John Doyle
The coroner's concerns
1. inconsistent engagement with specialist renal hospitals
“Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals.”
2. inadequate patient information sharing
“The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined.”
3. limited access to renal care guidelines
“Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients.”
4. inconsistent transfer responsibility
“There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers.”
5. inconsistent patient location decisions
“Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ, potentially affecting consistency in care approaches.”
6. inconsistent specialist-non-specialist collaboration
“There may be variation in how specialist renal hospitals engage with non- specialist hospitals that rely on their expertise, impacting collaborative efforts in patient care.”
Responses
2024-0618-Response-1-from-Coventry-and-Warwickshire-Partnership-Trust.pdf ↗· NHS England
Stated action
“these guidelines have been finalised and agreed between the Trusts and we enclose a copy.”
2024-0618-Response-1-from-George-Eliot-Hospital-NHS-Trust.pdf ↗· George Eliot Hospital NHS Trust
Stated action · 12 December 2024
“The Trust has now received management guidelines from the Renal Team at UHCW and below is a table showing what actions the Trust has taken to embed the information received. Description Action Taken New guidelines to be made easily Guidelines have been developed and are currently accessible on the Trust's intranet going through the Trust's ratification process prior to uploading on to the Trust's intranet.”
2024-0618-Response-2-from-Coventry-and-Warwickshire-Partnership-Trust.pdf ↗· NHS England
Stated action
“We recommend that all hospital switchboards, Emergency Departments and relevant personnel have a master copy of local specialist centre contact details so any query at any time can be appropriately directed.”
Stated action
“We recommend that all staff are advised of internal escalation routes. Relevant clinical colleagues should be aware of internal escalation routes to clarify whether off-site specialist input is required. We would expect this to be achieved by asking the Consultant responsible for the patient's care or their deputy.”
Stated action
“We advise that electronic information sharing in real-time should be the gold standard for information sharing. In the case of kidney patients, we would expect to be informed about all patients admitted for care in another hospital or elsewhere in our own hospital who have chronic kidney disease stage 5 (CKD G5) or who are receiving dialysis treatment or who have a kidney transplant.”
Stated action
“We confirm that staff at UHCW are aware of internal escalation routes. The escalation of concerns is via the renal registrar and renal consultant. We confirm that UHCW has shared and agreed with George Eliot Hospitals the indications for referral to us as a specialist unit, and the routes for referral.”
Stated action
“Electronic patient sharing of blood test results in real-time exists for patients who are already known to UHCW Renal Department, whether admitted to GEH or SWFT. In addition,”
Stated action · May 2024
“Turnaround times for all pathology labs are published in CWPS Handbook V16 May 2024.pdf.”
2024-0618-Response-2-from-George-Eliot-Hospital-NHS-Trust.pdf ↗· George Eliot Hospital NHS Trust
2024-0618-Response-from-NHS-England.pdf ↗· NHS England
2024-0618-Response-from-UKKA-and-BTS.pdf ↗· UK Kidney Association
Stated action
“We recommend that all hospital switchboards, Emergency Departments and relevant personnel have a master copy of local specialist centre contact details so any query at any time can be appropriately directed.”