Dear Mrs Hunt This letter is in response to the Regulation 28 Report to Prevent Future Deaths Issued by Mrs Louise Hunt; Senior Coroner for Birmingham and Solihull, on 26th October, 2016 following the inquest into the death of AR; date of birth 25th March 1999. The Matters of Concern raised in the Report were: There was poor communication between both hospitals in relation to Alfie'$ condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell 's Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 o morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all NORSE system entries cannot always be seen_ Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when Better guidance and education is needed for outlying hospitals: Norse is a secure messaging system that was developed initially to provide a more effective method of communicating with the Neurosurgical team about patients who required neurosurgical opinion: Before Norse was developed contact with Neurosurgery at QEHB was via telephone. The on call would the majority of their time answering the phone, often with unacceptable delays for the referring clinician and the patient: The Norse system has replaced the majority of those phone calls and has improved access to the Department; It allows a referral to be made and response to be given, providing an audit trail that was not previously available. Teaching Trust of Chair: Jenni Ord the University of Birmingham Acting Chief Executive: Dr Paul Harrison registrar spend

We believe that Norse is an effective tool for communication between secondary and tertiary specialties which has improved access to specialties at QEHB and enhanced clinical governance around that process_ It is important to reflect on the effectiveness of any system when there has been significant clinical incident To that end the following meetings have been held to identify areas of concern that could be improved: 10th November; 2016: Round Table meeting at Queen Elizabeth Hospital Birmingham ("QEHB" ) 5th December;, 2016: Meeting between clinical staff from Russell s Hall Hospital ("RHH") and QEHB. Issues Identified: The letter written following AR's attendance at the Neurosurgical Hot Clinic was written to the General Practitioner; but not copied to the patient or the referring doctor from RHH: There was unacceptable 27 turnaround for the letter_ 2 AR declined admission from the Hot Clinic. His case was discussed with a consultant; but he wasn 't reviewed by a consultant 3_ Visibility of patients on Norse at the referring centre is limited to the person who initiates the referral_ There are exceptions. The case can be shared with another user or users, which did not happen in this case. There should be one or more super users at the referring cenfre who have oversight of all activity o Norse. This is not currently in place at RHH, There are difficulties obtaining information on patients seen at QEHB when attend other hospitals as emergencies.
5. There is no Norse Users' Group It was noted that there are no guidelines for the management of patients known to have hydrocephalus in the emergency setting: A detailed action plan has been developed (attached to this letter) and the actions have been agreed by both UHB and DGFT: We have commenced on the delivery of these actions and recorded our progress On the action plan for you information. day they

Should you have any questions on the action plan o require any further information then please do not hesitate to contact myself or the Trust Chief Executive Paul Harrison,

Dear

Norse is a secure messaging syetem that was developed initially to provide more effective method of communicating with the Neurosurgical team about patients who required a neurosurgical opinion. Before Norse was developed contact with Neurosurgery at QEHB was via telephone. The on call registrar would spend the majority oftheir time answering the phone, often with unacceptable delays for the referring clinician and the patient; The Norse system has replaced the majority of those phone calls and has improved access to the Department, It allows referral to be made and a response to be given, providing an audit trail that was not previously available. We believe that Norse is an effective tool for communication between secondary and tertiary specialties which has improved access to specialties at QEHB and enhanced clinical governance around that process_ It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to Identify areas of concern that could be improved: 10 November, 2016: Round Table meeting at Queen Elizabeth Hospital Birmingham ("QEHB"). 5 December, 2016; Meeting between clinical staff from Russell's Hall Hospital ("RHH") and QEHB. Issues Identified; The letter written following AR's attendance at the Neurosurgical Hot Clinic was written to the General Practitioner, but not copied to the patient or the referring doctor from RHH; There was a unacceptable 27 day turnaround for the letter_ 2_ AR declined admission from the Hot Clinic. His case was discussed with consultant; but he wasn't reviewed by a consultant 3 Visibility of patients on Norse at the referring centre is limited to the person who initiates the referral_ There are exceptions. The case can be shared with another user or users, which did not happen in this case. There should be one or more 'super users' at the referring centre who have oversight of all activity on Norse. This is not currently in place at RHH: There are difficulties obtaining information on patients seen at QEHB when attend other hospitals as emergencies. they

5. There is no Norse Users' Group 6_ It was noted that there are no guidelines for the management of patients known to have hydrocephalus in the emergency setting: The actions set out in the attached table been agreed. trust that we have addressed the issues raised,