Dear Ms Hashmi Re: Mrs. Lindsey Parker (Deceased) Response to Regulation 28: Report to Prevent Future Deaths to Salford Royal NHS Foundation Trust. Please find below the response of Salford Royal NHS Foundation Trust following the inquest into the death of Mrs Lindsey Parker and the Regulation 28 Report which you issued on 19th December 2017. Your concerns were set out in the Regulation 28 Report as follows:
1. A lack of continuity in medical care. According to the family’s evidence, Mrs Parker was seen by 16 different doctors during the course of her last admission. Of these, seven were junior doctors (FY grade).
2. Matron’s review identified gaps in basic nursing care
— vital signs/observations not recorded, potentially affecting the NEWS and inadequate fluid balance chart completion. Both are critical to patient care and safety, particularly given Mrs Parker’s serious clinical diagnosis (TEN), against a backdrop of an already life limiting/threatening diagnosis.
3. Failure to adequately recognise the deteriorating patient and to act and/or escalate matters accordingly.
4. During the course of the evidence, Trust staff were unsure as to what qualifications the ‘Hospital at Night’ site co-ordinators held. They believed that most, if not all, were likely to be Nurses. My concern here is how/why nurses are deemed suitably qualified to manage out of hour’s medical prioritisation of care. 3 rd Floor Mayo Building, Stott Lane, Salford, M6 8HD

Response of Salford Royal NHS Foundation Trust Continuity of medical care We are very sorry that the family raised concerns in relation to the number of clinicians who attended Mrs Parker during her admission. In order to assist the family, I can confirm that the following specialist clinicians attended upon Mrs Parker during her last admission: Consultant reviews Dermatology Mrs Parker was initially seen by (Ward Consultant) and (named Consultant). These specialist Consultant Dermatologists were on call when Mrs Parker was admitted. Mrs Parker was later seen by and who were on call over the weekend periods during Mrs Parker’s admission. Palliative Care Mrs Parker was also seen by a specialist Palliative Care Consultant, . Registrar reviews Dermatology When Mrs Parker was initially admitted Dr Sharif was on call. Mrs Parker was also seen by and at the weekend and as on call cover and , , who attended as the Registrar covering the ward on those days. Ophthalmology Mrs Parker was seen by who is a speciality trainee in Ophthalmology Medicine Mrs Parker was seen by three Medical Registrars between 24 th June 2017 and 9 th July 2017 for medical review, as part of the Trust’s escalation policy following deterioration in her medical condition and a raised NEWS score. Junior Doctors During this admission period Mrs Parker would have been seen by three Junior Doctors who were assigned to ward M3. These were: (GPST1), FY2) and (GPST2). As described above I would like to reassure Mrs Parker family that she was seen by a total of three Junior Doctors and not seven. I do sincerely apologise that Mrs Parker family felt that she was seen by a number of different Junior Doctors and that this was not clear during the course of the evidence. Unfortunately, Mrs Parker was seen by a number of different clinicians due to varying shift patterns, on call out of hours care and because Mrs Parker required the input of various different specialities. Nevertheless it should have been explained to Mrs Parker family why there was a need for all the various medical input. I do hope the above 3 rd Floor Mayo Building, Stott Lane, Salford, M6 8HD

explanation provides Mrs Parker family with the rationale behind the multiple medical interventions from different clinicians. Different clinicians do work during the week and at weekends; and this is within normal practice. Please be assured a full handover would have taken place between clinicians, during this time. It is necessary both medically in the patient’s best interests to have clinicians from different specialities see and/or assess a patient during their admission. Compliance with adult observation physiological monitoring policy NEWS scoring NEWS was introduced to Salford Royal in November 2014, using a bespoke system that allows direct entry of vital signs into the patient’s electronic health record. All patients except those receiving terminal care and those in Critical Care wards have their vital signs entered into the Trust Electronic Patient Record (EPR) at a frequency that is determined by the care needs of the patient. Vital signs are entered at the bedside using a hand-held device (iPAD) and the Vital Signs can then be displayed in the EPR using the Clinical Summary display to show graphs or numbers. The electronic system calculates the National Early Warning Score (NEWS score) for each set of observations unless the observation set is incomplete. The NEWS score determines the frequency of clinical observation recording as follows: 0-2 3-4 5-6 >7 Patient stable Patient potential to Patient deteriorating Patient deteriorate Acute/critically ill Normal Extra vigilance Access and alert Senior medical observations Minimum 4 hourly Minimum 2 hourly review Minimum 8 hourly Minimum 1 hourly If the score is 5
- 6 an appropriate and timely clinical review should be undertaken by an Advanced Nurse Practitioner (ANP), Foundation Doctor, or middle grade /core trainee. For scores greater than 7 a timely senior medical review, Registrar (SPR) and/or Consultant) must also be undertaken
— as happened above. If a patient scores 3 directly upon 1 parameter (i.e. respiratory rate alone) or there is any other concern then medical advice should be sought in any event. Whilst the NEWS system at Salford Royal is effective, in the case of Mrs Parker there were occasions were the NEWS scores not completed and for this we sincerely apologise. Sadly, Mrs Parker did decline intervention on occasion and this meant that some of her observations were not completed. Mrs Parker was assessed as having capacity to make decisions; therefore, could not insist that the necessary observations were taken. 3 rd Floor Mayo Building, Stott Lane, Salford, M6 8HD

Fluid Balance Mrs Parker was having her fluid balance monitored (fluid intake measured against urine output to ensure hydration). Patients with the condition TEN can lose high amounts of fluid through their skin and it is essential to monitor the urine output as this will indicate if a patient is becoming dehydrated. Mrs Parker was having her urine output measured hourly and the overall daily balance would have been calculated at midnight. On two occasions the urine output was not charted hourly. This is below the expected standard and the individuals have reflected upon their practice and learned from this event. The Ward Matron has also discussed the learning with the ward team and made changes to the content of the daily ward safety huddle to acknowledge which patients are requiring hourly urine output monitoring. To provide assurance that this standard is maintained a Senior Nurse conducts a weekly audit of fluid balance charts. Recognition and response to deteriorating patient On review, although Mrs Parker’s clinical observations were escalated initially for review by the FYi and Dermatology Registrar, the nursing staff should have persisted to escalate them when Mrs Parker began to deteriorate. Again, this has been discussed with the staff involved for their individual learning and concerns regarding a response to deteriorating NEWS has been added to the ward safety huddle. Further monitoring is in place to ensure that elevated NEWS scores are escalated appropriately and within the timeframe stated in the adult observation policy via a weekly audit of the process. As a result of Mrs Parker’s case the staff have developed a visual aid to support the completion of timely clinical observations in a busy ward environment. The functioning, operational and clinical management of the hospital out of hours Salford Royal NHS Foundation Trust adopts the Hospital at Night’ model. This is a clinically driven and patient focused model, which uses both a multi-professional and multispecialty approach to delivering care at night and out of hours. The programme enhances patient safety and outcomes, and supports medical training and service delivery. The Hospital at Night concept proposes that the way to achieve safe clinical care is to have one or more multi-professional teams who have the full range of skills and competences to meet the immediate needs of patients. Salford Royal NHS Foundation Trust has successfully operated an out of hours triage system since 2006. Ward staff who have concerns about a patient, either triggered by a raised early warning score as a result of altered physiological results or other clinical concerns; such as uncontrolled pain, new onset acute confusion will submit an electronic referral. This referral is triaged within minutes by a senior experienced registered nurse who acts as the site coordinator. The site coordinator works within recognised parameters and frameworks. The calls are categorised as: Red urgent requires a response within 30 minutes Amber semi urgent requires a response within 1 hour Green routine work requires a response within 1-2 hours 3 rd Floor Mayo Building, Stott Lane, Salford, M6 8HD

These calls are allocated to the most appropriate member of the onsite team, who may be a Doctor. The most senior Doctor on site would be a Registrar grade supported by junior Doctors, Advanced Nurse Practitioners and Healthcare Support Workers. There are a number of on call speciality consultants available for advice or attendance when required. The Advanced Practitioner work force is made up of registered experienced nurses, with master’s degrees in advanced clinical practice. They are staff working at the top of their professional license and within their scope of practice. They can clinically assess, diagnose, treat patients and are non-medical perscriber’s and form an essential and valuable part of the healthcare workforce. I hope that this response provides assurance to yourself and Mrs Parker’s family that Salford Royal NHS Foundation Trust has worked hard to ensure lessons have been learned in this case and improvements have been made. Please do not hesitate to contact me if you require any further information in relation to our response.