Viola Burke

DRC/CS 

Ms Jacqueline Devonish, 
Coroner's Officer, 
127 Poplar High Street, 
London E14 OAE 

                   3 July 2015 

Dear Ms. Devonish, 

re:  Mrs Viola Burke dob 30-Apr-1934  

You sent our practice a Regulation 28: report to prevent future deaths. You feel that 
there were a number of actions the practice could have taken to prevent the death of 
this lady, mostly concerning the absence of a care plan for this lady.    

I thought it might be helpful  if I started by providing some additional background to 
care  plans.  The  Care  Plan  scheme  started  in  City  and  Hackney  in  June  2014  and 
therefore, in line with the scheme’s introduction, Mrs. Burke’s invitation to participate 
in  the  scheme  and  have  a  care  plan  provided  was  the  first  round  of  invites  the 
practice had sent. The terms of the contract were that the practice should invite 2% 
of  our  vulnerable  patients  over  75  who  we  considered  would  benefit  from  a  care 
plan.  The  invite  letter  explained  what  the  care  plan  was  and  that  we  would  contact 
them to arrange an appointment to complete the care plan with them if they wished 
to go ahead.  

Under  the  terms  of  the  contract,  we  were  obliged  to  see  them  by  the  end  of 
September  2014.  Patients  could  of  course  decline  and  might  do  so  actively,  by 
informing the practice that they did not wish to participate, or passively, by refusing 
to respond to the practice’s approach and invitations. 

This  initial  window  was  intended  only  for  the  first  group  of  patients  invited  and  the 
rules  of  the  contract  are  now  that  the  care  plan  has  to  be  completed  within  one 
month of inviting the patient. We sent Mrs. Burke an invitation on 26th June 2014 to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 have a care plan developed and our receptionists then rang her 3 times to arrange 
an  appointment  for  her  but  were  unable  make  contact  with  her.  In  light  of  this,  we 
added the code ‘Admission avoidance care ended’ to her notes as we had not been 
able  to  arrange  to  undertake  the  plan  within  the  allotted  time  span  for  the  initial 
invites.  
This code on the notes was only intended to make clear that we had not been able to 
undertake the plan in that year for her. We are limited by what codes are available 
on the national computer systems. Adding this code did not mean we would not offer 
her a care plan again. The scheme was in its infancy and nobody had decided how 
to  address  the  issue  where  a  patient  didn’t  respond  within  the  window  so  we  used 
this code as a pragmatic solution, simply to signal to ourselves the situation. It was 
intended  to  serve  as  an  audit  trail  so  that  we  may  know  those  patients  previously 
approached, so this could be demonstrated to the CCG. 

Care  plans  have  on  them  the  patient’s  past  medical  history,  present  medications, 
and contact numbers for the next of kin. It may then record information about what 
care  the  patient  would  wish  to  receive  in  the  event  of  becoming  unwell,  such  as 
whether  they  would  wish  to  go  to  hospital.  The  plans  are  supposed  to  include 
information  as  to  whether  a  ‘do  not  resuscitate’  discussion  has  been  undertaken, 
especially  as  we  are  often  talking  about  a  group  of  very  vulnerable  and  unwell 
patients.  

Care  plans  cannot  be  accessed  electronically  by  the  out-of-hours  service,  the 
Accident  and  Emergency  department  or  the  Ambulance  service.  City  and  Hackney 
CCG have been actively discussing how we can try and enable this to happen and, 
as I understand it, are presently working on the information technology to make this 
possible. This is not something that my practice could control. Care plans can only 
be accessed if the hard copy plan is taken by the patient and given to out-of-hours 
doctors or the ambulance service and indeed I am aware some patients do this. 

To  respond  to  the  4  points  listed  as  being  ‘Matters  of  concern’  as  required  I  would 
comment as follows: 

1.  You were concerned that no questions had been asked about the reason for the 
use of the asthma pump (salbutamol inhaler).  Looking back at this lady’s notes, 
 (GP) saw the patient on 15th July 2015 for a review. The cardiology 
specialists had questioned the reasons for the patients’ breathlessness in a letter 
to  the  surgery  after  seeing  the  patient  in  the  cardiology  clinic.  Having  taken  the 
patient’s  symptoms  and  findings  on  examination  in  to  account, 
  did 
not  feel  any  further  action  was  needed  at  that  time.  Again  from  what  I  can  see 
from the notes, it seems she decided not  to add the diagnosis of asthma to the 
notes. We are aware of how  important a diagnosis of asthma is. We do have a 
small  number  of  patients  who  say  they  find  that  Salbutamol  inhalers  are  helpful 
but  who  don’t  fulfill  the  clinical  criteria  for  making  a  diagnosis  of  asthma  and  so 
would  not  want  to  add  such  a  code  to  their  notes.  I  can  see  that 
considered  whether  or  not  the  patient  would  benefit  from  spirometry  (a  test  to 
demonstrate whether a patient may have chronic obstructive airways disease or 
asthma)  but  did  not  arrange  it  at  that  time.  She  states  that  she  did  not  think 
referral  to  the  respiratory  physicians  was  necessary  at  that  time.  We  do  make 
every  effort  we  can  to  ensure  that  patient  records  are  kept  accurate  and  up  to 

 
 
 
 
 
 date. For instance, and of relevance in this case, we employ a permanent notes 
summarizer to ensure information is transferred from other doctors accurately. In 
acknowledgement  of  the  concern  expressed  we  will  continue  to  do  this. 

no longer works at this practice so I have not been able to speak to her 

about her thoughts at the time. 

2.  I  have  explained  above  why  Mrs.  Burke  did  not  have  a  care  plan  at  the  time  of 
her  death.  Due  to  the  initiation  of  the  new  scheme  we  could  not  ensure  all 
patients in the practice had a care plan at once as it takes considerable time to 
undertake these. Therefore the approach employed was to target one group at a 
time for the invitations and care plans. Mrs. Burke would have come back on to 
the  list  of  patients  being  offered  a  care  plan  at  a  later  date.  To  address  this 
concern  and  ensure  that  patients  are  approached  if  they  have  not  initially 
responded to invitations in previous rounds, we have now put a system in place 
whereby  all  patients  identified  by  means  of  the  NELLIE  search  tool  (a  risk 
stratification  tool  developed  by  the  CCG)  who  are  considered  high  risk  of 
admission  are  identified  by  adding  13Zu  ‘At  risk  of  Emergency  Hospital 
Admission’, to their notes so that our administrators can re-run the search in the 
future.  We will be developing a protocol in EMIS where this code will now cause 
a ‘pop-up’ box to appear on the patient’s medical records to prompt the doctor to 
discuss  the  issue  of  care  plans  with  the  patient.    We  expect  to  have  this 
completed and operational by the end of July 2015. 

3.  You query the use of the code ‘Admission  avoidance  care  ended’ on this lady’s 
notes. I have explained the reason for using this code was purely pragmatic, an 
acknowledgement that the patient had been invited to participate but that no care 
plan had resulted from this invitation (in this case due to an inability to contact her 
on  the  telephone  although  we  rang  three  times  to  arrange  an  appointment  for 
her)  and  so  the  patient  should  not  be  on  the  register.  We  had  to  complete  the 
care plan before 26th September 2014 so that by the time she attended with her 
son and subsequently, it was outside the care plan window and ‘too late’ for us to 
complete.  The  Lawson  Practice  raised  the  issue  about  the  problem  of  how  to 
manage  non-attenders  at  the  Clinical  Commissioning  Forum  (a  regular  meeting 
between the CCG and its member GPs) and at an education session run by the 
CCG when care plans were first being discussed. Although attempts to re-invite 
patients  are  not  required  by  the  contract,  we  have  learnt  from  a  clinical  care 
perspective  that  this  would  be  helpful  and  thus  we  will  develop  the  protocol  as 
described above. 

4.  You  mention  that  the  intention  with  care  plans  was  to  ensure  that  the  London 
Ambulance  Service  and  OOH  Service  would  have  full  access  to  the  patient 
records of the most vulnerable patients.  Regrettably this is not the intention and 
neither is it what occurs. The Care Plan is intended primarily to be used to help 
patients  avoid  unnecessary  hospital  admissions, 
to  give  clinicians  an 
understanding of the patient’s present medical condition(s) and to record (where 
appropriate)  the  patient’s  expressed  wishes  at  the  time  it  is  written.  It  is  about 
having an agreed plan for people who are vulnerable and may not wish to go into 
hospital  or  may  wish  for  other  actions  to  be  followed  when  they  become  ill  and 

 
 
 
 
 
 
 have decided where they want to die. It is not designed to give full access to the 
patient’s  medical  records.  You  mention  questions  being  raised  about  how  the 
care plan would be kept up to date. This is very relevant and was raised with our 
CCG  some  months  ago  and  they  are  considering  how  best  to  do  this,  as  are 
CCGs  across  the  country  as  this  is  a  national  problem.  This  is  not  a  practice 
related  issue  and  is  outside  our  control  and  rests  with  the  CCG  and  NHS 
England.  However  we  are  willing  to  cooperate  fully  with  the  CCG  in  working  to 
make any changes in practice that are beneficial and will address these issues. 
You  mention  doctors  attending  out-of-hours  operating  in  a  medical  vacuum. 
Sadly  that  is  the  case  across  the  country.  It  is  not  something  my  practice  can 
address. It is not an issue that is practice related but might be something that our 
CCG  or  the  national  policy  makers  will  be  able  to  address.  I  cannot  respond  to 
these points therefore. 

We are continuing to work hard on trying to ensure all our vulnerable patients have 
care plans. We consider them very valuable and useful documents as the process of 
writing them together gives the patient an opportunity to think about their future care 
and  what  they  want  for  themselves.  It  gives  them  the  opportunity  to  ask  questions 
and to plan. We are working with our CCG to try and resolve some of the observed 
IT  problems  with  the  care  plans.  Our  CCG  is  working  to  try  and  ensure  limited 
access to the medical history and drug sections of the GP record for the out-of-hours 
service and the local hospital and hopefully this will be possible very soon.  

I trust this response meets with your satisfaction and wish to thank you for bringing 
these issues to my attention so that I might reflect on them further with the practice 
and our CCG. 

Yours sincerely, 

.