Dear Ms Harding Regulation 28 Report to Prevent Future Deaths following the inquest of Christine McNamara who died at Maidstone Hospital on 27 February 2015. am writing to respond to the concerns you raised during your investigation into the death of Christine McNamara, and to explain the actions that Maidstone and Tunbridge Wells NHS Trust has taken in order to address those concerns.
1) It was established during the inquest that here (sic) was no pathway or guideline in place for post ERCP patients who develop complications Our Medical Director discussed the issues raised in your report with representatives from the medical and surgical teams, and new pathway The Pathway for suspected post-endoscopy complication, perforation or leak) was devised to provide clear guidance to all staff on how to manage patients who have undergone endoscopic surgery. The pathway was implemented in January 2016,and a copy of the pathway is enclosed for your information. We are committed to ensuring that this pathway successfully addresses the potential issues regarding the appropriate escalation of unwell patients at all times wherever are within the Trust, and on whichever site. To ensure that the pathway adequately addresses the issues as intended, we will allow an initial period of 6 months for the pathway to become embedded, before conducting full review (scheduled for October 2016) to consider whether any further clarity is required by our staff As the pathway is already in effect; we are confident that it addresses the concern you raised.
2) Out of hours radiology can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells Surgical consultant cover at Maidstone Hospital want to start by assuring you that there is always a consultant general surgeon on call at all times and they can always be accessed by contacting switchboard in the event a junior member of staff does not know who is on call, switchboard has a list and can direct them as appropriate_ Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane; Maidstone_ Kent ME16 9Q0 Telephone: 01622 729000 Fax: 01622 226416 they

Maidstone and Tunbridge Wells NHS] NHS Trust During the week the consultant on call predominantly covers the Tunbridge Wells Hospital, which is the acute site with emergency admissions and an Associate Specialist (senior surgeon) covers the Maidstone Hospital site out of hours, but with access at all times to the consultant on call. Consultant to consultant radiology referrals out of hours appreciate that; taken out of context; the need for a consultant to consultant referral for radiology out of hours can seem onerous, but want to assure you that there are sound clinical reasons underpinning the policy. Out of hours, junior doctors manage the immediate treatment of patients escalating patients for additional investigations andlor procedures where necessary In the past we have had instances where junior doctors were escalating the treatment of unwelllseriously unwell patients without consultant input: This resulted in consultants being adequately involved in the treatment decisions of their patients , so to resolve this we introduced the consultant to consultant referral thereby ensuring there is always adequate consideration of all treatment options_ Ast explained at the inquest hearing, although CT scans are helpful in diagnosing patients by no means the only diagnostic tool, and where possible alternatives (which do not expose patients to potentially harmful levels of radiation) should always be considered. Where necessary, based on clinical presentation, we always provide CT scan for patient who requires one including out of hours_ Thank you for taking the time to bring your concerns to my attention: At Maidstone and Tunbridge Wells NHS Trust we always welcome the opportunity to learn from the experiences of our patients_ and trust that this response provides you with sufficient assurance that we have acted decisively_