Dear Mrs Hunt Inquest touching the death of Ann Swoffer Response to Regulation 28 Report to prevent future deaths write in response to the Regulation 28 report made by you following the Inquest into the death of Ann Swoffer; which concluded on 22 January 2019. University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths and responds as follows (using the numbering in your report): heard clear evidence that practice and procedures in place at Good Hope Hospital at the time were not consistent with accepted practice or national guidelines This raises considerable concer as t why the practise was s0 different and what monitoring is in place to ensure consistent ctices in accordance with national guidelines are_in place The department caring for the deceased at the time were not following accepted practice or BSG guidelines. It is essential that the person who leads the restructuring of the practices and protocols is an expert and can ensure that the necessary details are considered and implemented Consideration needs to be given as to who should lead the restructure and review recognise that you heard evidence that practice at Good Hope Hospital was out- with appropriate guidelines: This was also presented as such in the Trusts Sl report: A subsequent review has identified that the guidelines are recognised and used by the clinical team at Good Hope Hospital. The default position is that oesophageal dilatation should not be undertaken unless there are specific indications, which should then be fully documented in the medical record, which unfortunately did not occur in Ms Swoffer's case Chair: Rt Hon Jacqui Smith Chief Executive: Dr David Rosser (he prac

The national guidelines for the diagnosis, staging and management of oesophageal cancers are adopted on all sites within the Trust: To summarise, the national guidelines recommend that: tumours are not dilated for diagnostic purposes enteral feeding is considered for patients with nutritional compromise (British Society of Gastroenterology guidelines 2011): The guidelines allow for some discretion to endoscopically cross tumour where this may be the most effective route for nutritional support;, or on occasion to identify the distal extent of the tumour; information that may be required to determine the potential for curative management The Trust's endoscopists, including those at Good Hope Hospital, avoid oesophageal dilatation whenever possible, due to risk of tumour perforation which would render the patient inoperable for cure, as well as exposing them to other complications including sepsis. In the event that it is deemed necessary to dilate an oesophageal cancer; the team that currently service Good Hope and Heartlands Hospital have published excellent outcomes in one of the largest oesophageal cancer stenting series in the UK, with & perforation rate of just
0.8% (Surgical Endoscopy 2017
31.2280-2286): This compares favourably to the published literature which report the frequency of this complication to be approximately 3%. It is also the case that oesophago-gastric services across all Trust sites have good cancer outcomes benchmarked and publicly available in the national oesophago-gastric cancer audit The Trust has an established, standardised upper gastrointestinal cancer pathways agreed and updated through a specialised multi-disciplinary structure which has been in place for over 10 years across different sites_ These have been consolidated into a single pathway in place across all sites at the Trust since September 2018. The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019. The core team members include clinical nurse specialists , dieticians, accredited consultants and single management structure_ This will provide even , greater consistency of management; including single location for surgery. This realignment is being overseen by the Executive Director Strategic Operations, working with Divisional Directors and Clinical Service Leads for the upper gastrointestinal surgical departments based at the Trust 2 The deceased deteriorated as a result Of a late perforation over the August Bank Holiday weekend:. Junior staff did not identify the problem and did not escalate this to senior staff, was told a 'work force issue' meant senior staff were not present in the hospital at the time_ Patients who become iIl at the weekend need t0 receive the same standard Of care as in the week Consideration needs to be given to how this can be addressed, the the

At the time of Ms Swoffer's admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and o site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend: We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of or of week: We have further increased routine on site attendance by range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside times they are present For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased's admission. This has been changed s0 that a gastroenterology consultant attends for a ward round over the weekend. There is general concern that all sites with the Trust are not integrated and are not following the same protocols_ It is important that patient receives the same standard of care based on current guidance The long ter goal of the Trust is full integration of service delivery, creating single, multisite departments across all specialities. This process has begun in a number of areas, for example upper gastrointestinal cancer services as described above_ unified, cross-site operational structure will be established by May 2019. A short-term goal includes alignment of protocols and guidelines across all sites, itself significant task that is nevertheless proceeding at pace: In some circumstances the Trust will choose to maintain different but acceptable protocols until there is unification of service delivery: This reflects the fact that choices between valid standards of care are often determined by particular local operational considerations In these circumstances single protocol will be established upon service unification: would like to assure you that all protocols in place across our sites are based upon current national guidance and are subjected to a rigorous review process, overseen by multi-disciplinary review team_ Therefore, irrespective of differences in the detailed protocol in use, patients can expect the same outcome based standard of care_ would Iike to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously which hope is demonstrated by the steps we have taken and will continue to take going in the future