Department of Health Office of the Chief Medical Officer T; Richmond House E: 79 Whitehall London SW1A 2NS W: www.gov.uk Our reference: Your reference: Mrs A Pember MM Senior Coroner Northamptonshire 110 Whitworth Road Northampton NN14HJ Wednesday 30'^ August 2017 Thank you for your letter of 14 June 2017 about the death of Mrs Dianne Macrae. I was very saddened to read of the circumstances surrounding Mrs Macrae's death. Please pass my condolences to her family and loved ones. I have noted very carefully the conclusion of the inquest and the areas of concern you have detailed. I can appreciate how distressing these circumstances must be for Mrs Macrae's family. Your concern is that those involved in the management of patients undergoing similar elective spinal surgery are aware that internal haemorrhage is a rare but recognised complication. You also issued your Report to the Royal College of Surgeons, the Royal College of Anaesthetists and the Nursing and Midwifery Council and I am advised that they have replied to you on this point. I hope their replies have been helpful. I am advised that the Royal College of Surgeons has brought your concern to the attention of the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS), who have written to their members. The SBNS and BASS have recommended a number of learning points including increasing patient awareness of the risk of major vascular injury: educational learning for all staff involved in this area of surgery; and ensuring there are clear arrangements in place for access to urgent vascular imaging and acute services. I am further advised that the Royal College of Anaesthetists is taking action to increase awareness of the possibility of concealed haemorrhage resulting from spinal surgery through patient safety bulletins, e-learning and other educational material.

Dear Mrs Pember, 1 am writing in response to your letter dated 16 June 2017 regarding an inquest held on 17 and 18 May 2017 and the Regulation 28 report you enclosed. It was saddening to learn of the death of Mrs Macrae following elective spinal surgery but I thank you for sharing this Information with us. The College has followed your direction to consider what actions it could take to try to help to prevent future deaths of this kind. We have shared your letter with our colleagues In the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS) and discussed with them how best to do this. The Presidents of SBNS and BASS have jointly prepared a letter to send to their members, highlighting a number of learning points. I have enclosed a copy of this letter for you information.

Dear Madam

Re: Dianne Jane MACRAE (deceased) – Letter to prevent future deaths

Further to your report to prevent future deaths made under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013, I am writing to provide you with our response.

I note your concerns about the need for all persons caring for a patient undergoing routine lumber decompression and discectomy to be aware that internal haemorrhage is a rare but recognised complication of surgery. I also note that no concerns have been raised about the conduct of any individual nurse involved in the care provided to Mrs Macrae.

We are the UK regulator of registered nurses and midwives. Our principal functions are to establish the standards of education, training, conduct and performance for nurses and midwives and to ensure their maintenance. Our overarching objective is to protect the public, including by promoting and maintaining both proper professional standards and public confidence in the professions we regulate.

We are currently undertaking a wholesale review of our education standards, including the pre-registration standards of proficiency that nurses must meet before being registered with us. We intend that these new standards of proficiency for registered nurses will include specific standards relating to patient assessment and the management of patient deterioration. We are undertaking a full public consultation on the draft standards, which is due to conclude on 12 September 2017, following which we will carefully review the feedback we receive from our stakeholders before finalising the standards. We will also take into account the concerns you have raised in your report about complications of surgery.

Please note that as there are currently about 612,274 nurses and midwives on our register working in many different areas of practice across the UK, it is not our usual practice to issue specific clinical advice to nurses and midwives about individual cases. Such clinical advice may be more appropriately raised by relevant employers or on occasion by the Department of Health, NHS England ( or the NHS leadership in the

devolved administrations) , or the National Institute for Health and Care Excellence (NICE). We will be sharing our response with the Department of Health.

If you have any further concerns arising from this case which you consider fall within the NMC’s regulatory remit and which I have not addressed in this letter, please do not hesitate to contact me again.

Dear Madam In response to your Regulation 28 letter to prevent future deaths following the Inquest touching the life of DIanne Jane Macrae, notwithstanding your previous Indication that Woodland were not required to respond. For completeness, I can confirm the hospital has considered and taken action for each point of cause for concern you have raised, this includes but is not exclusive to the following action. The hospital has reflected on the case at Clinical Governance Committee, and will reiterate the findings and conclusion of the Inquest at the next Medical Advisory Committee, 20'^ September 2017. The case and the learning points were also discussed at the theatre team meeting, and will be included at a reflective learning session in the next three months, which is led by Matron. As standard practice now since this tragic outcome, if an anaesthetist or surgeon is re-called to the hospital, both Consultant Surgeon and Consultant Anaesthetist are asked to attend. The Senior Management Team (SMT) who provide on call support 24/7 are all very clear on this and ensure this happens as part of the escalation process for any deteriorating patient, or when a Consultant is asked to return to the hospital. The new Matron is in the process of establishing a multi-disciplinary deteriorating patient committee where cases are discussed, to establish learning from incidents and near misses, the findings will also be published in the new "Clinical Matters" staff and Consultant Newsletter. Ramsay Health Care UK Operations Limited Registered Office; 1 Hassett Street, Bedford. MK40 IHA Registered in England No. 1532937 People caring for people

• The spinal neuro surgeons and Consultant anaesthetists working at the hospital are very aware of this case and now have a high suspicion to exclude post-operative internal bleeding. The holistic learning from this case will be shared with all Consultants following the Medical Advisory Committee meeting on the 20*'' September 2017 via our Consultant Newsletter.
• A bed side Haemocue machine has been installed in recovery, to allow patient bedside testing of haemoglobin by recovery staff. This enables recovery staff to initiate this test as part of their observations to inform attending clinicians of the haemoglobin level in the instance of a deteriorating patient.
• An emergency skills drill was undertaken in recovery in May 2017, and a programme of such drills is being rolled out through the clinical areas involving Consultant Anaesthetists. The hospital would like to reiterate their condolences to the family of Dianne Jane Macrae, and confirm that the action in relation to the matters of concern that you have raised have been addressed as outlined above. If you require any further information please do not hesitate to contact me. Kind regards.