University Hospitals of Leicester NHS Trust

“As an immediate action after the inquest the matron met with all nursing staff on the ward to discuss what had occurred in this case. In particular ward staff University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal”

“Additionally, as part of our wider learning, our Clinical Director for the Clinical Management Group (CMG) will, along with the Medical Lead for Imaging ensure that there is a continuous teaching session for CMG staff on the issue of lnterventional Radiology for Surgical patients ; describing the techniques, complications, frequency of observation for each different procedure, identification of complications and escalation . This will have occurred before the end of December 2015”

“Furthermore our Head of Nursing for the CMG will ensure that there is an audit undertaken to monitor the compliance with nursing instructions following radiology procedures. This audit will have been completed by the end of November 2015 and repeated thereafter according to its findings.”

“the Trust intends to introduce a system for electronically recording nursing observations. This system (E-obs) is expected to be in place by the end of March 2016 and is led jointly by our Interim Deputy Medical Director and Assistant Chief Nurse.”

“Our Medical Lead for Imaging, in consultation with surgical colleagues, will have completed this work by the end of December 2015.”

“Our Interim Deputy Medical Director and Assistant Chief Nurse are currently rewriting the EWS training package and will use what occurred in this case to ensure that clinical staff are given clarity on the actions that they must take when there is either doubt as to the reliability of any particular EWS score or the EWS score is considered to require escalation. This work is due to be completed by the end of March 2016.”

“The Trust is in the process of procuring a trust-wide web-based system to manage our on-call rotas. Our Chief Medical Information Officer expects to have this system available for use throughout the Trust by the end of this calendar year.”

“the Head of Midwifery will ensure that the guidelines for the management of the second stage of Labour (lntrapartum Care: Healthy Women and their Babies Guideline) will be reviewed by the end of September 2014, and will strengthen the guidance on the need to use the emergency buzzer in emergency situations.”

“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.”

“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.”

“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.”

“the junior doctors involved in the care of Mrs [name redacted] will be particularly reminded about the importance of fully considering pre- admission medication.”

“A plan was therefore made, prior to discharge, that Mrs [name redacted] should attend her pre-arranged appointment on 4th October 2012 with .”