From the Rt Hon the Earl Howe PC. Parliamentary Under Secretary of State for Quality (Lords) Department of Health Richmond House 79 Whitehall David Llewellyn Roberts London SWIA 2NS HM Senior Coroner- North and West Cumbria Fairfield, Station Street Cockermouth Cumbria, CAI3 9PT 1 8 AUg 2014 21 L(_ Kolkkz Thank you for your letter to Jeremy Hunt about the death of Mr Ian Reid. I am responding on his behalf; as the Minister responsible for quality. Your report advised that Mr Reid needed hip revision surgery, which was delayed while the hospital tried to source the appropriate components. The operation was successfully carried out on 29 July but Mr Reid had contracted pneumonia the night before and died on 27 August: You were concerned that the type, manufacture and specification of Mr Reid'$ previous hip implant could not be found on any of his records and the hospital that had treated him previously could not provide this information. You asked two questions with regard to this concern; whether action could be taken to enable patients to have a document confirming the necessary details of each implant so that this information is readily available in case of further fracture; and if there could be a system to ensure that hospitals have a clear accessible record which can be passed to the surgeon who will carry out any revision_ It is best practice for the type of implant used in surgical procedures of this nature to be noted in the patient'$ medical records. However; aS you have identified, practice is not consistent across the NHS. NHS England has recently established a reference group to take forward the recommendation made by the Surgical Never Events Taskforce in February 2014. This taskforce was commissioned to examine and clarify the reasons for these serious patient safety incidents, and to produce a report recommending how might be eradicated. The report is attached for your convenience and can be found at the link below: 2014 AUG Yo m encu they

http:IIwww england nhs uklourwork/patientsafetylnever-events/surgicall One of the recommendations of the report is to develop national standards for operating department practice. This will support all providers of NHS funded care to develop and maintain their own detailed standardised local procedures. One of the agreed national standards concerns the 'prosthesis fication process which proposes to include details of all prosthesis use in the patient record: Current timescale for the development of the Standards is early 2015. Once standards been developed, the next phase of this work will be to address how should be implemented and this will include requirements for educators, commissioners and regulators. In addition, the Governments Information Strategy "The Power of Information: all of us in control of the health and care information we need" was published in 2012 A copy can be found on the GOV UK website via the following link: The Power of Information: The Strategy sets a ten-year framework for transforming information for health and care. It aims to harness information and new technologies to achieve higher quality care and improve outcomes for patients and service users_ The strategy encourages for information to be recorded once, at first contact with professional staff, and shared securely between those providing care supported by consistent use of information standards that enable data to flow (interoperability) between systems, whilst keeping our confidential information safe and secure. Interoperable records are intended to join up health and social care systems, putting the patients first, and ensuring that patients do not have to negotiate their way through a number of unconnected services at the point when are ill and vuinerabie. Lastly, may be interested in the work of The National Joint Registry (NJR) which was set up by the Department of Health and Welsh Government in 2002 to collect information on all knee, ankle; elbow and shoulder replacement operations and to monitor the performance ofjoint replacement implants. The website can be found at http://wWW njrcentre org uk/njrcentreldefault aspx. [ that this information is useful and [ thank you for bringing the circumstances of Mr Reid's death to our attention_ S&nly EARL HOWE key - veri have they Putting May they you hip; hope ` I_