Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 33
University Hospitals Sussex NHS Foundation Trust Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
View source
University Hospitals Sussex NHS Foundation Trust Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
View source
University Hospitals Sussex NHS Foundation Trust Develop and implement the Maternity Improvement Program with maternity safety support.
View source
University Hospitals Sussex NHS Foundation Trust Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
View source
University Hospitals Sussex NHS Foundation Trust Complete the Clinical Negligence Scheme for Trusts year 4 submission requirements and achieve 154 of 155 requirements.
View source
University Hospitals Sussex NHS Foundation Trust Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
View source
University Hospitals Sussex NHS Foundation Trust Develop and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
View source
University Hospitals Sussex NHS Foundation Trust Conduct team learning at structured clinical governance events.
View source
University Hospitals Sussex NHS Foundation Trust Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
View source
Care Quality Commission Publish the completed Trust-wide well-led inspection report on the CQC website.
View source
Care Quality Commission Conduct enhanced monitoring, engagement and inspections of the Trust’s maternity services.
View source
Care Quality Commission Share information and work collaboratively with HSIB.
View source
Care Quality Commission Establish regular Trust engagement meetings to monitor training, deteriorating-patient audits, HSIB actions, maternity safety actions, inspection action plans and mortality indicators.
View source
Care Quality Commission Request information demonstrating the Trust’s compliance with the Regulation 20 duty of candour.
View source
Care Quality Commission Seek confirmation that the Trust has an established process to isolate medical equipment potentially involved in an event.
View source
Care Quality Commission Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Amend guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
View source
NHS England Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
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NHS England Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
View source
NHS England Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
View source
NHS England Launch the Patient Safety Incident Response Framework for developing and maintaining systems to respond to incidents and improve patient safety.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Amend guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
View source
NHS England Work with DHSC and RCOG to consider delivering adequate, sustainable obstetric training posts for safe staffing.
View source
NHS England Implement the Immediate Action Areas from the Ockenden Report.
View source
NHS England Work with system partners to identify poorly performing units, promote compassionate care and common-purpose teamwork, and respond honestly to challenge.
View source
NHS England Develop patient-safety training materials for staff and clinical practitioners across roles and career stages.
View source Respondent positions A position is what a recipient says about a concern when it does not describe a specific action. 11
University Hospitals Sussex NHS Foundation Trust The Trust disputes the reported timing and duration of the cardiac arrest and says return of spontaneous circulation occurred earlier than stated.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
University Hospitals Sussex NHS Foundation Trust The Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
University Hospitals Sussex NHS Foundation Trust HSIB investigation replaced the need for a parallel local investigation under national guidance, so no concurrent local investigation was required.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
NHS England RCoA is responsible for clarifying anaesthetic-machine arrangements in its guidance, while CQC will respond to the report and recommendations.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
NHS England The existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
NHS England The Trust is considered the most appropriate body to respond to the specific concerns raised.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
NHS England Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists An established system for calling additional clinical support was already in place for challenging emergencies, so no new escalation system was required.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
NHS England Local NHS Trusts are responsible for decisions on local workforce and resources and for mandating consultant medical training and clinical procedures.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
NHS England HEE is not responsible for decisions on local NHS workforce or resources, or for mandating consultant medical training or clinical procedures.
Outside remitThe respondent said that this matter was outside its role or authority. View source
NHS England The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Outside remitThe respondent said that this matter was outside its role or authority. View source
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to undertake anaesthetic morbidity and mortality reviews and share learning
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths , and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to disseminate institutional learning from unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths .
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated , which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to investigate potential anaesthetic-related causes of unexpected deaths
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure ) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to remove and assess anaesthetic equipment for faults after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault . Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a robust system to trigger investigations into unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
” Is this part of a recurring concern? Yes — Inadequate safety incident investigations .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Delays in recognition of surgical emphysema during cardiac arrest
Wider context from the report “2. Surgical emphysema
There was a delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest (medical specialist registrar, consultant obstetricians, anaesthetic core trainee, anaesthetic specialist registrar and the on call consultant anaesthetist) despite indicative clinical signs of deep cyanosis, gross whole body swelling with the need to remove the increasingly constrictive hospital wrist band and endotracheal tube tie, alongside sub-cutaneous crepitus and an abdominal drainage bag noted to be tense with air .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
Wider context from the report “1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation . Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces . Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
Verbatim wording from the response “c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery-through the SALG’s Patient Safety Update.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
Verbatim wording from the response “However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the Maternity Improvement Program with maternity safety support.
Verbatim wording from the response “Following the CQC visit to our maternity services in 2021 we have worked with the Maternity Safety Support Program (MSSP) and developed our Maternity Improvement Program (MIP) with their support.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
Verbatim wording from the response “The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the Clinical Negligence Scheme for Trusts year 4 submission requirements and achieve 154 of 155 requirements.
Verbatim wording from the response “We have also worked hard to achieve the requirements of year 4 of the Clinical Negligence Scheme for Trusts (CNST). The Trust achieved 154 of the 155 requirements for our submission which is a huge achievement and is indicative of our focus on the safety of our maternity services. Our evidence was rigorously assessed by the internal auditors (BDO) and reviewed by the Local Maternity and Neonatal system governance lead and ICB panel.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
Verbatim wording from the response “b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
Verbatim wording from the response “Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct team learning at structured clinical governance events.
Verbatim wording from the response “There has been a strong commitment to learning from these events from the anaesthetic team as well as the wider MDT. The following points demonstrate that commitment:” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
Verbatim wording from the response “b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the completed Trust-wide well-led inspection report on the CQC website.
Verbatim wording from the response “A Trust wide Well Led inspection was undertaken on 4 and 5 October 2022. The report is still undergoing quality assurances processes and will be published on our website in due course.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct enhanced monitoring, engagement and inspections of the Trust’s maternity services.
Verbatim wording from the response “Over the last 18 months, CQC have discharged its regulatory function through enhanced monitoring, engagement and inspection of maternity services at each main hospital site.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share information and work collaboratively with HSIB.
Verbatim wording from the response “1.) Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
2.) Seek confirmation that the Trust have an established process for the isolation of any medical equipment involved when an event happens when equipment may be involved.
3.) Information sharing and collaborative working with HSIB.
4.) CQC will request information from the Trust which demonstrates compliance with Regulation 20: Duty of Candour.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish regular Trust engagement meetings to monitor training, deteriorating-patient audits, HSIB actions, maternity safety actions, inspection action plans and mortality indicators.
Verbatim wording from the response “Action CQC intends to take is to agree with the Trust regular engagement meetings to monitor and have oversight of the following:” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request information demonstrating the Trust’s compliance with the Regulation 20 duty of candour.
Verbatim wording from the response “1.) Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
2.) Seek confirmation that the Trust have an established process for the isolation of any medical equipment involved when an event happens when equipment may be involved.
3.) Information sharing and collaborative working with HSIB.
4.) CQC will request information from the Trust which demonstrates compliance with Regulation 20: Duty of Candour.” Source location Response from Care Quality Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek confirmation that the Trust has an established process to isolate medical equipment potentially involved in an event.
Verbatim wording from the response “1.) Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
2.) Seek confirmation that the Trust have an established process for the isolation of any medical equipment involved when an event happens when equipment may be involved.
3.) Information sharing and collaborative working with HSIB.
4.) CQC will request information from the Trust which demonstrates compliance with Regulation 20: Duty of Candour.” Source location Response from Care Quality Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
Verbatim wording from the response “1.) Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
2.) Seek confirmation that the Trust have an established process for the isolation of any medical equipment involved when an event happens when equipment may be involved.
3.) Information sharing and collaborative working with HSIB.
4.) CQC will request information from the Trust which demonstrates compliance with Regulation 20: Duty of Candour.” Source location Response from Care Quality Commission
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Verbatim wording from the response “Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.” Source location Response from Royal College of Anaesthetists
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
Verbatim wording from the response “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
Verbatim wording from the response “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
Verbatim wording from the response “I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports receive are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the Patient Safety Incident Response Framework for developing and maintaining systems to respond to incidents and improve patient safety.
Verbatim wording from the response “With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Verbatim wording from the response “Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.” Source location Response from Royal College of Anaesthetists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with DHSC and RCOG to consider delivering adequate, sustainable obstetric training posts for safe staffing.
Verbatim wording from the response “We recognise that both the Ockenden Report and the review and report into maternity and neonatal services in East Kent: 'Reading the signals,' have placed a much-needed focus on what now must be done to raise standards of care in maternity services. We are working to implement the Immediate Action Areas in the Ockenden Report. This includes the recommendation that the Department of Health & Social Care (DHSC) must work with the Royal College of Obstetricians and Gynaecologists (RCOG) and HEE to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come.” Source location Response from Health Education England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Immediate Action Areas from the Ockenden Report.
Verbatim wording from the response “We recognise that both the Ockenden Report and the review and report into maternity and neonatal services in East Kent: 'Reading the signals,' have placed a much-needed focus on what now must be done to raise standards of care in maternity services. We are working to implement the Immediate Action Areas in the Ockenden Report. This includes the recommendation that the Department of Health & Social Care (DHSC) must work with the Royal College of Obstetricians and Gynaecologists (RCOG) and HEE to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come.” Source location Response from Health Education England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with system partners to identify poorly performing units, promote compassionate care and common-purpose teamwork, and respond honestly to challenge.
Verbatim wording from the response “Regarding the independent investigation led by ████████ into failings in East Kent; like our system partners we are working at pace to ensure the four areas for action are considered and implemented:” Source location Response from Health Education England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop patient-safety training materials for staff and clinical practitioners across roles and career stages.
Verbatim wording from the response “I would like to draw your attention to the work, which HEE has led on, around training in patient safety. This carefully designed training series is designed to be used by staff and clinical practitioners at all stages of their career and regardless of whether their roles are patient facing or not. This is because we believe that patient safety is everyone’s business. Patient safety training materials have been developed by Health Education England, with NHS England and NHS Improvement, The Academy of Medical Royal Colleges and e-learning for healthcare. Completion of this training is helping to ensure health and care services will be made as safe as possible for patients and service users.” Source location Response from Health Education England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes the reported timing and duration of the cardiac arrest and says return of spontaneous circulation occurred earlier than stated.
Verbatim wording from the response “We raise two matters in respect of the factual accuracy of the Regulation 28 Notice in respect of the following passage of text.” Source location Response from St Richards Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
Verbatim wording from the response “You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs.” Source location Response from St Richards Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HSIB investigation replaced the need for a parallel local investigation under national guidance, so no concurrent local investigation was required.
Verbatim wording from the response “The coroner raises the concern that there was no local investigation by the anaesthetic team before or after the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been contrary to national guidance.” Source location Response from St Richards Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RCoA is responsible for clarifying anaesthetic-machine arrangements in its guidance, while CQC will respond to the report and recommendations.
Verbatim wording from the response “Regarding your concerns around there being no temporary removal of the anaesthetic machine used in this case, or the downloading of information from the machine, we welcome RCoA’s commitment to update its guidance accordingly, to ensure responsibilities around this are made more explicit. We are also aware that the Care Quality Commission (CQC) will be issuing a response to your Report and will review their response and any recommendations made in due course.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
Verbatim wording from the response “NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is considered the most appropriate body to respond to the specific concerns raised.
Verbatim wording from the response “NHS England have reviewed the response to your Report from University Hospitals Sussex NHS Foundation Trust (hereafter "the Trust") whom we consider the most appropriate body to respond to the specific issues raised. We note that the Trust has identified learning points and strengthened its training for relevant staff members following Teegan’s death as well as the ongoing improvement work to their maternity services, implemented through the Maternity Improvement Programme.” Source location Response from NHS England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
Verbatim wording from the response “With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An established system for calling additional clinical support was already in place for challenging emergencies, so no new escalation system was required.
Verbatim wording from the response “There are mechanisms to support staff to respond to challenging clinical emergencies, such as that described in your report. All organisations should have a clear system for calling for additional clinical support in emergency situations and it is clear from your report that this was in place at St Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of Anaesthetists¹ can be helpful during a crisis when the cognitive load can impair performance. They are only effective, however, if the organisation has ensured that all staff are given the time to become practised in their use.” Source location Response from Royal College of Anaesthetists
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS Trusts are responsible for decisions on local workforce and resources and for mandating consultant medical training and clinical procedures.
Verbatim wording from the response “To respond to your concerns, I will first clarify HEE’s current role in relation to the education and training of the medical, nursing and health workforce. HEE is currently a non-departmental public body accountable to the Secretary of State and Parliament. On the 1 April 2023, Health Education England will become part of a new organisation within NHS England. As part of the NHS, we work with partners to plan, recruit, educate and train the health workforce. HEE’s primary functions will continue; this being to serve the people of England by educating, training, and developing healthcare professionals. However, HEE does not have responsibility for decisions on the local NHS workforce or resources and nor do we mandate training or clinical procedure for consultant medical staff, this is the responsibility of local NHS Trusts.” Source location Response from Health Education England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HEE is not responsible for decisions on local NHS workforce or resources, or for mandating consultant medical training or clinical procedures.
Verbatim wording from the response “To respond to your concerns, I will first clarify HEE’s current role in relation to the education and training of the medical, nursing and health workforce. HEE is currently a non-departmental public body accountable to the Secretary of State and Parliament. On the 1 April 2023, Health Education England will become part of a new organisation within NHS England. As part of the NHS, we work with partners to plan, recruit, educate and train the health workforce. HEE’s primary functions will continue; this being to serve the people of England by educating, training, and developing healthcare professionals. However, HEE does not have responsibility for decisions on the local NHS workforce or resources and nor do we mandate training or clinical procedure for consultant medical staff, this is the responsibility of local NHS Trusts.” Source location Response from Health Education England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Verbatim wording from the response “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.” Source location Response from Health Education England
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