Dear Ms Topping Mr Ernest Higgs (Deceased) Response to Regulation 28 Report to Prevent Future Deaths This letter comprises the formal response of Epsom and St. Helier University Hospitals NHS Trust ("the Trust") to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 27 April 2016 ("the Report"), made subsequent to the inquest into the death of Ernest Higgs, which was opened on 24 June 2015 and concluded on April 2016. The Trust would like to again express our deepest sympathy and condolences towards the family. Background Mr Higgs was an eighty- four year old man who suffered with mild moderate dysphagia, Parkinson's disease, recurrent aspiration pneumonias, acute renal impairment and advanced small vessel ischaemic disease. Mr had been resident at Milner House, (a nursing home in Leatherhead) since September 2014. On Thursday 15 January 2015 Mr Higgs was seen by a GP at Milner House who diagnosed aspiration pneumonia and prescribed antibiotics and requested that he undergo blood tests. We understand from the Inquest report that the sample bottles and the written consent for the blood test was obtained by Milner House on Friday 16 January 2015 but that the blood samples were not taken until Monday 19 January 2015. Great care to every patient, every day Patient Advice Liaison Service (PALS) 020 8296 2508 Main Switchboard 020 8296 2000 Chairman Laurence Newman Chief Executive Daniel Elkeles Higgs and

On Monday 19 January 2015, before the blood tests were processed Mr Higgs' condition deteriorated and he was admitted to Epsom Hospital where he was treated for likely aspiration pneumonia with IV antibiotics. Mr Higgs died at 22.10 on 20 January 2015 on Buckley Ward of Epsom Hospital: The Inquest concluded that Mr Higgs died of natural causes as a result ofaspiration pneumonia. The Trust involvement in the inquest was limited to the fact that Mr Higgs died at Epsom Hospital. The Trust was not deemed to be an interested party at the inquest but (Foundation Doctor, who no longer works at the Trust) as the Doctor who signed Mr Higgs' death certificate, was asked to attend. I he Preventing Future Deaths Report The Report raises the following concerns: It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015_ No record was made in the multi-disciplinary notes by the GP of her attendance at Milner House. Care UK, the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However; it appears that the BMA advice to GP's; 'Quality First Managing Workload to Deliver Safer Patient Care' advises against GP' $ in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes_ Advice given by the GP over the telephone to make Mr Higgs 'nil by mouth' was not recorded and no confirmation of that advice was sent by email. There did not appear to be a safe system in place to ensure telephone advice was accurately sent and received. There was conflicting evidence from Care UK and Epsom Hospital about out of hours provision at the hospital pathology laboratory for community care providers resulting in a significant delay to a diagnostic blood test undertaken; Trust response; The Trust is unable to comment on the first and second concerns raised except to note that whilst Mr Higgs was at Epsom Hospital, on 20 January 2015, wwas approached by one of Mr Higgs' relatives who had concerns that despite Mr Higgs' GP having recently instructed Milner House that Mr Higgs should be nil by mouth and fed by PEG tube they had seen Mr Higgs with half chewed food in his mouth: The following day Dr Wolrich raised a posthumous safeguarding alert in light of this_ Great care to every patient; every Patient Advice and Liaison Service (PALS) 020 8296 2508 Main Switchboard 020 8296 2000 Chairman Laurence Newman Chief Executive Daniel Elkeles the filling being day

In relation to the Coroner's third concern the Trust confirms that there is twenty four hour access to the Trust'$ pathology department, seven days a week and that the staff at Milner House would have been able to access the out of hours pathology department at Epsom Hospital either via drop off in A and E or by contacting the biochemist on call at any time between 14 and 19 January 2015. The blood results would have been processed within a matter of hours of them being delivered and the results would have been given to whoever was listed as the contact on the request slip which must be provided when the bloods are left with the pathology department Whilst all GPs should be aware of the twenty four hour access to the Trust'$ pathology department, seven days a week, as a reminder; we are including the following statement within the newsletter sent to the GPs within the Trust's catchment area, due to be sent later this month: URGENT ACCESS TO PATHOLOGY OUT-OF-HOURS Following the recent death of a patient admitted to Epsom Hospital, we wish to remind all GPs with elderly patients, particularly those in care homes, that there is twenty four hour access to the Trust' $ pathology department, seven days a week: On call staff (both medical and technical) can be contacted via the Trust switchboard to arrange analysis When urgent processing is required, samples should be marked as urgent and dropped off either directly to the lab or out of hours via A and E who will arrange to deliver them to Pathology: In addition to being sent to a patient's GP, the results will also be given by phone to whoever is listed as the contact on the request form: We will also be sending a letter to each of our three local CCGs requesting that this information is passed on to all registered care homes in their area. hope that this letter is of assistance_

Dear Mr Travers Re: Mr Ernest HIGGS (Deceased) Regulation 28 Report to Prevent Future Deaths Thank you for your letter with regards the Regulation 28 Report for Mr Ernest Higgs; was sorry to read about the circumstances of his death and would like to extend my condolences to his family: have reviewed your 'matters of concern' and noted items 1 and 2 are of particular relevance in relation to the delivery of primary care. It should be noted that nursing homes have private contractual arrangements with general practitioners, often known as a 'retainer' and responsibility for contracting and commissioning of primary care is currently held by NHS England. At NHS Surrey Downs Clinical Commissioning Group (CCG) we have been concerned with the general quality of care provision within local nursing and residential homes, recent evidence from the Care Quality Commission would reinforce this view with number of nursing and residential homes rated as either 'inadequate' or 'requires improvement' . The actions we are taking are detailed below: Our Quality Committee have undertaken an in-depth analysis of the issues relating to nursing and residential care home quality, this was supported by the Care Quality Commission, Surrey Care Association, Healthwatch Surrey, Surrey County Council and NHS safeguarding specialists. The outputs of this in-depth analysis will lead to changes in the way we commission and assure quality of services. Interim Chief Officer: Ralph McCormack Clinical Chair: Dr Claire Fuller being key

2 Our Quality Team are working collaboratively with Surrey County Council and local safeguarding leads to quality assure nursing and residential home providers and support those in difficulty where care concerns arise 3_ We are at the final stages of developing a nursing home Primary Care Standard (PCS), the PCS is a proactive health assessment and intervention by a general practitioner at least twice per year for every nursing home resident; will also ensure that the requirement to clearly document and evidence instructions by a general practitioner is also included. We are recruiting specialist dietician who will act as a central resource for local nursing and residential homes, particularly for those residents who require specialist nutrition through enteral or parenteral feeding regimes, as was the case with Mr Higgs.
5. NHS Surrey Downs CCG leads the Continuing Healthcare (CHC) function on behalf of all CCGs in Surrey, as a 'spot' commissioner have asked the CHC team to raise concerns should find poor documentation either from the nursing/residential home andlor poorly documented communication between general practitioner and care home staff. 6_ have asked Surrey Care Association to communicate with its members the importance of contemporaneous documentation, care home and sub contracted staff registered with professional regulator such as the Nursing and Midwifery Council or General Medical Council have a professional obligation to ensure documentation is accurate and contemporaneous hope this letter provides you with assurance that we are taking this Regulation 28 Report to Prevent Future Deaths seriously and would be happy to provide further details should you require

Dear Ms. Topping ref Ernest Higgs section 28 response Thank you for asking us a practice to respond to your concerns raised regarding Mr EH, We have had a number of discussions around this case including discussion as a significant event In response to your concerns raised
1) Confusion over multi-disciplinary notes: We feel we need to await clarity from the BMA on their position regarding writing in the multi- disciplinary notes before committing to a stance It is currently the practice view that it should be the responsibility of the nurses attending with the doctor to be writing contemporaneous notes of the interaction We are happy to clarify any issues regarding instructions at the time of the visit however if the advice ofthe BMA differs from this we will consider a policy to address this We have discussed this with the nursing home in question and are in agreement that staff will be responsible for writing contemporaneous notes while we are in attendance
2) Around advice given over the telephone to nursing homes in general We have drafted a practice policy to address this issue. As far as we are aware itis recognised practice that; when taking advice over the phone, nurses are advised to have the advice ratified by another nurse present: We are happy to follow any complex instructions up with written advice (see attached) House House Surrey they

3) In response to the issue over the delay in blood Having had sight of the response from Epsom Hospital this issue appears to have been resolved with an action plan and will ensure local nursing homes covered by the practice are aware of 24 hour pathology cover: We are obviously as a practice happy to work collaboratively with any nursing homes we attend to in order to ensure communication is safe and effective within the parameters advised to us by the BMA We will be auditing our responses to nursing home phone requests 6 months after implementation to ensure there is sensible use of discretion in faxing information If there are any outstanding issues which you feel we need to address please do not hesitate to contact the practice Jon behalf of Ashlea medical practice taking - we