Dear Mrs Brown Re: Regulation 28: Report to Prevent Future Deaths

I write in response to the Regulation 28 Report to Prevent Future Deaths sent to NHS England, Central Midlands and confirm that this case was discussed at the Performance Advisory Group (PAG), held on Wednesday 24 February 2016. The remit of the PAG is to consider all concerns raised any relevant information and recommend options for the management of these according to the NHS England Framework for Managing Performer concerns. The information reviewed included:
• The Coroners Regulation 28 Report
• Patient Medical Records
• Central Nottinghamshire Clinical Services (CNCS) Serious Incident (SI) report
• response to Assistant Coroner, background information and Sepsis Screening Toolkit poster
• reflective report The PAG considered the case and concluded that the following actions should be undertaken:
• has been requested to reflect on his record keeping at his next appraisal and on the diagnosis and treatment of patients with suspected sepsis. The PAG was assured that had shown significant reflection and learning into this case and , having considered the options put forward, agreed to close this case within the Practitioner Performance Team process. Continued/ ... High quality care for all, now and for future generations

2.

16 March 2016 NHS England has, through the local medical committee, highlighted the importance of diagnosing sepsis and the use of the sepsis screening tool (attached).

Dear Mrs Brown Re: Report to Prevent Future Deaths in the case of Caroline Elisabeth Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 16" October 2015, bringing (o my altention the Coroner s concerns arising from Ihe inquest into Ihe death of Mrs Caroline Elisabeth Robey. would Iike t0 assure that within the East Midlands Ambulance Service (EMAS) all matters related t0 patient safely are taken extremely seriously. The delivery of high quality, evidence based care is at the heart of the Trusl's clinical strategy. This work is conlinuous, however, trust you take assurance from Ihe measures oullined in this response which are pertinent for the lime-frame from the date of Mrs Caroline Elisabeth Robeys' death to the present day: The concerns defined in the Prevention of Future Dealh nolice perlaining (0 the inquest into the death of Mrs Caroline Elisabeth Robey:
1. No Screening tool was used by the community health providers, and so opportunities were lost to consider the diagnosis of sepsis and refer as an emergency for hospital admission treatment: A patient safely alert was issued on the 2 September 2014 by NHS England clearly sets out the resources available in the provision of a UK Sepsis clinical tool kit, but this has not be recognised or adopted by health care providers in this case. Inadequate note was made of the number of different attendances Mrs Robey had initiated despite previous good health; and there is no suggestion that she was a frequent attender or had ever sort medical attention inappropriately. Lfi< "25123 City & Sul 14 CURLERSDRICT 1 7 DEC 2015 FSJC'=0) Robey you will Sepsis and 6i"" 5

East Midlands Ambulance Service [HI NHS Trust Emergency Care | Urgent Care | We Care Background East Midlands Ambulance Service (EMAS) serves a resident population of 4.8million across the East Midlands region (Derbyshire , Leicestershire and Rulland , Lincolnshire (including North and North East), Northamptonshire and Nottinghamshire) , across 6,425 square miles Each year we respond t0 over 616,000 emergency and urgent calls; Sepsis screening_tools In March 2015 EMAS introduced an updated sepsis screening tool (both adult and paediatric) based upon the Sepsis 6 red flags and NHS England Safety Alert (2014) (appendices Ia and Ib) Prior to this EMAS had in place a generic sepsis screening tool based upon Ihe same features as (he updated tool but did not have specific paediatric element included (appendix 2). In addition to the Sepsis screening EMAS has in place the Paramedic Pathfinder Triage tool (PP) The PP tool is a pre hospilal assessment based around Ihe widely used and validaled National Early Warning Score. This an objective screening tool which is based upon both physiological parameters and clinical presentations to allow for safe See and Treat care and also to ensure the early recognition of the sickest patients requiring Emergency Department admission: Since its introduction in April 2014 94% of staff have compleled training The applicalion of Ihis tool in Ihis case would have required Emergency Department conveyance based upon (he presenting symptoms. A copy of Ihe PP tool can be found in appendix 3. Communication and Education As a of our annual education programme for 2014/15 assessment and management was included for all clinical slaff and continued into the 2015/16 plan t0 allow for all staff t0 underlake this education; The educational material for this is found in appendix 4 In addition t0 educalional material; awareness of staff has been promoted via clinical bulletins issued over the period of the last four years Following this incident a further clinical bullelin has been issued t0 highlight the learning gained from (his incident and other cases where Sepsis management could have been improved (appendix 5). In addition t0 our allocated annual education programme Paramedic Pathfinder has been delivered as an additional face t0 face education session t0 all clinical staff from 2014. This tool was primarily launched for Paramedics but has now been extended t0 include other ilified clinicians within EMAS; As with any patient safety incident or incident investigation learning is taken both organisationally and at an individual clinician level as required. In such cases, as & part of the investigation process, the EMAS organisational learning team is utilised to develop support programmes for any member of staff noted to have a Iinked educational need or support: It is essenlial Ihat learning is laken across all levels; Ihis ensures (hat responsive changes t0 practice are achieved. In this case supportive programme was provided to the clinician both as a supportive and developmental measure. This process is supported by a number of policies within EMAS such as the Supporting Capability Policy: Triage guide Sepsis part qual key

East Midlands Ambulance Service [HS] NHS Trust Emergency Care | Urgent Care We Care trust that the measure and safeguards cited above and evidenced in the appendices provide you with the appropriate level of assurance in relation to the commitment and planning of EMAS in relation to patient safety and Ihe management of suspected sepsis. Yours Sincerely Sue Chief Execulive SusaQ_Ioy9 > Noyes

WS West Leicestershire Clinical Commissioning Group CCG Headquarters Woocgate From the office of; Loughborough Telephone: Leicestershire Your CEMIGA/00705-2015 LEI| 2TZ Tel; 01509 567 700 Fax: 01509 567 792 11 December 2015 HM Coroner For Leicester City and South Leicestershire The Town Hall Town Hall Square SRE Leicester aiCT LEI 9BG "2015 Dear Mrs Mason Re; Caroline Elisabeth Robey Requlation 28 Report write further to your report made in accordance with paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 29 of (he Coroners (Invesligalions) Regulations 2013. As oullined within your report; it is considered that action should be taken to prevent future deaths and that NHS West Leicestershire CCG has the power t0 take such action; am now in a position to provide you with the following information. would firstly Iike t0 clarify that NHS West Leicestershire CCG is the commissioner of the Loughborough Urgent Care with Central Nottinghamshire Clinical Services (CNCS) providing the clinical services from the Loughborough Urgent Care Centre: This response has been jointly prepared by both the CCG and CNCS can confirm that the matters raised Mrs Robeys care has been formally reported a5 Serious Incident (SI) and is being managed through the CCG's Sl process will now respond to each of your specific requests for information in turn. No sepsis screening tool was being used by the community health care providers, and s0 opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment Please see the enclosed action plan developed by the Loughborough Urgent Care Centre. As you will note , an organisational sepsis policy has been developed and during April and 2015 all staff at the Loughborough Urgent Care Centre completed & training course in sepsis recognition. In addition, work is currently ongoing at the Loughborough Urgent Care Centre t0 implement the sepsis6 pathway: Patients Practices; Pantners ref: and May

A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis tool kit; but this had not been recognised or adopted by the health care providers involved in this case would again refer you to the enclosed action plan developed by the Loughborough Urgent Care Centre_ As you will note, an approved system t0 review and implement patient safety alerts at the Loughborough Urgent Care Centre will be developed by January 2016, with regular assurance reports subsequently provided t0 the Clinical Govemance Commiltee at CNCS on the implementation of all relevant Patient Safety Alerts In addition, the CCG s Head of Infection Control has arranged for an email to be circulated to all GPs within Leicester, Leicestershire and Rutland (LLR) entilled 'Managing Sepsis" follows: In September 2014 NHS England issued a Stage Two Patient Safety Alert relating t0 the prompt recognition of sepsis and the rapid initiation of treatment. This alert was sent all GP's by NHS England via lhe CAS system on 3 September 2014. The aim of the alert was t0 raise awareness of sepsis and signpost GP's set Of resources developed by the UK Sepsis Trust; and others; support the prompl recognition and initiation of treatments for all patients suspected of having sepsis: Following a Coroner's case Ihe CCG has re-issued the alert reminding GPs of the need t0 ensure staff have access t0 both adult, paediatric and infant sepsis screening and action tools that can be used for palients presenting On atlendance developing suspected infection: Staff are reminded that the resources should now have been introduced into clinical practice; particular Ihe administration antibiotics within one hours ofsuspicion of sepsis The UK Sepsis TrustToolkit; General Practice management Sepsis guidance available al; hlp Ilsepsistrust org wpcontentfuploads/2015/08/1409322498GPtoolkit2014pdf can further confim that a WLCCG Board GP Dr Chris Barlow; has a meeting arranged with Dr John Parker; Critical Care Consullant at the University Hospitals of Leicester (UHL); on 15 December 2015; as UHL have successfully implemented a number of quality improvement projects for sepsis in UHL, lhey have offered t0 meet with the CCG wilh the aim of sharing their experiencelmaterials and t0 provide support in ensuring that staff have a developed understanding of the management of sepsis. Following the above meeting, a Protected Learning Time (PLT) event will subsequently be arranged t0 further raise awareness of sepsis within primary medical care. Inadequate note was taken of the number of different attendances Mrs Robey had initiated despite previous good health; and there was no suggestion she was & frequent attender or had ever sought medical assistance inapproprialely would again refer you t0 lhe enclosed action plan developed by the Loughborough Care Centre. As you will note clinical newsletter was circulated in July 2015 to alert clinicians at the Loughborough Urgent Care Centre to learning points from the case of Mrs Robey: In addition, the Loughborough Urgent Care Centre are the process of developing & Local Operating Procedure for multiple attendances, which is t0 be approved and implemented by February 2016. It is my understanding that the CCG's Chief Nurse liaised with the Head of Quality at NHS England regarding the actions of the specific GPs involved in Mrs Robey s care and received assurances that Dr Khokar has been referred to their Professional & Practice Information Gathering Group (PIGG) t0 review their individual performance as a practitioner_ out first Urgent key has has

Dr D Youseff has been confirmed as a Foundation Year 2 GP, and therefore this matter has been referred t0 Health Education East Midlands (HEEM): trust that the above information is of assistance, but please do not hesitate to contact me if you require any further information: