Dear Ms Skerrett Diana Ruth Hughes am writing in response to the Regulation 28 report received from You on 22n May 2015 in connection with the inquest into the death of Mrs Hughes. have read the report carefully and have discussed this case with the Trust's legal representative can confirm that as a result of the Trust's own internal investigation undertaken before the inquest, the following actions were identified, and work on these actions in underway: Consideration is being given to amending the WHOISurgical checklist document to include an additional instruction to direct staff at the end of the procedure to check whether 'special instructions for post-operative care have been physically written on the operation note_ 2 Consideration is being given to a review of the Trust documentation policy to establish that the record of the surgicalloperative procedure should be completed on new operation note document specifically designed to record that clinical information. In Mrs Hughes' case , the operation notes were written onto a medical continuation sheet; in red pen: This is currently acceptable Trust policy. 3_ It is also intended that any new operation note document incorporates heading to specifically identify 'Special Instructions' for post-operative care This work is led by Consultant General Surgeon and Speciality Director for Surgery, Who gave evidence at your enquiry: The progress of these actions will be monitored through the monthly meetings of the Safety Experience and Risk Group (SERG) chaired byE Director of Safety: Chair: Professor Clair Chilvers DSc Chief Executive: Dr Frank Harsent PhD, MBA WWW gloshospitals nhs uk BETTER FOR YOU Katy being

Gloucestershire Hospitals [NHS] NHS Foundation Trust hope this is the information you require. Please do not hesitate to contact me if | can be of further assistance