Dear Mr Heming Sam Antony Crick; Deceased am writing in response to your Regulation 28 report dated 25 August 2017, following the inquest hearing into the sad death of Mr Sam Antony Crick: In vour Regulation 28 report you sought reassurance in relation to issues surrounding the neurosurgical management of Sam Crick at Queens' Hospital (the 'Trust' ); 5 areas of concern were highlighted which address in turn, below_ Lack of a Serious Incident Report (SIR) into the death: Trust Response An SIR was not initially triggered in this case as the Trust was not notified of Sam Crick' s death: The Trust only became aware of Sam's death when Consultant Neurosurgeon wrote to the family to investigate why the patient had not attended a clinic appointment with in 2016_ It is normal practice for the Division to discuss all deaths at the Trust within 30 of death and where indicated to notify of a potential Sl in accordance with the Trust's Incident & Serious Incident Policy. At the time of Sam'$ death the Trust had no process to review externally reported deaths_ This will be addressed in the SIR with a recommendation that all externally reported deaths are reviewed weekly as part of a Morbidity and Mortality session to identify any lessons and feedback to referring hospitals. Following receipt of the Coroner's Regulation 28 report a Significant Incident (SI) notification was completed by the Division and an Sl declared by the Trust'$ corporate team on 31 August 2017. Sl investigations are currently ongoing and the report will be shared with the Clinical Commissioning Groups (CCG's); Barking, Havering and Redbridge Clinical Commissioning Group (BHRCCG) North East London Commissioning Support Group (NELCSU) on or before 23 November 2017. The CCG'$ then has 20 days to consider the report and agree the findings_ 88 %i KiecrJu Sx # UCLPartners ARH-IP PRIdd dscblg 'Amgy Hojhul> SAFETY SMOKEFREE (Otent Chorio Acting Chair Chief Executive: Matthew Hopkins May days and

Once the report has been agreed by the CCG's the report will be shared with the family. The Trust will implement an action plan in the timescale agreed in the SIR, based on the lessons learned from this case_ The neuro-radiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the re-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of intracranial pressure. Irust Response The neuro-radiological review of the CT scans in November 2015 ad early December 2015 did not highlight the brain parenchymal herniation through the re-existing burr hole as this finding was missed. This is a an exceptionally rare complication; the Neuro-radiologist who reported the scan and who has 17 years of experience as a Consultant Neuro-radiologist has never previously encountered this complication. The Trust acknowledge this finding was missed by the reporting Neuro-radiologist but does not accept that the finding was 'obvious' as suggested The worsening hydrocephalus and raised intra cranial pressure were both documented on the 26 January 2016 imaging and reported on 4 February 2016. The further subtle finding of the herniation, were not noted. The ongoing SIR investigation will include recommendations on improved management of patients with known, high, raised intercranial pressure including clear guidelines on how to escalate concerns and the development of a Rapid Review Access Clinic to enable appropriate triage of patients The last face to consultation between the neurosurgeon and Sam was on 03.02.16 but the written neuro-radiological report of the 26 January 2016 CT scan was not available until February 2016 s0 this report was not considered by the neurosurgeon as it was not available for this consultation. This report did highlight some alarming features of herniation but this vital information was therefore not considered (prior to Sam'$ appointment on 3 February 2016) Irust Response Responsibility for following up imaging requests rests with the requester and the Trust accepts that in Sam's case, the imaging was not available for his clinic appointment on 3 February 2017 as it should have been. In reviewing radiology processes the Trust has identified the need to improve the quality of radiology requests. On 17 August the Medical Director cascaded to all clinical staff a set of standards expected of clinicians in making radiology request: A copy of the email dated 17 August 2017 is attached for your information. D. The neurosurgeons examination on 02.12.15 did not find frank papilledema vet an examination by consultant ophthalmologist at the Luton and Dunstable hospital on 18 November 2015 and 24 December 2015 had found papilledema at both appointments. The consultant neurologist' $ referral letter Luton rising face key from

and Dunstable indicated a finding of papilloedema also and stated an ophthalmic review was sought but there appears to have been no attempt to find out the outcome of the Luton's assessments Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of vears after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton: Trust Response The Consultant Neurosurgeon involved in these examinations is no: longer practicing in the Trust and is therefore unable to personally comment: failures are however, being investigated as part of the ongoing SIR and recommendations will be made to ensure that these issues do not happen To BHRUT and the CQC E. There have been a number of Regulation 28 reports issued by Nadia Persaud, Senior Coroner for the area of Eastern Area of Greater London raising concerns over a number of clinical deaths_ In addition a CQC inspection in September 2016 and October 2016 (report published in March 2017) have made of the Trust 'requiring improvement' in a number of respects when measured against standards. The CQC report published in 2013 referred to previous mortality alert concerning septicaemia shunting in hydrocephalus where the hospital review found no obvious deficits in clinical or operative quality. This inquest was an independent review where expert evidence exposed shortcomings in the management of hydrocephalus. It is not clear whether the circumstances of this death were disclosed during the most recent inspection_ Trust Response The circumstances of this patient's death were not disclosed during the most recent inspection by the CQC as this information was unknown at the time; routine disclosure of individual patient deaths is not a CQC requirement_ Since April 2017 all Trusts have been required to collate and publish quarterly information on deaths in accordance with National Guidance on Learning from Deaths. The Trust has developed 'Learning Deaths' policy in accordance with the national guidance which sets out how the Trust responds to and learns deaths of patients who die under its management The Trust is committed to continuing to learn from Inquests. Please let me know if you require further information:

Dear Mr Heming Thank you for sending CQC a copy of the prevention of future death report issued following the death of Mr Sam Crick CQC has contacted the provider Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) to request written confirmation and evidence of the action they have taken to date following this death and any additional action intend to take in response to the prevention of future death report: BHRUT are due to conclude their serious incident investigation into the death of Mr Crick this week and will share their findings with CQC accordingly_ We note the legal requirement upon BHRUT to respond to your report within 56 days In your report you have additionally asked CQC to provide further clarity on a few points that have dealt with individually below: they

Increase in number_of Regulation reports raising concerns over number of_ deaths at BHRUI The CQC, in communication with the trust and relevant stakeholders, have recognised the increase in frequency of Regulation 28 reports relating to BHRUT. With a view to addressing this at a trust-wide level, the CCG has implemented an enhanced programme of review with the trust: The CCG have been provided with quality risk profiling tool by NHS England which includes self-assessment by the trust and assessment from their regulatory stakeholders (CCG, CQC, NHSE); which is based on the Key Lines of Enquiry (KLOEs) of the CQC. This is a means for the trust to evaluate and score their performance in relation to risk management in key areas, while a similar score is completed by stakeholders_ The scores gathered from this process are then discussed in a mediated meeting: Where there are discrepancies between self-assessment and assessment from stakeholders, action plans for improvement are put in place_ Members of the trust senior leadership team attended the first meeting in November where CQC were present: There was not enough time to discuss all the matters of concern and a follow up meeting, which will include a focus on Regulation 28 reports, is to be planned for early January. Recent inspection of BHRUL and related findings: In 2016, we carried out a focused inspection of a number of core services that had previously been rated as requires improvement_ The neurosurgery provision would fall under the core service of surgery, which was not included in our most recent inspection of the trust; as our intelligence monitoring did not lead us to have specific concern about surgery services at this time. However; this is an agreed priority for future inspections The radiology provision was covered under the outpatients department; where the main concern was around medical staffing vacancies in the radiology department: Recent stakeholder engagement (particularly with the CCG) has raised concern in relation to risk management and governance. The Trust recently returned their Provider Information Return (PIR) , a location level assessment that provides essential data and information to support the ongoing monitoring of quality of care and to plan and inform inspections. Along with other sources of intelligence_ we considered the PIR at a regulatory planning meeting (RPM) in early December where proposals for inspection were discussed and agreed. The_previous mortality alert concerning_septicaemia shunting_in hydrocephalus where the hospital review found no deficits _in clinical or_operative quality _that was referred to in the 2013 CQC inspection report of BHRUL:

The CQC outliers team reviewed the information the Trust provided at the time. It was noted that a case note review had been undertaken for the 13 patients identified in the analysis and that the reviewers concluded that in none of the cases of external ventricular drainage was there any evidence that drain placement was a factor in the patients' death. Subsequently, additional enquires were not undertaken: Euture regulatory action: Following the recent RPM; we are planning to inspect specific core services at BHRUT in the first part of 2018. As part of our next phase inspection methodology, this will include specific consideration to how well-led the trust is; hence, we are scheduling a further 3 day in-depth inspection of the leadership and governance of the trust: Please do let me know if you require any further information in relation to any of the above. We will be happy to update you in due course.

Dear Mr Heming, Re: Regulation 28 Report to Prevent Future Deaths Sam Crick (died
04.03.2016) Thank you for your Regulation 28 Report dated 2 August 2017concerningthe death of Mr Crick on 4 March 2016. Firstly, would like to express my deep condolences to Mr Crick's family: The regulation 28 report concludes Mr Crick's death was a result of complications of raised intracranial pressure resulting from late failure of an endoscopic third ventriculostomy: It was also concluded that a timely neurological intervention would saved his life_ Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the administration of opiates in someone with raised intracranial pressure andl or an altered level of consciousness. Specifically, you are concerned that the opiate could act as a respiratory depressant leading to raised levels of carbon dioxide in the blood which could ultimately be fatal and, therefore, constitutes a risk of future deaths: As a result; NHS England has given careful consideration to your recommendation and has sought professional advice from the Society of British Neurological Surgeons (SBNS): They have discussed this case in greater detail at their Council meeting and agreed that it would be beneficial to increase awareness among professionals on the use of opiate medication in patients with intracranial pressure: Consequently, the SBNS have recommended the most effective solution to address these concerns would be for the NHS t0 issue a guidance statement jointly with the Royal College of Emergency Medicine _ This will focus on treating patients with raised intracranial pressure and urge extreme caution in relation to the use of opiates: NHS England will work with these professional bodies to help produce and distribute this statement nationally within the next 6 months: High quality care for all, now and for future generations the have

We are pleased to learn Luton and Dunstable hospital have since developed a local standard operating procedure (SOP) for such cases: However, further work would be needed to validate their guidance to determine if this guidance should be adopted nationally: We believe that rather than sharing this SOP, the above suggested guidance will have a greater impact across the NHS by effectively reaching the right professions with a national statement NHS England acknowledges the concerns you have raised with the Trust and we will seek their assurances that have addressed such matters in Iine with the Serious Incident Framework We will also suggest to the Trust that an independent review of the case management ought to be carried out as this would be helpful in understanding the failings in this case and to prevent any future deaths: Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information.