Dear Ms Kearsley, Re: Michael Guy Hutchence (Deceased) am writing in reply to the letter of 20 June 2016 from Mr Pollard, concerning the inquest of the above named patient: As always, am grateful to you for highlighting your concerns on the Regulation 28 'Report to prevent future deaths' and for providing me with an opportunity to respond: Your concerns are as follows:
1) For no other reason, other than the convenience of hospital bed managers, Mr: Hutchence was moved at least four times from ward to ward within hospital: The Trauma Nurse Team manage the Trauma and Orthopaedic beds in the hospital and when patient needs admission from the Emergency Department (ED) we aim to them on the correct ward, based on their orthopaedic injury, although this is always dependent upon bed availability Mr Hutchence was admitted to Ward D1 (our Trauma Admissions Unit) from ED: He then had further moves to Ward D4 and the Short Stay Surgical Unit (SSSU): Unfortunately it is often necessary to move Orthopaedic patients between wards within Trauma a Orthopaedic Unit (Wards D1 D2, D4, ad M4) ad our SSSU (Surgical Short Stay Unit) to create bed capacity for admitting patients from ED in order t0 comply with the 4 hour wait in ED target Moves are undertaken out of hours following discussion with the Senior Manager on call and Senior Nurse on Site Cover We often move patients to SSSU to ensure we have enough acute beds for more complex trauma.
2) The quality and accuracy of the nursing and medical notes left much to be desired and it was noted that Mr Hutchence was cared for by non-specialist nurses on number of occasions and even when he was in the I.T.U: he was looked after by a trainee nurse: The Trust is currently in process of installing an electronic patient record (EPR) system , which is computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper and electronic records, information will be available to them online in one place. We already use variety of electronic systems to help staff look after our patients, but the EPR will all this information together: EPR will improve patient safety and outcomes by standardising pathways underpinned by best practice it will remove issues relating to the illegibility of written records and will also assist with the completion of important documents, as the system will' employ 'force function' meaning the record cannot be left incomplete. The roll out for the system will be completed in 2017 . In the meantime we will continue to try to improve our written records by undertaking monthly 'live' spot audits of 30 inpatient records across the wards All nurses caring for patients in critical care are registered nurses; however; there are many trainee critical care nurses, all at varying points within their training: All new starters t0 the area have a 6- 8 week induction package, which includes being supernumerary and working alongside a trained critical care mentor. All staff new to the area undergo National Competency Programme taking 12 to 18 months to complete; Your Health: Our Priority: Your the put the the bring The Step they

then go on to complete a further 12 months of training to become a fully qualified and accredited critical care nurses_ All staff undertaking critical care training are supervised by the co-ordinator and Mr Hutchence was at no time looked after by a nurse not qualified t0 do so.
3) Mr Hutchence wasadministered his anti-coagulant simply on the basis ofhis body weight: He weighed 99.8 Kg and the difference between a daily dose of 40 mg: of Clexane and a twice daily dose of of Clexane is arbitrarily set at a body weight of 100 Kg: Should there not be a rather more refined way of assessing the dose required? have referred this to our Haematology Lead Consultant; who has advised: There is limited evidence to thromboprophylaxis in a patient who is overweight; this can also be sald for those with low body weight, renal impairment with low creatinine clearance levels, patients in pregnancy and infants. The American College of Chest Physicians (ACCP) advises clinicians to follow manufacturer recommendations for antithrombotic dosing: Manufacturer's information for Enoxaparin (Clexane) and other Low Molecular Weigh Heparins do not recommend dosage adjustments for extremes of body weight; however there are 'off-licence' doses of 40 mg SIC BD and 60 mg BD in patients with weights of 100-150 Kg and those greater than 150 Kg respectively_ VTE prophylaxis regimens are not 100% effective in any group of patients and there will be occasional failures of antithrombotic therapy_ On the basis of an individualised patient risk and benefit assessment, a clinician may feel compelled to prescribe a more aggressive dose than what is advocated in national guidelines. This practice is not recommended without clinical evidence of efficacy and safety"_
4) In addition to the above problem, the body weight was recorded on some occasions in metric and others in imperial weights. This can and does Iead to confusion: On one page the predicted weight was 15 stone 10 Ibs which was in fact the actual weight and not the predicted weight: For the purpose of the accurate delivery of many drugs, including anticoagulants, accurate weight recording is essential: There is currently a ongoing awareness drive to ensure all staff are recording weight and height in the metric format
5) There was a shortage of trained nurses in the hospital and this may have led to at least one of the "'ward moves' and D2 was closed due to lack of staff: D2 (an elective inpatient ward) was closed following NHS England advice for us not to undertake any elective work, apart case work, due to winter bed pressures throughout the NHS at that time_ As a result of this we merged the staff D2 with SSSU which was open 7 a week and increased to 32 patients at a weekend, giving uS extra capacity for emergencies spare staff were utilised to support gaps in staffing on other areas
6) was told the ideal way of elevating patient's is by using Braun's frame. There was (and apparently still is) shortage of these within the hospital such that Mr Hutchence's leg was at all times elevated by pillows. This was a potential for causing or contributing to the formation of D.VT:s have referred this to Consultant Orthopaedic Surgeon; who has advised; There is no direct evidence that elevation of an injured lower limb has ay effect on the incidence of venous thromboembolism; elevation of the injured limb is employed to reduce swelling: The method of elevation does not impact on the risk of venous thromboembolism; however the advantage 0f the Braun frame is that the is better supported in the elevated position, as the leg tends to fall off pillows or the pillows compress and the degree of elevation is lost" can advise that four new Braun frames have since been purchased and were delivered to Ward D1 on 25 July 2016; we now have 8 in total. There is still potential that outlying trauma patients, in the winter period, may still have pillows utilised as an elevation method.
7) Mr Hutchence was taken to theatre for the operation and this could not be started as the kit for the operation was found to have non-sterile status as the outer wrapping had been breached. The operation was delayed whilst another kit was obtained but this was also found to be defective: The 2 solely 40mg guide from day from days Any leg using leg very busy

operation was then aborted and off for a further two days, during which time Mr Hutchence was immobile the risk of D.V:T. and P.E: was inevitably increased: Mr. Hutchence was scheduled for surgery on the trauma list for open reduction and internal fixation of fractured left tibia and fibula on 19"" January 2016. It has not been possible t identify a particular cause for the breaches in the wrappings Great care and attention is given to maintaining the integrity and sterility of the instrument tray wrappings It is standard theatre practice that careful ad thorough checking of instrument tray wrapping is undertaken by the theatre practitioner prior to use In this case, the routine checking identified the breaches and appropriate action was taken to re-sterilise the instrument trays On discussion with HSDU it was determined that; as the instrument trays were heavy, the trays would require additional cooling time and would therefore not be available until approximately 16.30 hrs . Discussion then took place between and the Anaesthetist[ ladvised that procedure was likely to take at least two hours and it was agreed that there would be insufficient time to undertake Mr Hutchence $ surgery on that day informed the team that he would make arrangements to reschedule Mr; Hutchence for surgery on 21 January 2016, when he had a scheduled operating session Jpoke to Mr: Hutchence in the theatre reception to inform him of issue with the instrument trays and that his surgery would have to be postponed until 215t January 2016. It is unfortunate that Mr Hutchence experienced these delays; however to have proceeded when the integritylsterility of the trays was in question would have been unacceptable hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if you have any further questions regarding this matter: