provide streaming services within the Urgent Care Centre at Newham University Hospital, Following the sad death of Mrs Shahida Begum on Joth July 2018, worked with the Emergency compartment consultant] to draw up a concise internal incident investigation report; enclose a copy of this as it makes a number of recommendations Those relating to the GP Co Operative are as follows: have met the GP's involved with the care of Mrs Shahida Begum:[ have discussed their involvement with her care and the diagnoses of Sepsis and the ability to recognise early signs of Sepsis undertaken an audit of consultations forl and have referred themselves to the General Medical Council for a review of their involvement in this case. Registered in England and Wales Company No. 02969668 Registered Office Newham NHS Urgent Care Centre Newham General Hospital, Glen Road, London E13 8SL writing have

NHS Newham GP Co-operative Ltd Newham General Hospital Glen Road, London E13 8SL Tel: No: 020-7511 4448 Fax No: 020-7474 7127 AIl reception and clinical staff at Newham GP Co Operative are required to do annual Sepsis training (since Aug 2018) All patients discharged home with an infective illness Newham GP Co- operative are given the Sepsis Trust Patient Information Leaflet (copy attached) Each consulting room in Newham GP Co-Operative has a laminated copy of the Sepsis Trust Triage Tool An audit was undertaken for 20 streamed patients to review appropriate Sepsis screening and guidelines were being followed. enclose a copy of the concise internal incident investigation report and the Sepsis Trust Leaflet with advice for Patients being discharged home, with an infective Illness_ Following receipt of your letter meeting took place on 4th July withl the consultant in emergency medicine in Newham University Hospital medical directors of Newham GP Co- Operative the CCG officer for Urgent Care. A number of suggestions were made to improve the safety of the screening process as recommended in your letter: The software and computer screens in the Urgent Care Centre and the Streaming room to be adjusted so that clinical observations and vital signs are more easily seen and the Sepsis scores (NEWS (adults) PEWS(children) to be clearly visible on the screen
2. Where a patient is streamed for a GP consultation the score to be cut and pasted from the hospital system (EPR ~ electronic patient record) to the GP system (EMIS or Adastra): 3 The EPR hospital system to be adjusted so that NEWS and PEWS are automatically calculated by the computer once relevant clinical observations have been added. On any occasions where the patient is streamed by the GP before all clinical observations have been entered on the EPR system by the health care assistant the GP Streamer will review the streaming decision once the data is added. 5_ All staff including GP streamers, healthcare Assistants and GP' $ working within the Newham GP Co-Operative are alerted to a fact Registered in England and Wales Company No. 02969668 Registered Office Newham NHS Urgent Care Centre Newham General Hospital, Glen Road, London E13 8SL from

NHS Newham GP Co-operative Ltd Newham General Hospital Glen Road, London E13 8SL Tel: No: 020-7511 4448 Fax No: 020-7474 7127 that any NEWS score above 2 will require further investigation and monitoring_ attended the serious incident meeting at Newham hospital on gth July 2019 with Emergency Primary Care Consultant) to discuss the changes recommended at the meeting with on 4th July 2019. Newham GP Co Operative is committed to working closely with our colleagues in the Emergency and Urgent Care Centres at Newham University Hospital. We have good working relationships with the staff and clinicians in both units The Newham GP Co Operative greatly appreciates the advice and guidance, (and Education) provided by the consultants in the Emergency department at Newham University Hospital hope the actions that have been taken both individually by the Newham GP Co- Operative and working with Barts NHS Health Trust reflect how seriously we have taken the death of Mrs Shahida Begum. We are committed to learn from the event and the recommendations in your letter dated 18th June 2019 and the attached report. On behalf of The Newham GP Co Operative would be very to receive any further instructions or advice