Oxford University Hospitals NHS Foundation Trust

“We convened a group of experts at the Learning Multi-disciplinary Team meeting including the Orthogeriatrician team and the Anaesthetist involved in this case and have agreed that whilst the same principles of the AAGBI guidelines apply to patients with periprosthetic fractures as to other femoral fragility fractures, these cases present a more complex risk / benefit analysis due to the increased length of operation and complexity of the surgery and therefore each patient will require an individ”

“This process was reviewed and clarified at the Learning Multi-disciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant [name redacted] team and the escalation will go through the on”

“The OUH Mortality Review Process includes dedicated training for senior clinicians in conducting Structured Mortality Reviews (SMR). SMRs are presented to the Trust Mortality Review Group which is composed of a range of consultants. The SMR discussion for this case did involve an anaesthetist when it was presented at MRG. We have strengthened the SMR training, guidance and report template to include a requirement to discuss any concerns about poor clinical care raised in the SMR with the”

“Following this inquest, a concise procedure for contacting the Vascular Team at OUH has been developed and approved by the TVVN which clearly sets out the referral process for patients who have a vascular emergency within the Network. This will be sent to all NHS and private providers in Thames Valley and provides details on how to contact the on-call Vascular SpR and on-call Vascular Consultant.”

“Action Plan, there are a number of recommendations concerning the policy for the insertion and use of NG tubes in infants and a recommendation that the nurse involved be reassessed for NGT competence. It appears that the action points were due for completion at the end of 2019 and beginning of 2020. In particular, I have seen the more user friendly policy and the 'at a glance' appendix that now forms part of the policy.”

“the Trust has undertaken a number of steps to address your concerns, details of which are set out below.”