Andrey Wakefield

University Hospital of North Staffordshire NHS)

NHS Trust
Your Ref: AAH/738-13 10 wa Executive Suite
Our Ref: KER/INQ/068/13 eM Trust Headquarters
\ City General Site
17 June 2014 \ Newcastle Road
Stoke on Trent
Mr Haigh ST4 6QG

Senior Coroner
Coroner’s Office ii
No 1 Staffordshire Place

ST16 2LP

Dear Mr Haigh
Re: Audrey WAKEFIELD (deceased)

Further to my letter dated 29 April 2014, | am pleased to provide a response to your report under
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of
Mrs Wakefield.

Background

On 8 January 2013 Mrs Wakefield had a stroke and was admitted to the University Hospital of North
Staffordshire NHS Trust (UHNS). She was discharged on 12 January 2013 and on 16 January 2013
moved to live in a care home. On 21 February 2013 she fell at the home, attended Stafford Hospital
and was discharged back to the care home. She was then admitted again to UHNS in a poorly
condition on 24 February 2013 but deteriorated despite treatment. She moved to the Douglas
Macmillan Hospice on 10 April 2013 and died there the next day. Death resulted from the effects of
the stroke and the fall on 21 February 2013.

Concerns

HM Coroner, Mr Andrew Haigh, raised concerns at the inquest regarding the standard of care
afforded to Mrs Wakefield although he acknowledged that matters may well already be in hand. In
particular, Mr Haigh commented that:

1. At the inquest, | was greatly assisted by EE consuttant Stoke Physician at your
hospital. He indicated that when Mrs Wakefield was discharged from UHNS on 16 January
2013 the communication of relevant discharge information to Mrs Wakefield’s GP was not
good. The reason was that there is a good communication system from the hospital and the
GPs in the Stoke on Trent area but this did not apply to more distant practices
(Mrs Wakefield’s practice was in Stone). EEBindicated that steps were being taken to
improve this. With Stafford Hospital moving to come under control of your Trust the situation
could be quite serious as a number of GPs practices are likely to be involved. It may be that
this is being addressed in any event but | should be grateful it you could check that an
effective system of discharge information will apply wherever a patient’s GP practice may be

situated.
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University Hospital of North Staffordshire INHS|

NHS Trust

Continued... 2

Under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of
the Coroners (Investigations) Regulations 2013, where the Coroner has concerns regarding the
potential for future deaths, his function is to identify points of concern but not to prescribe solutions.
The UHNS was in the process of considering solutions for the matter identified by the Coroner and is
able to provide an update on the current position.

Action Taken

The University Hospital of North Staffordshire NHS Trust has considered the Coroner’s concerns and
has outlined below the actions taken in conjunction with the wider Local Health Economy (LHE).
UHNS does not have a unilateral obligation to resolve the issues and the Trust therefore continues to
work in partnership with the LHE IM&T Group and the local Clinical Commissioning Groups.

1. At the time of the inquest UHNS had already implemented an electronic clinical
correspondence solution across Stoke and North Staffordshire Clinical Commissioning
Groups; this was implemented in 2011/12. This process facilitates the electronic delivery of
discharge letters (including Maternity and ED letters) to all GP practices in Stoke on Trent and
North Staffordshire. Currently, as was heard at the inquest, GP Practices outside of these
areas receive a printed discharge letter.

In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on
Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with
the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and
Cheshire. UHNS funded the one-off development of the solution with the supplier however
there is a requirement for each GP practice to pay an annual fee for the on-going delivery of
electronic clinical correspondence. This is a matter requiring on-going negotiation although it
is common practice nationally, for Clinical Commissioning Groups to fund this within their local
area.

The GP practices in Stone were ‘switched on’ by 12 June 2014, including the GP practice
which provided care to Mrs Wakefield. All of the remaining Stafford and Cannock GP
practices (South Staffs) have committed to being switched on by the end of July; this allows
some time prior to UHNS and Mid Staffs Hospital acquisition which is due to occur on
1 November 2014.

A total solution for all areas is proposed to be delivered in three separate phases based on
geographical area; South Staffordshire, Shropshire and Cheshire and | wrote to them on
29 April 2014. This will include remote implementation and training where possible, and GP
practices will also be supported by a dedicated IT trainer, telephone support during
implementation and Standard Operating Procedures. We are still awaiting confirmation from
Western Cheshire, South East Staffs and Seisdon, Shropshire and Vale Royal and South
Cheshire who have not yet confirmed that they will pay the annual practice charge. | will write
to them again to ask them to do this however it may be helpful for you to do the same given
that the request came from you.

| sincerely hope that the information set out above providés H M Coroner, Mr Haigh, with assurance
that the University Hospital of North Staffordshire NHS Trust has taken the matters arising from the
inquest touching upon the death of Mrs Wakefield seriously. The Trust endeavours to learn from
every opportunity where the standards of care expected by our patients have not been achieved and
on this occasion, | am pleased to see that the Trust was already in the throes of dealing with

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University Hospital of North Staffordshire INHS|

NHS Trust

Continued... 3

problems arising from the anticipated amalgamation of of Mid Staffordshire NHS Foundation Trust
and UHNS.

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me
directly.

Best wishes

Yours sincerely

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