Latest CQC Report On Trust Outlines Concerns In Safety And Leadership

The wife of a King’s Lynn man who died in Queen Elizabeth Hospital following problems during a routine ward transfer has spoken out after the hospital failed to implement a new policy within a timescale put to them by the local coroner’s office.

Peter Knight, who was oxygen dependant as a result of a lung condition, was admitted to hospital with a chest infection in June last year.  During a transfer from the Medical Assessment Unit to the Necton Ward, Peter received no oxygen which led to deterioration of his condition.  He passed away a few hours later.

An inquest at King’s Lynn Magistrate Court was heard in January this year. A conclusion of death by accident was recorded at the inquest, with the Coroner noting that the lack of oxygen during transfer caused, or more than minimally contributed to, his death.

At the inquest, Senior Coroner Jacqueline Lake asked the Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust to take steps in reviewing its transfer policy and re-training staff.  She requested an update by mid-March on the progress made.

However, upon contacting the Trust towards the end of March, the Coroner was told that while new documentation had been put in place, implementations had not yet been trialled.  The Coroner put forward her concerns that sufficient steps had not been taken to complete the policy within the timescale agreed at the inquest and issued a Regulation 28 request to the Trust to take action to prevent future deaths.

Within the request, the Coroner said:  “I am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest.  In my opinion action should be taken to prevent future deaths.”

The Trust issued a response in May to confirm that the new Transfer of Patients Policy (Inter and Intra Hospital Transfer) had reached the final draft stage for approval on 26 April, which was ratified at the Clinical Governance Committee meeting on 7 May, with a full Trust-wide launch scheduled in June and further audit and use of the document carried out two months afterwards.

A Care Quality Commission inspection report in September last year rated the Trust as inadequate in terms of safety, effectiveness and how it is led. 

A further inspection of the Trust took place between March and April this year, with the report published on 24 July.  It outlined that the Care Quality Commission still has concerns surrounding the safety and leadership of the Trust, and the Trust has been asked to provide a report stating the actions it will take to make improvements.

Following Peter’s death, his wife Donna instructed specialist lawyers at Irwin Mitchell to support her throughout the inquest, and she has spoken out following the length of time it has taken the Trust to implement a new policy in the hope that lessons can be learned and no other family will suffer like she has.

Expert Opinion

“This has been a terribly difficult time for Donna, losing Peter and then having to relive it all again at the inquest in January.

While nothing will bring Peter back, we welcomed the Coroner’s decision to request a new transfer policy from the Trust. It was deeply disappointing, however, when it was not implemented in the timescale that was given.

Although we are pleased that the Trust has now implemented the transfer policy and put safety measures in place, the latest inspection report of the Care Quality Commission is deeply concerning. Safety and leadership are still significant areas of concern.

The Trust is required to report to the Care Quality Commission about the action it intends to implement to improve patient safety. We hope that the appropriate measures will now be put in place to ensure that nobody else has to watch a loved one suffer like Peter did before he died.”
Sophie Bales - Associate

Donna said: “Peter was such a loving husband and I miss him every day.  Losing him so suddenly was devastating, but I was pleased with the Coroner’s decision earlier this year to ask the Trust to make improvements.

“Although we have been advised that a new transfer policy has been put in place and improvements have been made, we are very concerned about the outcome of the latest report regarding patient safety. I think this is unacceptable and it has upset me to think that the Trust is not doing what it should be.  Lessons need to be learned, as I really don’t want anyone else going through what I have.”

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