Margaret Wright

GR Rt Hon Alistair Burt MP

Minister of State for Community and Social Care

Department

of H ealth Richmond House
79 Whitehall

London

SWIA 2NS

POC3000915979 re as

Ms J. Leeming ,

Senior Coroner

Coroner's Officer

HM Coroner's Court

Paderborn House, Howell Croft North 23 JUL 2015

Bolton, BL! 1QY

Dore Ws loaning

Thank you for your letter of 11 May 2015 following the inquest into the death of
Margaret Wright. I was very sorry to hear of Mrs Wright’s death and wish to extend
my sincere condolences to her family.

There are two areas of concern that you raise for our attention as a result of the
inquest:

The first relates to the system of GP patient home visits:

- At the time, the doctors at Mrs Wright’s local GP practice did not routinely phone
the patient or family members to obtain further information about the patient’s
situation following a request for a home visit. Had this happened at the time,
then Mrs Wright would have received a priority visit (although you point out that
this may not have altered the outcome).

- Since Mrs Wright’s death a system of phoning the patient/family prior to a home
visit has been introduced by the GP practice concerned and in the local area.

The second, and most concerning, highlights the fact that the GP practice did not
receive a patient discharge summary for Mrs Wright, from Manchester Royal
Infirmary, leaving the home visits doctor unaware of her recent surgery.

The responsibility for sending a discharge summary rests firmly with the discharging
Trust. The Trust has confirmed that, on discharge, a patient’s discharge notification
should be posted to their GP and a copy filed within the hospital’s patient records.

Staff at the Trust have reviewed Mrs Wright’s notes and have found that a copy of
the discharge notification to her GP was electronically signed by the hospital doctor
on 8 December 2014 and filed in her medical records. The notification contains
details of diagnosis, treatment, discharge medication, out-patient follow up plans and
other relevant information.

Mrs Wright was discharged from hospital on 11 December 2014. Her GP should
have received the discharge information by the time of her request for a GP home
visit. The Trust cannot confirm that the letter was actually posted, or subsequently
received, by the GP practice. This part of the process is not currently tracked or
logged. However, the Trust is planning to utilise email and electronic links to enable
tracking of whether discharge information has been sent and received.

On home visiting itself, GP practices, under contracts with NHS England, are
required to provide services to their patients that include a home visit in cases where
there is a clinical need.

However, the clinical care of the patient in a home setting is one which needs careful
consideration by the GP. The Royal College of General Practitioners (RCGP) is
aware of the importance of this point and its training curriculum includes advice on,
and prompts GPs to consider, the risks of seeing patients in different contexts,
including the home.

The chapter of the Curriculum dealing with patient safety and quality of care
contains a hypothetical “case illustration” setting out an account of the
circumstances surrounding a patient’s death, where home visiting had been a key
factor, and the challenges that the case presented to the practice. Doctors in training
using this resource are prompted to consider how seeing patients in a different
setting such as the home, on a busy day, might impact upon clinical care.

http://www.rcgp.org.uk/training-exams/gp-curriculum-overview/~/media/Files/GP-
training-and-exams/Curriculum-2012/RCGP-Curriculum-2-02-Patient-Safety-and-
Quality-Of-Care.ashx

In addition, the importance of considering the contextual aspects of clinical care are
emphasised in a further chapter of the GP Curriculum entitled “The GP in Wider
Professional Environment”.

http://www.rcgp.org.uk/training-exams/gp-curriculum-overview/~/media/Files/GP-
training-and-exams/Curriculum-2012/RCGP-Curriculum-2-03-GP-In-Wider-
Professional-Environment.ashx

ae

Department
of Health

The introduction states: “As a clinical and general practitioner at the frontline of
health services, you will need to understand not only how to work within systems of
healthcare but also how to work with those systems for the benefit of your patients.

This will require an understanding of the context, structures and processes in and by
which care is delivered that goes beyond that of your specific clinical role”

NHS England has advised that its Primary Care Patient Safety Expert Group, which
focusses on primary care and general practice concerns, is currently considering
home visits. At their next meeting, to be held within the next six weeks, the group
will consider the best way to ensure home visits are appropriate to individual patient
needs. I would be happy to update you with their findings in due course.

In addition, I understand the National Institute for Health and Care Excellence is
currently drawing up guidance on “Home Care”, with a planned publication date of
September 2015.

Furthermore, I can advise that NHS England is making efforts to improve the safety
of patient discharge. In August 2014, a Patient Safety Alert was issued which
launched a national programme of work to support organisations in improving the
communication and management of patient information at handover. One of the
initial priorities is to share best practice to improve the quality and timeliness of
communication.

I hope that you find this reply helpful and I am grateful to you for bringing the
circumstances of Mrs Wright’s death to my attention.

Jousy rear,

ALISTAIR BURT

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