Dear Ms Bourke Thank you for your correspondence regarding a prevention of future deaths notice following the inquest on Angela West.

You describe three areas of concern:

Ms West was identified as being at increased risk of surgical complication given her underlying renal disease. Ms West’s surgery was listed for a Thursday. The effect of this was that much of her care in the period following her deterioration was dealt with under weekend staffing arrangements.

Appropriate plans were made on the basis that Ms West had renal disease and needed regular dialysis. The procedure was planned with the renal team and Ms West was dialysed as per normal on the Wednesday and again on Friday. The surgery was moved around to accommodate this.

The Royal London Hospital is fully operational over seven days and 24 hours; high risk surgery can be performed at any time including weekends. Elective high risk surgery has to be performed every day during the working week and weekend staff are fully prepared and set up for post-operative care of high risk surgeries. We recognise that these high standards need to be maintained for all patients and on all our acute surgery wards.

The following has also been implemented to strengthen this aspect:

 The out of hour’s surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week  The junior doctor’s induction programme now contains a section around clinical escalation. Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES

Telephone: 020 32460641

Chief Medical Officer Alistair Chesser

 The numbers of overall doctors in the surgery department have increased and there is a good mixture of skills sets throughout shifts.  This specific case has also been presented three times at various fora including the surgical Mortality and Morbidity meeting. This has ensured that a large number of clinical staff have learned from this case.  A safety event has taken place which also focused on the lessons to be learned from this case.  Enhanced training on the management of the deteriorating patient is continuing to be provided to all clinical staff

Ms West was located on a general surgical ward.

All our surgical wards expect to look after high risk patients and it’s not unusual to have renal patients such as Ms West on our wards as we have a large cohort of renal patients at the RLH as we are a large renal unit.

The doctors and nurses on the ward are highly skilled at dealing with a range of general and complex complications.

The renal team, being on site, are easily available when required, and review all inpatients daily seven days a week if needed, irrespective of the ward on which the patient lies.

We recognise the risks for patients when the skills and attentions of two or more specialties are involved. Each of the teams involved has discussed their role in ensuring strong teamwork.

The investigation highlighted issues relating to Ms West becoming dehydrated. Neither I nor the clinical investigators were able to locate any fluid balance charts for Ms West.

Our legal team have in fact found a fluid chart started in the early hours of the day that she died. However after the initial operation it was expected that Ms West would go home so we would not expect a fluid chart for this earlier period. On the renal unit a fluid balance would be kept during dialysis

Although Ms West was known to be a patient who did not make urine (due to her kidney disease) we would expect that when she deteriorated a fluid chart would be started to measure other fluid losses and fluid intake. This indeed was started, but could not be found during the original investigation. The measurement and management of fluid balance is part of the learning for this clinical team and for the wider organisation from this incident.

I am very happy to discuss or clarify any of the above points