Dear Mrs Mason

Re: Karen Lesley Sutton

Thank you for the letter of 4th September 2013 that your Assistant Coroner wrote to me in accordance with Regulation 28 of the Coroners Rules following the conclusion of the inquest that was held into the death of Karen Sutton.

I note the concerns that are raised in that letter namely:-

1. That the immunology team were not notified of Mrs Sutton’s admission to hospital.
2. That Mrs Sutton was discharged home without prophylactic antibiotic medication.
3. That Mrs Sutton was left to arrange her next outpatient appointment with

which occurred on the 4th October 2012.
4. That admissions were not shared between departments.

All four of your concerns raise the issue of communication.

When Mrs Sutton was admitted the following process was in place and should have been followed. The admitting Consultant should ensure that s/he is aware of the clinical needs of the patient and further ensure that s/he consults appropriately with other clinical specialties where the patient has complex needs which fall outside of that consultant’s competence. As a result of your concerns we have strengthened our current process by undertaking the following actions:

a) The Medical Director has written to all Consultants in the Trust to remind them of their duty to contact specialist teams in the event of a patient with complex needs being admitted to hospital and placed under their care if a patient’s care needs fall outside the Consultant’s competence.

b) We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust. In the run-up to the

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integration of this software we will ask every Consultant in the Trust to identify the patients in their service whom they feel fit into this category in order to ensure that the process is successful.

In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre- admission medication.

As to your third concern the circumstances surrounding the outpatient appointment with

are unusual. I am informed that the on the 25th May 2012 an outpatient appointment with was booked for 4th October 2012 in accordance with normal procedures. As you are aware Mrs Sutton was subsequently admitted under the care of the respiratory team. It would seem that whilst there was a plan made on the 2nd October 2012 to cancel this appointment, as Mrs Sutton was then an inpatient, our Patient Administration system (HISS) indicates that this cancellation had not been put into effect by the 3rd October when Mrs Sutton was discharged. A plan was therefore made, prior to discharge, that Mrs Sutton should attend her pre-arranged appointment on 4th October 2012 with . This plan was described in the discharge letter which would have been available to

in hard copy form from the patient as well as being available electronically on our ICE System. I am assured that the Immunology Team have access and can use the ICE system to obtain patient information on previous admissions.

I am assured by our Medical Director that it can be appropriate for patients to arrange their own outpatient appointments though this will depend on the clinical circumstances that prevail at the time. This does not however remove the need for appropriate communication between different specialisms. As indicated above we have taken action to strengthen this aspect of care and will be taking the further action described.

I hope that this is helpful and addresses the issue identified in your Regulation 28 Report. I would be very happy to provide any further information or to meet with you to discuss this matter further.