Dear Ms Lake; am responding to the Regulation 28 report dated the 24t December 2014 which was received by the Trust o the 29th December 2014 in relation to the on-going investigation into the death of Mr David John Mountain can confirm that the organisation has undertaken a detailed analysis of the circumstances of Mr Mountain's death; All clinicians involved in his care have been spoken to and a number of immediate changes have been made: The Cardiology team are implementing clear guidance for all doctors within the Emergency Department, the Medical Assessment Unit and the Surgical Assessment Unit which highlights the clinical areas which should be investigated if patient admitted following recent permanent pacemaker insertion: This guidance will be shared with the relevant senior clinical decision makers and in place by the end of February 2015. In the event that any abnormal results are identified; the cardiac technician now directly contacts the referring clinical team in hours (or the on-call Medical Registrar out of hours) thus enabling prompt clinical response to be made. Alongside this, we are moving to an electronic reporting system for all test results including echocardiography. Scoping of this major IT project has commenced and we anticipate that it will be in place by the end of 2015_ This will allow doctors access to reports immediately when are entered onto the system and will eliminate the need to transfer a paper copy report from one area of the hospital to another.
3. Cardiology Consultants are now routinely present on site on Saturday and Sunday to review cardiology patients and provide advice to all clinical teams within the Hospital. Chalr: Edward Libbey Interim Chlef Executivc: Manjit Obhrai Patron: Her Majesty The Queen 315434+9 0mmj705^404 #RaN FEB - 2015 key they

13 February 2015 The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust This is an important part of the Trust's move to 7 services and ensures that senior decision making can occur every of the week. The planned recruitment in the next six months of further joint appointments (QEH/ Papworth) will make cardiology services sustainable for the future at the Queen Elizabeth Hospital: would be grateful if you could pass on my condolences to Mr Mountain's family and my apologies for any additional distress which has been caused to them at this difficult time. hope that this information is sufficient to answer your outstanding concerns but if you have any further queries, please do not hesitate to contact me.