Alan Tear

“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.”