Heart of England NHS Trust

“The Trust accepts that, at the time of Mr [name redacted] death, there were no Trust guidelines in existence regarding the management of potentially unstable fractures in frail patients that are for conservative (non-operative) treatment. Following the findings from this report, guidelines will be formulated for clinicians to follow for these patients. These will include recommended timescales for follow-up and x-ray reviews to be used in conjunction with clinical judgement. The new guidelines will be”

“e they are in the process of reviewing the electronic systems to ensure robustness; e they have a comprehensive training programme in place to ensure that junior doctors are aware of the discharge process; e the individual clinicians involved have been asked to review this significant event in their annual appraisal; and e the event will form part of their internal quality improvement process - the Bisny Business Forum", to ensure that all learning is understood by clinicians”

“In the circumstances where a consultant radiologist does not believe that a requested radiological investigation is likely to identify new clinical information or lead to clinical intervention, before the request is declined they will now discuss the case with a HEFT peer consultant radiologist to seek a second opinion and ensure that their assessment is both reasonable and logical.”