Dear Mrs Mason Re Michael Andrew Pollard Thank you for the Regulation 28 report sent to us on 5 March 2015 by your Assistant Coroner; note that the matters of concern relate t0 the on-call rota held by switchboard t0 enable contact to be made to the on-call Gl consultant: You felt that two points needed t0 be considered: - That the on-call rota must be up to date, accessible by both switchboard and those clinicians who need t0 access it, and Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas the current rota: am now in a position t0 respond. All Clinical Specialties arrange their on-call rotas in advance and report these rotas to Switchboard, Although some specialities are able use a web-based system this is still largely paper-based system at present and Switchboard transcribe this information, 24 hours in advance of it being needed, to produce a daily on-call rota for the entire Trust; As you will appreciate it can sometimes be necessary to make changes to the on- call arrangements whether because of sickness or for other personal reasons. In these cases the responsibility for notifying switchboard of the change remains with the doctor who has arranged for hislher period of on-call to be covered by a colleague Thereafter it is the responsibility of Switchboard staff to update the information so that it is captured in the daily on-call rota they prepare. This rota University Hospitals of Leicester NHS Trust includes Glenfield Hospital. Leicester General Hospital and Leicester Royal Infirmary ebsile; WW leicesterhospitals nhsnet Chairman; Mr Karamjit Singh Chiel Executive: Ar John Adler May and

details all on-call staff across the Trust for the in question and contains contact details for on-call staff: Clinicians who need t0 access the on-call information can do so via Switchboard; From this you will see that we have a central single point for amending the on-call rota and process both for keeping it up to date and also accessible clinicians Generally this system works well but unfortunately did not do so on this occasion. understand that prior t0 the conclusion of this inquest your Assistant Coroner was provided with a copy of the Trust's Investigation Report into Michael s death and which indicates that regrettably there was delay in identifying the correct on-call gastroenterologist as the on-call rota had not been properly updated As indicated in the Investigation Report there is to be a review of the system by the Switchboard Management Team. These matters will be reported t0 our Adverse Events Committee which requires assurance that actions identified in such Trust Reports are followed up and can confirm that this will occur here. As a result of this inquest our Interim Medical Director has written t0 all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will; by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to the on-call rota updated The Trust is in the process of procuring a trust-wide ~based system manage our on-call rotas Our Chief Medical Information Officer expects t0 have this system available for use throughout the Trust by the end of this calendar year; Once adopted this system should strengthen and improve our processes with information uploaded in real-time and visible t0 clinicians_ hope that this response assures you that we take these matters seriously. you wish for any further information please do write to me again. Kind regards