Dear Mrs Hunt As requested have reflected on the content of your report aimed at preventing future deaths. Central Surgery has discussed the case as a significant event as well appreciate that you are concerned to prevent future deaths_ On reflection believe in the case of Mr Logue the standard of my medical care, both in history taking and examination fell short of my usual practice. have learned to be extra vigilant for post- operative complications and not to rely solely on the history given by the patient or just on their general appearance would like to reassure you that in the past year have successfully managed two cases of biliary sepsis am pleased to say that received positive comments from both relatives and colleagues in relation to my care for these patients_ am, if required, able to provide you with documentary evidence to support this statement: The care of Mr Logue was discussed at a significant event analysis meeting at Central Surgery: My GP colleagues did not think that routine examination of every post- operative patient was indicated and that use of sepsis check list was not routine practice. However, it was agreed that in future it would be prudent to undertake a more detailed examination and to accurately and fully record the findings in any consultation. Some of the GPs in the practice have surgical training and considered that the hospital could be more proactive in contacting patients at home after major surgery. spoken to the hepatobiliary co-ordinator at University Hospitals, Birmingham and was advised that following a liver transplant; patients are contacted at home within one week of surgery, but that this is not the case following bile duct surgery: am aware that following cardiac surgery in University Hospital, Coventry every patient is contacted by the Iiaison nurse within a few days following discharge. Following the significant event meeting am now, on behalf of the practice , in the process of contacting Professor Muiesan to discuss with him how communication in relation to postoperative care can be improved. Yours sincerely, Dr Emma Eedle RECEIVET 2 2 DEC 2045 have

J.Cotterill E.Eedle D.Black Central Surgery N.Cook J Barhey LArmstrong CORPORATION STREET, RUGBY, CV21 3SP Tel: 01788 524366 A.Winter ALSO AT BILTON GREEN. RUGBY. CV22 7LY Tel: 01788 818939 B.Sriram T.Rayment Z. Hughes L. Marshall Dr T Atwal 23rd December 2015. Mrs L Hunt; Senior Coroner for Birmingham and Solihull Areas, 50 Newton Street; RECEIEC Birmingham, B4 6NE L JAN : ; Our ref: RB/2015/12-1 Your Ref: 002189/2015 ( T ORGANIAS) Dear Mrs Hunt; Re: Report on Preventing Future Deaths (Mr Michael Patrick Joseph Logue) Your report and the concerns that you raised have been reviewed under our_clinical review Process. As is our normal Procedure your concerns were raised as a Significant Event: The Practice has carried out a significant event review. The review noted that during the home visit Dr Eedle did not carry out a physical examination of the patient: During the review process it was noted that a physical examination of post-operative patients was not always indicated and that the use of a sepsis check list was not routine practice. The review benefited from input from GP Colleagues who are qualified Surgeons and or have surgical experience: As such it was also observed that the hospitai did not appear to have been proactive in its follow-up care. Following the Significant event review the following actions were agreed for immediate implementation:
1.0 That the event be shared with all clinicians to improve their work practices_
2.0 That in future more detailed examination of the patient in such cases should be carried out and the results of which should be fully recorded in the patient notes
3.0 Dr Eedle to contact the Hospital to see how communication can be improved to support the care of Post-Operative patients If you require any additional information please do not hesitate to contact me.