Dear Mr Singleton Regulation 28 Report to Prevent Future Deaths: Jean Helen Hannon (dated 30/9/15) am writing in response to the regulation 28 report received by East Lancs Hospitals NHS Trust in relation to the above deceased patient, which was forwarded to me A review of Mrs Hannon's medical records has been undertaken in light of your report, this was conducted by Consultant Physician. On review of the case-notes it is noted that Mrs Hannon had a spinal cord injury following laminectomy in 2011, following which she suffered with quadriplegia. It is the belief of that Jean Hannon did not have autonomic dysreflexia , and that there is no substantiating evidence in the case-note to say that she did: The only time autonomic dysreflexia was mentioned was during a case conference on the 12th March 2012 where the family of Mrs Hannon were present and no physician was present: At the case conference the condition was mentioned by Mrs Hannon's daughter where she asked what would be the implications on her mother's care of autonomic dysreflexia_ The documented agreed' plan following the case conference did not mention this condition, and nor does it appear in the records to have been mentioned to the ward staff afterwards who would have been able to discuss it in more detail. If this opportunity had arisen then the staff would have been able to explain that there was no evidence of autonomic dysreflexia. It is believed that Mrs Hannon suffered condition more accurately termed autonomic instability. Autonomic dysreflexia syndrome differs significantly autonomic instability, with this latter diagnosis being a common finding in patients who have had spinal cord injury. Safe Personal Effective from

East Lancashire Hospitals NHS NHS Trust Dr Wilson has noted that Mrs Hannon's GP does not reference the condition as past medical history during admissions to Royal Blackburn Hospital and so adding to our view that this was not a confirmed and actual working diagnosis. Of greater concern to us is the issue relating to the capture of chronic and on-going conditions for patients presenting urgently to our services In order that clinical staff treating patients are fully aware of such conditions we have we undertaken number of actions: 1 The Trust now has access to a case summary from the patients GP notes via an electronic system called 'EMIS web'. This means that printed summary of the case record is included as part of the patients case notes for every urgent and emergency admission: For planned admissions this information is gathered during the pre-admission processes. These arrangements have now been in place since April 2015. a consultant geriatrician, is piloting the use of daily problem lists as technique for documenting on-going concerns during ward rounds and daily assessments. This has been used in other hospitals specifically to address the issue of relevant clinical information not being passed on. This is currently in the pilot phase and will be rolled out to other areas after evaluation. hope that this clarifies the clinical confusion and also our response to the wider issue of the capture of important clinical information: If you feel that there is anything more we can do in this instance then please do not hesitate to get in touch with me. Kind regards.