Dear Madam Trust Response to Regulation 28 Report Barry John Tucker In response to the Regulation 28 Report you made at conclusion of the inquest into the above named's death on 17 March 2017 [inquest heard on 11, 12, 16 January 2018] please find herewith the Trust's Response_ Documentation In preparing this Response we have considered: The patient's concurrent medical records; Review of clinical guidelinesl best practice; Face to face discussions with all staff involved; Staff statementslritten accounts; Patientlfamily account of event and perspective obtained through discussion with them; Group discussion (After Action Review); Staff support for investigation; Staff feedback from incident and findings. Brief background: Mr Tucker was a 71 year old man admitted to Eastbourne District General Hospital (EDGH) to undergo robotically assisted radical cystectomy and ileal conduit formation for bladder cancer on 1th September 2017 . Four days later he was discharged with open access to the Urology Assessment Unit: Mr Tucker was readmitted on 16th September. The next he underwent surgery at Brighton and Sussex University Hospital (BSUH) and an emergency laparotomy (surgical opening of the abdominal cavity) was performed: He was subsequently transferred to the Intensive Care Unit (ICU) post operatively where his condition deteriorated further. Mr Tucker died on 17th September 2017. The cause of death was recorded as Ia multiple organ failure, 1b. small bowel ischaemia due to septic shock and bronchopneumonia, Ic. City the home day

papillary transitional cell carcinoma of the bladder and
2.superior mesenteric artery atheroma The post mortem findings did not highlight a problem from the initial surgery undertaken at EDGH; It is unclear if the rapid decline in condition could have been predicted or identified earlier had there been improved documentation with patient information and consultant input. Key Time Line Events: July 2017 Mr Tucker was seen at BSUH with symptoms of haematuria and following investigations diagnosis of invasive transitional cell carcinoma of the bladder was made_ The Multi-Disciplinary meeting between BSHU and East Sussex Hospitals NHS Trust determined the most appropriate course of action was surgery for Cystoprostatectomy (removal of the bladder and prostate) which would be undertaken at Eastbourne District General Hospital (EDGH)_ July 2017 Reviewed by the Consultant Anaesthetist and a nurse for pre assessment and was deemed fit for surgery. 1706 Admitted to EDGH to undergo a robotically assisted radical September cystectomy and ileal conduit formation for bladder cancer_ 2017 12 September
18.45 Mr Tucker was transferred to the private patient unit, 2017 14t6 On the morning round, the surgical fellow noted Mr Tucker September was nauseous however; his abdomen was soft and non- 2017 tender Mr Tucker underwent an oesophago duodenoscopy (OGD) the procedure notes that there was moderate oesophagitis and the stomach was full of thick liquid and food and therefore the procedure was abandoned and advised to rebook OGD_ 15* Mr Tucker was discharged home with open access to the September Urology Assessment Unit. (The blood results and all 2017 observations were within normal limits) There is no record of the discharge advice given_ 76th Tucker telephoned the Urology Assessment Unit at September EDGH for advice as Mr Tucker was reporting back and 2017 abdominal pain despite taking the prescribed analgesia. Advised to return to EDGH for stronger pain relief. 204h Mrs

16th
20.40 Mrs Tucker contacted the unit again and was advised that Mr September Tucker should return to EDGH and an emergency ambulance 2017 was offered_ 16t6 21:30 Paramedics discussed with the on-call Urology Registrar to September return to EDGH, Unfortunately there was rapid deterioration 2017 so he was taken to the nearest A&E at BSUH 17th
04.00 Mr Tucker underwent surgery at BSUH and an emergency September laparotomy (surgical opening of the abdominal cavity) was 2017 performed. 1706 Mr Tucker was transferred to ICU post operatively where September condition deteriorated further. 2017 20:35 Mr Tucker died Cause of death recorded as multiple organ September failure , small bowel ischaemia due to septic shock and 2017 bronchopneumonia, papillary transitional cell carcinoma of bladder and superior mesenteric artery atheroma. Coroner's Concerns: (1) Mr Tucker received no pre-Op preparation Trust Response According to the records, Mr Tucker was seen in the pre assessment clinic at EDGH on 20th 2017 both by the nurse and anaesthetist in preparation for surgery. It is documented in the anaesthetist's letter to the consultant; GP and patient; that Mr Tucker needed to contact the GP for blood pressure monitoring Mr Tucker was pre-operatively assessed at EDGH and saw a nurse and consultant anaesthetist. There is no record of what patient information leaflets were given. The Trust acknowledges that good record keeping was below par in this instance and has undertaken to retrain staff about the importance of recording all instances of doctor patient contact. (2) The urology consultant was away during his admission and he had no senior input: Trust Response The consultant responsible for the care of Mr Tucker was on annual leave and therefore no other senior clinician was appointed to cover. There was an experienced doctor seeing Mr Tucker each while he was on the ward. This doctor was surgical robotic fellow who had completed his training and was applying for consultant posts He was experienced in robotic surgery and was working at the level of a consultant In addition 17t6 the July his day

there was urology consultant of the week in place who was available for additional support and advice or contact with the visiting BSUH consultant: There is no record in the patient notes of any escalation to the urology consultant of the week and this was most likely due to no concerns identified by the doctor to escalate. Mr Tucker was reviewed by a Consultant Anaesthetist on 14 September 2017 . Recommendation Action Source of assurance Lead Dea Date action embedded in dlin comp practice leted Patients must be Discussed at Observed at safety Clinical Feb Feb assigned to Clinical huddle on ward lead 2018 2018 consultant who is Governance present (to see the meetings consultant of the week to cover for annual or study leave) Patients must be Job plan to be Audit of notes in 3 Clinical Job plan reviewed by amended to months to ensure lead amended consultant daily post- include daily consultant review has Feb 2018 for operatively. rounds taken place audit May 2018 (3) The Enhanced Recovery Nurse Specialist was also away during his admission: He never met her or received any paperwork her: Trust Response There is an Enhanced Recovery (ERAS) nurse in the Trust with expertise in this type of surgery; however, were on annual leave during Mr Tucker's stay. This nurse would have visited Mr Tucker while he was on Michelham ward to ensure he was progressing well: Recommendation Action Source of Lead Deadline Date assurance comp action leted embedded in practice Review the request Ward team to be ERAS support Head of May 2018 for funding second aware of ERAS nurse evident in Nursing ERAS nurse and if not leave and provide the patient notes possible ensure that expertise Application and process for appropriate for second ERAS leave cover to mitigations and nurse to division be monitored cover arrangements are put in place from they leave

(4) He never received copy of the leaflet "Enhanced Recovery after having Cystectomy" Irust Response There is care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain great deal of detail of Mr Tucker's post-operative progress The Trust acknowledges learning opportunity presented here and has implemented the action plan below: Recommendation Action Source of Lead Deadlin Date assurance compl action eted embedded in practice The Cystectomy Pathway The pathway Audit of Lead patient documentation must documentation it documentatio consulta 2018 be updated and used for all to be reviewed n at 3 months nt surgical cases no matter and circulated to surgeon what ward to include the key latest Cystectomy Enhanced stakeholders Preparation Event and Recovery Pathway (CEPER) guidance and ensure clear to what patient information is provided and when (with sign off to state completed) and the discharge processl requirements; (5) Mr Tucker's hospital notes arriving from Michelham Ward were suboptimal; lacking continuity, incomplete and unhelpful Trust Response The Trust acknowledges that the hospital records were not entirely optimal. However, Nursing care records are documented daily , per shift and Mr Tucker's medical post- operative care rounds were also recorded in his patient notes_ There was a plan noted however, it was not always confirmed that it was completed. Mr Tucker was transferred to ITU post operatively and all relevant documentation was completed. Mr Tucker was then transferred to the private patient unit on 12 September 2017 at 18.45. The nursing care plan from the private patient unit documents the following: bloods tomorrow; hourly urine measurements; Fortisip supplements; light diet; physiotherapy; pain team review; stoma team review. key the May

Hourly measurements of urine are noted on the fluid chart 12/9/17 but the fluid inputloutput is incomplete on 13/9/17 . The pain team reviewed Mr Tucker on 14/9/17 when he reported no pain, but was experiencing nausea and vomiting: Analgesia was amended and adjustment to anti emetics note was made to check pain levels on mobilising and to contact the team further adjustment required_ There are daily ward round records from the medical team, which provide comprehensive record of the post-operative round which reflects the stages in post- operative recovery, however contained limited detail as to how Mr Tucker progressed against the plan The post-operative daily round documentation has since been amended to include more detail: (6) Eastbourne DGH's system for recalling patients to the Urology Ward following discharge, if need to go by ambulance; is flawed. Trust Response If Mr Tucker was stable when the ambulance crew assessed him, he could have returned to EDGH where he had recently been cared for. The policy for South East Ambulance NHS Trust is to take patients to the nearest emergency unit to ensure swift access to investigations, imaging and surgical interventions if a patient is highly clinically unstable, as Mr Tucker was_ The crew on scene did contact EDGH who had agreed to accept Mr Tucker; however the ambulance crew could not the ambulance down long drive and had to call for 4x4 vehicle for this_ During the time the crew were on scene, Mr Tucker deteriorated further and the operational manager who also attended the scene made the decision to take Mr Tucker to the nearest hospital which was Royal Sussex County at Brighton. There was no delay in transfer due to communication between the Ambulance Service and Eastbourne Hospital: The on scene was due to the complex extrication from the home to the Ambulance and the clinical condition of Mr Tucker pain key they they get delay

(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients Trust Response A protocol is in place and the discharge process has been reviewed Post-operatively Mr Tucker was discharged from ICU to the private patient unit (patient choice). This is not specialist Urology Unit; which would have been more suitable for his post-surgery care_ The discharge notification document did not include the nausea and vomiting and oesophago duodenoscopy (OGD) required to be completed at out-patient clinic. Mr Tucker's bloods or clinical observations upon discharge did not indicate sepsis_ There is no record of any concerns that were escalated to the ESHT on call consultant or the BSUH surgeon_ The team caring for Mr Tucker did not havelidentify any concerns other than the nausea and vomiting which felt was managed appropriately. There are documented care records on 13/9/17 by the physiotherapist who stated that the patient was asleep and there was a plan made with Mrs Tucker to walk with the patient later in the Mr Tucker's bowels should have been starting to work again before discharge Bowel sounds were noted. Stoma was noted to be healthy and abdomen was soft. The nursing notes note a small bowel movement on 14/9/17 . On 14/9/17 the physiotherapist reported that patient declined to walk or practise stairs: Cough was noted to be strong and and no further input from physiotherapy was required: Mr Tucker was reviewed by the medical team, physiotherapist; acute team and stoma nurse prior to discharge_ The discharge planning documentation was completed in the care record. The gastroenterology team were consulted and changed the OGD plan although the documentation around this change of plan is poor_ There is no record of the post-operative discharge information given to Mr Tucker: As a result of the learning taken from this episode of care, the Trust will be implementing the action plan below. they being day- dry

Recommendation Action Source of Lead Deadline Date assurance comp action leted embedded in practice Patients undergoing Private patient Admissions Michelha Feb 2018 Feb major urology cancer unit advised not to monitored m unit 2018 surgery should be cared accept bookings administra for on the urology ward, for these patients tor with more experienced doctors and nurses. These patients are not suitable for private patient unit. Urology specialty Conduct urology Completed Specialty April 0218 documentation audit to specialty audit to audit lead identify themes and review core improvements in criteria and documentation. determine if accurately reflects care records Action identified gapsllearning: The urology specialty to personnel to Audit Clinical Doctors For agree a robust process be identified to 2018 lead identified audit for ensuring Electronic complete 1 Feb 2018 May Discharge notification is documentation for 2018 signedlchecked by a discharge and senior doctor; audit over 3 months trust the above Response sufficiently answers the matters raised in the Regulation 28 Report: Should you require any further information please do not hesitate to let me know.