Stockport NHS Foundation Trust

Noted (AI summary) NHS England expresses condolences and explains the context of shared decision making and risk assessment, referring to existing national guidance and tools. It states that commenting on the specific clinical decision is outside of NHS England's remit, and refers to the Trust's response regarding handover communications. The Trust has rolled out mandatory consent training and has a focused approach in place to support safe and timely transfers. A daily meeting has been established to identify patients who can be stepped down from ICU care to ward level care. The response acknowledges national guidance from NICE and the British Geriatrics Society and states that Stockport NHS Foundation Trust has taken steps to improve information and training relating to shared decision making and consent. Martha's Rule is being expanded to all acute inpatient sites. Medical examiners have been implemented on a statutory basis.

Noted (AI summary) NHS England states that Stockport NHS Foundation Trust plans additional weekend lists to reduce Stress Echocardiogram waiting times and hopes to achieve a 6-week standard by 31st January 2025. NHS England is not developing an MR angiogram service at this stage. Stockport NHS Foundation Trust plans an additional 20 weekend lists for Stress Echo to clear the backlog by 31st January 2025, aiming to achieve a 6-week standard for all patients. The Trust is also reviewing CT Coronary Angiogram service provision as part of its service development programme for next year. DHSC acknowledges the concerns but states that the procurement of diagnostic equipment falls under the responsibility of the trust and NHS England, who are better positioned to respond.

Noted (AI summary) The Trust reviewed the concerns regarding record keeping, communication and discharge process. They maintain that the patient's medical presentation at the point of discharge was appropriate, and apologise for the distress caused to the family.

Noted (AI summary) EMAS has shared a revised handover tool with network partners and plans to implement it across its footprint in May 2018, subject to governance approval; is working to promote the use of recorded facilities at receiving units; is exploring expanding its recording ability, incorporated into a wider IT infrastructure plan; clinical staff have been provided with clinical guideline books and an electronic app version is planned for launch in April 2018; staff have been reminded of the importance of escalating advice call failings. The Department of Health references existing NICE guidance and a forthcoming guideline on intrapartum care for high-risk women. It also describes the role of the Healthcare Safety Investigation Branch (HSIB) in investigating serious incidents and the "Safer Maternity Care" initiative which sets an expectation of a 20% reduction in serious incidents by 2020. HSIB acknowledges receipt of the coroner's concerns but states that the case occurred before their operational start date and therefore does not meet their criteria for investigation. They will use the information to help build a wider picture of safety issues in the NHS.

Noted (AI summary) The Trust provides context regarding patient transfers and staffing levels, but does not describe specific actions taken or planned in response to the coroner's concerns.