Audrey Kelly

From Dr Dan Poulter MP
Parliamentary Under Secretary of State for Health
Department Richmond House

79 Whitehall
of Health Landa
POCS 855166 aan
Tel: 020 7210 4850
Mr J Pollard
Senior Coroner
Senate Sit 10 JUN 2014
1 Mount Tabor Street
Stockport
SK1 3AG

Dewy wv fed,

Thank you for your letter following the inquest into the death of Audrey Lily Kelly. In
your report you conclude that the medical cause of death was acute myocardial
insufficiency, coronary artery atheroma and systemic hypertension.

On 17" November 2013 Mrs Kelly complained of abdominal pain and the out of hours
(OOH) doctor attended. He was unable to access her GP medical notes and so was not
aware that she had an allergy to the antibiotic Trimethropim. He prescribed this same
antibiotic and she took three of the tablets as prescribed. She was then found dead at
home two days later. Although the initial concern was her consumption of these
tablets to which she was allergic, it turned out that she died of natural causes.

You raise the following matters of concern:

e The OOH doctor and nurse who took the call at the Stockport OOH service
could not obtain the electronic patient notes held by the patient’s own GP. The
senior administrator of the OOH service also confirmed that neither he nor the
hospital emergency departments had direct access to GP notes.

e You state that this lapse in procedures will inevitably lead to further lives being
lost and you consider there is an immediate need for directions to be issued to
all out of hours providers and the appropriate Clinical Commissioning Groups
to the effect that there must be free and unfettered access to all the GP notes in
such circumstances.

Currently, there is a national system in place that allows access to information from
GP records by healthcare staff working in urgent and emergency care settings. This
system is the Summary Care Record (SCR) which has been developed by the Health
and Social Care Information Centre (HSCIC).

The SCR is an electronic record which contains key information relating to an
individual patient such as their medications, allergies and adverse reactions. The
record may, with the explicit consent of the patient, contain additional information
relating to their clinical needs.

Data for the SCR is extracted directly from the GP record and is then held securely on
an infrastructure known as the National Spine.

SCRs can be viewed electronically by authorised healthcare staff providing urgent or
emergency care to patients, anywhere in England, any time of day or night. Viewing
of the records is via a web-based SCR application which is both relatively cheap and
easy to implement.

Authorised healthcare staff are issued with their own individual SmartCard to access
the system. These SmartCards are configured to include role-based access controls so
that only healthcare staff who can demonstrate a legitimate relationship to the patient
can access the clinical information in the SCR. In addition, any accesses that are made
to the records are potentially auditable.

Currently (April 2014) 37.5 million people in England have Summary Care Records
(66% of the population) and the number of SCRs is increasing at a rate of
approximately 200,000 each week.

From 1“ April 2014, GP practices are contractually required to provide an automated
upload of their summary information on at least a daily basis to the Summary Care
Record, or have a published plan in place to achieve this by 31° March 2015. This
requirement is a result of contract negotiations between the BMA’s General
Practitioners Committee (GPC) and NHS Employers (on behalf of NHS England) on
changes to the General Medical Services contractual arrangements in England from
April 2014.

The NHS Standard Contract, mandated by NHS England for use by commissioners for
all contracts for healthcare services other than primary care, also stipulates that:

“the Provider must ensure that all Staff involved in the provision of urgent care are
able to view key Service User information from GP records, whether via the Summary
Care Records Service or a locally integrated electronic record system.”’ (NHS
England December 2013)

In addition, there are other commercially available solutions for sharing patient
clinical information. Some GP IT system suppliers such as TPP SystmOne and
EMISweb are working with local health communities to implement local solutions for

sharing clinical information from the GP record with clinical staff in organisations
which provide urgent and emergency care away from the patient’s GP surgery.

With regard to the local position in NHS Stockport Clinical Commissioning Group
(CCG), I can confirm that SCRs have so far been created for 34% of registered
patients at 28% of their GP practices. This percentage is significantly impacted by the
availability of SCR compliant GP systems within NHS Stockport CCG.

However, NHS Stockport CCG plans to progress SCR uploads across the local GP
practice community. The SCR roll out will be supported by GP systems migrating or
attaining SCR compliance. In addition, HSCIC will provide significant resource and
support to local NHS organisations in Stockport when SCRs reach a certain level
(circa 50 — 60% of local patient population).

I am pleased to report that a number of organisations are already successfully utilising
and realising the benefits of SCR across the Greater Manchester region, including
those listed below:

Royal Bolton Hospital

Bury OOH

NW Manchester OOH

Fairfield General Hospital

Royal Albert Edward Infirmary
Wrightington Hospital

Oldham OOH

The Royal Oldham Hospital

North Manchester General Hospital”

ooocoooo.°8

Stockport also has a local health record solution (Stockport Health Record) which is
limited to staff and patients within NHS Stockport only and provides access to clinical
information in the Patient’s GP record such as test results, medications, allergies and
social care or mental health information relevant to the patients’ medical care.

The health record is kept on a secure database that is maintained by NHS Stockport
CCG and is never sent to other areas outside the health and social care system. Access
to the record is restricted to professionals with a duty of care to the person and is only
accessed through the secure NHS Network at the point of care.

So, for example when a patient is registered with Stockport GP Practices, information
concerning any allergies they may have can be accessed from their health record when
attending the Emergency Department at Stepping Hill hospital (Stockport NHS
Foundation Trust) or when calling the local GP Out of Hours provider (Mastercall),
providing the patient has not dissented to local record sharing.

This local approach to sharing care records has been highlighted as a national
exemplar and was a successful DH Common Assessment Framework (CAF)
demonstrator site.

However, I acknowledge that none of the above explains why neither Mastercall nor
the hospital emergency department could access Audrey Kelly’s GP records on the
day in question. My officials have therefore contacted the Stockport CCG about this
case.

The CCG has confirmed that both Mastercall and local hospital departments and
emergency departments have access to view summary shared GP records for patients
in all but one Stockport GP practice, through the Stockport Health Record (SHR)
system. The final outstanding practice is yet to sign a data sharing agreement, but has
verbally agreed to share data in the meantime.

On the day in question, Mastercall staff accessed shared patient records for Stockport
patients, on over 40 occasions. The CCG have confirmed that Audrey Kelly had a
shared record which was available to view and which included her allergy to the
antibiotic specified in your report.

Mastercall have stated that at 14:06 on the day in question, they tried and failed to
access the patient’s record on the SHR. However, audit data from the SHR does not
show any activity between 13:19 and 14:48.

Stockport CCG are currently investigating this matter further, specifically regarding
the attempted access to the record at the time. Although their technical audit of the
Stockport Health Record (SHR) showed no attempted access during the relevant
times, this could be explained by a break in connection between the SHR and
Mastercall’s clinical system. The CCG are working with suppliers to attempt to
understand exactly the root cause and whether it was a human or system error.

The CCG have also written to Mastercall to arrange a meeting to understand the issues
more fully, and improve processes for the reporting of issues relating to the SHR.

I can also report that there are plans to further develop an integrated records solution
in Stockport. The CCG has recently implemented plans for wider access and increased
multi organisation record sharing to support integrated care models. As part of wider
service reform plans, the CCG is also in discussions with suppliers and providers
around sharing access to the full GP record (including any free text contextual notes).

I hope that this response is helpful and I am grateful to you for bringing the
circumstances of Mrs Kelly’s death to my attention.

Qiaut vy,

jb

DR DAN POULTER

RG From Dr Dan Poulter MP
Parliamentary Under Secretary of State for Health

Department

of Health ae 9 Whitehall
POCS 873078 London

SW1A 2NS

Mtr J Pollard Tel: 020 7210 4850
Senior Coroner
Coroner’s Court
1 Mount Tabor Street 10 JUL 2014
Stockport
SK1 3AG

Dewy we FMée

Thank you for your further email of 12" June 2014 in response to our reply of 1 1" June 2014
about the Regulation 28 report into the death of Audrey Lily Kelly.

In your email you requested that I contact you again when Stockport Clinical
Commissioning Group (CCG) had completed the further investigations that were outlined in
my original response as follows:

Stockport CCG are currently investigating this matter further, specifically regarding
ihe attempted access to the record at the time. Although their technical audit of the
Stockport Health Record (SHR) showed no attempted access during the relevant
times, this could be explained by a break in connection between the SHR and
Mastercall’s clinical system. The CCG are working with suppliers to attempt to
understand exectly the root cause and whether it was a human or system error.

The CCG have also written to Mastercall to arrange a meeting to understand the issues
more fully, and improve processes for the reporting of issues relating to the SHR.

My officials have now been in touch with Stockport CCG about your further request.

Ican confirm that Stockport CCG has now undertaken further investigations involving the
GP out of hours provider Mastercall, to ascertain exactly why access to the shared patient
record for Audrey Kelly failed.

Mastercall report that the nurse who had been unable to access the system was a new
member of staff and had not yet been provided with an NHS smartcard. As a result, she was
unable to access a shared Stockport Health Record. The nurse however continued with the
diagnosis by asking for medical history.

Mastercail have confirmed that all relevant members of staff now have an NHS Smartcard.
In addition, Mastercall have confirmed that their mobile practitioners, who carry out home
visits, do not have access to patient records from their mobile ‘Toughbook’ computing
devices. Hence, when the GP visited the patient’s home, the GP also did not have access to
the health record and the information it contained regarding allergies.

Stockport CCG is already enagaged in continual improvement work in this area. However, as
a result of this investigation, the CCG is also planning the following measures:

© to seek formal assurance from Mastercall about processes for new starters and
contingency plans for when practitioners do not have Smartcards.

* to work with Mastercall to map and analyse processes and systems in place for
accessing shared records. This should enable the CCG to identify and mitigate any
further risks.

* to work with Mastercall to ensure that it has fit for purpose mobile solutions in the
future, with access to the right information at the point of care. This will be managed
as part of a project improvement plan reporting through the CCG’s governance
structure.

I hope that this further response is helpful and once again I am grateful to you for bringing
the circumstances of Mrs Kelly’s death to my attention.

Ok WV |

DR DAN POULTER