Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0391, written 28 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Sep 2015 |
|---|---|
| Reference | 2015-0391 |
| Deceased | Harry Pryal |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust · Boroughs Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon. Jeremy Hunt, Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS 2. Ms Trish Anderson, Chief Officer (Chief Executive) Wigan Borough Clinical Commissioning Group, Wigan Life Centre, College Avenue, Wigan WN1 1NJ 3. Mr Andrew Foster, Chief Executive Wrightington Wigan & Leigh, Royal Albert Edward Infirmary, Wigan Lane, Wigan WN1 2NN 4. Mr Simon Barber, Chief Executive 5 Boroughs Partnership NHS Foundation Trust, Hollins Park House, Hoilins Lane, Winwick, Warrington L WA2 8WA 1 | CORONER + T am Alan Peter Walsh, Area Coroner, for the Coroner Area of Manchester West Ps T CORONER’S LEGAL POWERS I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations lL 2013. 3 | INVESTIGATION and INQUEST On 26" January 2015 I commenced an Investigation into the death of Harry Pryal, 84 yrs, born 23" September 1930. The Investigation concluded at the end of the Inquest on 4" September 2015. The medical cause of death was 1a) Bronchopneumonia 1b) Traumatic Spinal Cord Injury The conclusion of the Inquest was Harry Pryal died as a consequence of injuries sustained in an accidental fall in circumstances where an X-Ray identifying a suspected cervical spine fracture was not reported and the fracture was not diagnosed for a period of 5 days following the X-Ray and 6 days following the fall in which the injury was sustained. —| [4 CIRCUMSTANCES OF THE DEATH 1. Harry Pryal died at Salford Royal Hospital, Eccles Old Road, Salford on the 8" January 2015. 2. Mr Pryal had been admitted to the Lakeside Unit, Leigh Infirmary, Leigh on the 5 November 2014 complaining of ongoing low mood with reduced energy levels, poor motivation, hopelessness and decreased appetite. The Lakeside Unit is under the Governance of the 5 Boroughs | Partnership NHS Foundation Trust (hereafter referred to as ‘SBP’)) and is on the same site as Leigh Infirmary, which is under the Governance of Wrightington Wigan and Leigh NHS Foundation Trust (hereafter referred to as ‘WWL’. . There was a Service Agreement for the provision of Radiology between the 1* April 2014 and the 31% March 2015 between 5BP and WWL, which included the provision of Radiology at Leigh Infirmary, Leigh and a copy of the Service Agreement is attached hereto. » On the 30th December 2014 Mr Pryal had a fall in his bedroom at the Lakeside Unit and on the same day a Doctor from the Lakeside Unit requested an x-ray examination by completing and submitting the appropriate form to WWL. The form requested x-ray examinations of chest, cervical spine and a shoulder. The x-rays were conducted at the Leigh Infirmary, Leigh by WWL on the 31* December 2014 under the terms of the Service Agreement for the provision of Radiology. The xrays were not reported in writing until the 14% January 2015, when the report referred to a separation of the spinous processes of C5 and C6 and disruption of the alignment of the facet joints below C5. The report also referred to further imaging indicated. The written report was only received on the 14°" January 2015 after Mr Pryal’s death, which occurred on the January 2015 During the evidence there was a conflict between 5BP and WWL with regard to the interpretation of the Service Agreement in relation to the reporting of x-ray examinations under Paragraph 2.1 on page 15 of the Agreement. 5BP interpreted the reporting of the examination to be within 72 hrs of the examination whereas WWL interpreted the provision as_web viewing of the x-ray within 72 hrs of the examination and the reporting of the examination at some time in the future without any time indication. The evidence at the Inquest from 5BP was that they were unable to view x-rays by use of web viewing because the software used by 5BP was not compatible and SBP did not have a network connection to WWL for web viewing of the x-rays. Furthermore 5BP gave evidence that the Doctors and the Psychiatrists at the Lakeside Unit would not have the expertise to identify or interpret x-rays by web viewing without a formal report by a Radiologist. . The clinical lead Radiologist for WWL gave evidence at the Inquest that he was not aware of the terms of the Service Agreement and that Mr Pryal was treated as an outpatient for x-ray examination by WWL at Leigh Infirmary, whereas the agreement provides that Mr Pryal should have been treated as an in-patient which would have affected the time lines for reporting x-ray examinations. . The evidence at the Inquest indicated that Doctors in Psychiatry at the Lakeside Unit would be dependent upon referral to and advice from the | medical team at WWL based at the Royal Albert Edward Infirmary, Wigan (hereafter referred to as ‘RAEI’) for treatment and care of patients in the Lakeside Unit with regard to any physical health needs. On the 1* January 2015 at 03.35 hrs a Doctor from the Lakeside Unit made a note that he discussed Mr Pryal with the on call medical registrar at the RAEI and he made a note with regard to a plan in relation to medication and follow up of the chest x-ray. The note did not refer to the name of the medical registrar at RAEI. The evidence given by witnesses from WWL showed that any referrals by heaith professionals outside WWL would not be noted and there would be no reference on any system or notes held by WWL with regard to the name of the Doctor giving advice nor with regard to the details of the advice. Furthermore evidence was given that the absence of notes in relation of such matters was not limited to WWL and the same procedure existed in many, if not all, Hospitals nationwide, . On the 2™ January 2015 Mr Pryal was reviewed by a Doctor at the Lakeside Unit and there was ongoing deterioration in his presentation and he was drooling from his mouth with increased pain. There was a note that his neck was slightly deviated to the right side and he reported difficulty in raising his left hand. A CT scan was requested and the Doctor liaised with the medical team at WWL requesting an urgent transfer, a complete physical examination and an urgent CT scan in view of him having had a stroke. Mr Pryal was transferred to the RAEI on the 2" January 2015 and the notes accompanying Mr Pryal to the RAEI referred to the history of falls x 3 and other conditions but did not refer to the x-rays on the 31% December 2014, nor a report in the SBP notes that “Harry self reported that his neck was sore and that he cannot straighten his neck posture”. The notes accompanying Mr Pryal to the RAEI also mentioned “need for a CT scan to rule out a stroke”, -» When Mr Pryal arrived at the RAEI he had a CT scan of the head and brain which reported moderate cerebral atrophy with no evidence of an acute stroke in the form of a bleed or an infarct. On the 3 January 2015 Mr Pryal was seen by the Consultant Stroke Physician, who suspected that Mr Pryal may have had a minor stroke and he advised to continue further care on the stroke pathway. The Consultant gave evidence at the Inquest that he was not aware of the x- rays conducted on the 31% December 2014 and he was not aware of the information relating to the fall nor the neck pain, particularly the report that Mr Pryal’s neck was sore and he could straighten his neck posture, as recorded in the 5 BP notes on the 1° January 2015. The Consultant also gave evidence that if he had been aware of the above information he would have looked at the x-rays and taken further action with regard to the symptoms, in addition to advising care on the stroke pathway. 9. On the 5" January 2015 at 10.30 hrs a FY1 Doctor on the Stroke Unit at RAEI recorded that Mr Pryal was complaining of neck pain and had weakness in both the upper limbs. The Doctor arranged either an urgent MRI scan of the brain and spine or an urgent CT scan of the cervical spine. 10. The scans were discussed at a Neuro-Radiology MDT Meeting on the 6" January 2015 when the x-ray of the cervical spine conducted on the 31% December 2015, which was not reported in writing at that time, was considered by a verbal report for the first time and it was noted from the x-ray that there were abnormalities in the region of C5/C6 with subluxation and the meeting noted the Possibility of possible cervical spine fracture. 11. On the 6" January 2015 a MRI Scan of the whole spine was done and Mr Pryal was referred to the Spinal Neurosurgical Unit at the Salford Royal Hospital (hereafter referred to as ‘SRH’). Mr Pryal was transferred to SRH on the 7* January 2015 when it was obvious that Mr Pryal had a chest infection, which was being treated with antibiotics. In fact there was evidence that Mr Pryal was suffering with a suspected chest infection on the 30" December 2014 at the Lakeside Unit when treatment with antibiotics was commenced. The Consultant Spinal Surgeon gave evidence that if he had been aware of the findings on the X-rays conducted on the 31% December 2014 he would have requested an immediate CT scan with a view to a transfer to the SRH to conduct surgery to stabilise the cervical spine of the fracture. When Mr Pryal was transferred to the SRH on the 7 January 2015 he refused surgery in relation to the spinal fracture but he did accept antibiotics in relation to the chest infection. The Consultant Surgeon was Satisfied that Mr Pryal had capacity to make the decision but he also obtained advice from a Consultant Psychiatrist to confirm that Mr Pryal had sufficient capacity to refuse surgery. 12. Mr Pryal was treated with antibiotics for the chest infection but deteriorated and died on the 8" January 2015. - 1 ORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. During the Inquest evidence was heard that i. 5BP contact WWL for advice in relation to medical treatment for patients at the Lakeside Unit on a regular basis as a matter of rotocol. The Doctors in chiatry at the Lakeside Unit, are LI dependent upon such advice for the treatment and care of ai patients. The evidence identified that there is no note of the advice in the records maintained by WWL, neither to identify the Doctor giving advice nor the content of the advice. Furthermore evidence was given that this was a situation arising on a nationwide scale. The absence of any notes prevents a record of the advice for the Purpose of continuity of treatment and any subsequent referrals, Particularly in a case when the Doctor giving the advice is no longer available and further advice is requested by the referring Doctor for medical treatment. The Service Agreement entered into between 5BP and WWL for the period from the 1* April 2014 to the 31% March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation the interpretation of clause 2.1. The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the Operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1* April 2013 to the 31% March 2014 and from the 1* April 2015 to the 31% March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place. The evidence identified a tack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh. During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the Provisions in all Agreements may not be performed in accordance with the requirements of each Agreement. The evidence given by WWL was that there were no time lines in relation to the reporting of x-rays performed at the Leigh Infirmary, other than national timelines, although it was accepted | that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring Clinicians at the time of the Consultant Radiological reporting”. It was accepted that if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay. WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant Clinical finding” would not be reported to the referring clinician for some time after the examination. An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay. iv. 5BP accepted that the Service Agreement provided for web viewing of the x-rays but accepted that the software operated by 5BP does not allow web viewing of x-rays and 5BP did not have network connections to view the x-rays electronically by access to the WWL network. In any event the Consultant Psychiatrist from the Lakeside Unit indicated that the Doctors in her team based at the Lakeside Unit, may not have the expertise to interpret the x- rays on web view and the Doctors would be dependent upon a formal report, either verbal or written, from the Radiologist. v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI, The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone cail to the Radiologist or a note of Priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed. vi. Evidence was given at the Inquest that there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit. There was no Service Agreement for the provision of physiotherapy and occupational therapy and no understanding as to who would provide such services. The evidence indicated that the Clinical Commissioning Group in Wigan would provide the services and 5BP were not in a position to enter into agreements for the provision of services from elsewhere. Evidence was given by 5BP that the Clinical Commissioning Group in Wigan had not provided services so that the physical health needs of vii. 2. Irequest you to consider the above concerns and to carry out a review with regard to the following. A review of the notes in relation to names, times and content and patients in the Lakeside Unit, were not being satisfied in relation to physiotherapy and occupational therapy. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. The Secretary of State for Health, 5BP and WWL. The provision of notes within hospital records in relation to any telephone referrals or other referrals from health professionals for advice in relation to the treatment and care of a patient. The review should include the retention of such notes for observation by other clinicians who may become involved subsequently to ensure continuity of advice in relation to treatment and care. The review is requested by the Secretary of State in view of the evidence that the absence of notes is a problem on a nationwide scale. SBP and WWL A review of the liaison, understanding and interpretation of the provisions of the Service Agreement in relation to Radiology for the period from the 1% April 2015 to 31% March 2016 and any subsequent years, taking account of the evidence heard at the Inquest. The review should include the operation and performance of the terms of the Agreement and should extend to the involvement of the two Trusts, particularly on the same site at Leigh Infirmary, Leigh. The review should also take account of any other Service Agreements in existence and entered into by both trusts either collectively or individually. SBP and WWL A review of the electronic systems, which allow access by 5BP to network connections in relation to WWL systems, particularly to allow web viewing of x-ray examinations in accordance with the Service Agreement. SBP the provision of training or retraining of clinicians and all staff in relation to the recording of appropriate notes, including requests for x-ray or other examinations and transfers to other hospitals. —t v. WWL A review of the reporting times for x-ray examinations with particular reference to triage to identify any urgent or unexpected significant clinical findings, which will need to be communicated to the referring clinicians at the earliest time. vi. Clinical Commissioning Group Wigan and 5BP A review of the provision of physiotherapy and occupational therapy to deal with the physical health needs of patients at the Lakeside Unit, to ensure that appropriate treatment is available to those patients. rE ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I | believe you and/or your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd November 2015, I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION T have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. P| Mr Pryal’s son. Tam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated Signed OA~ 28th September 2015 Alan P Walsh ——|
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
25 NOV 2015 Your ref: 30092015regulation28HP 23 November 2015 PRIVATE AND CONFIDENTIAL 5 Boroughs Partnership NHS) NHS Foundation Trust Simon Barber Chief Executive Hollins Park Winwick Warrington Cheshire WA2 8WA Tel: 01925 664001 Fax: 01925 664052 Mr A Walsh Email: Coroner's Officer H M Coroner's Office Paderborn House Civic Centre Bolton BL1 1QY Dear Mr Walsh Re: ee a Thank you for your letter dated 28 September 2015 with regards the inquest findings into the death of Mr Pryal and the directions given under regulation 28 of the Coroners and Justice act 2009 (a2013). | would like to inform you that many actions were being progressed by a number of the organisations prior to the inquest and this has enabled the Trust to provide you with a detailed response. In preparing this response 5 Boroughs Partnership NHS Foundation Trust (the Trust) have worked jointly with Wrightington, Wigan and Leigh NHS Foundation Trust and have been in contact with Wigan Clinical Commissioning Group to ensure that all actions align to achieve a more integrated care pathway. | would like to advise you of the actions the Trust has taken since receiving your letter. Taking your points in turn | can confirm the Trust has taken the following steps: i. The provision of notes within hospital records in relation to telephone referrals or other referrals for advice in relation to the treatment and care of the patient. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA « Mini Com Number 01925 664094 We have developed a standardised proforma for use on transfer between the Trust and Wrightington, Wigan and Leigh NHS Foundation Trust to be kept within the care record. These proforma have been created by the clinicians who will be using them and have been discussed at the Wigan Medial Staff Committee (minutes available). We have shared this work with our colleagues in Wrightington, Wigan and Leigh NHS Foundation Trust who are looking at a pilot to test the clinical appropriateness of the proforma. A directive has been given to all clinicians within the Trust relating to the recording of clinical advice by specialist services. In Mr Pryal’s case, this was with the medical registrar for medicine. There is a requirement that all clinical advice we receive is fully recorded, with emphasis on the recording of the name, grade and contact details of clinical colleagues we speak to. This has been sent out for immediate action via an internal email. Although this incident occurred in Wigan, it is important to share the wider learning across the Trust. To facilitate the learning this incident will be discussed at the next Lessons Learned Forum on 24 November 2015 chaired by our Medical Directors. Further dissemination of the lessons learned from this incident will be developed at the forum and will be communicated Trust wide. ii. A review of the liaison, understanding and interpretation of the service level agreement in relation to radiology. A joint review of all SLAs held between Wrightington, Wigan and Leigh NHS Foundation Trust and 5 Boroughs Partnership NHS Foundation Trust is underway. This includes, and has started with the service level agreement for the provision of radiology services. The review process will incorporate the following steps: a) A thorough review of the service specification by 5 Boroughs Partnership NHS Foundation Trust clinicians to assure themselves that the service specification is sufficiently robust and specific to support the provision of clinically safe services. b) A review of the service specification by Wrightington, Wigan and Leigh NHS Foundation Trust to ensure that the agreed service specification is deliverable. c) A review of the wording in the service level agreement to remove any ambiguity and to ensure a consistent interpretation by both parties. d) The identification of key performance indicators / management information to be provided to allow for appropriate monitoring of the service provided. e) Identification of a 5 Boroughs Partnership NHS Foundation Trust clinical and operational lead for each service level agreement. f) Scheduling of routine service review meetings between 5 Boroughs Partnership NHS Foundation Trust and Wrightington, Wigan and Leigh NHS Foundation Trust. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000 \ Better View... of mind & body Feedback from 5 Boroughs Partnership NHS Foundation Trust clinicians on service specifications is being sought and an initial meeting with Wrightington, Wigan and Leigh NHS Foundation Trust has taken place. iii. Review of electronic systems At present each organisation is responsible for the creation, safe storage and maintenance of its own clinical records. As we move to an ever increasing paper-light NHS, we are now doing more and more on computers. In Mr Pryal’s case, there was a failure between the Trust and Wrightington, Wigan and Leigh NHS Foundation Trust to appropriately locate or share information critical to Mr Pryal’s care. As an immediate but interim step, we have received agreement from Wrightington, Wigan and Leigh NHS Foundation Trust to have secure web- based viewing to all diagnostic reports via a system that can only be accessed from an NHS computer via a secure log in. The provision of the log-in accounts is in progress but early signs are that all substantive medical staff will receive one, and we are reviewing how we manage out of hour’s access with the medical rotation of doctors. This challenge will form part of our on-going action plan. Wigan Borough Clinical Commissioning Group has set out commissioning intentions for the 2016/17 contract with the focus on delivery of the borough’s major transformation programme. In November 2015 the urgent care service who deliver out of hours care and assessment were granted access to the Medical Interoperability Gateway. This allows real time access to all primary care records that the service has permission to see. Whilst this doesn’t directly link to Mr Pryal’s case, this is a further step taken to align health information in the Wigan Borough. All clinical letters and information routinely sent to a GP, in this case information from Wrightington, Wigan and Leigh NHS Foundation Trust to GPs will be accessible with patient consent to Trust staff. As the Trust is moving to a purpose built bespoke mental health hospital in 2016/17, an IT work stream has been initiated to review all future IT connectivity needs to ensure that all these systems are fully compatible in the new hospital once we move off Wrightington, Wigan and Leigh NHS Foundation Trusts site. This project has recently incorporated North West Ambulance Service. iv. Review of notes The Trust’s records manager is reviewing the process for clinical record audit in line with recent organisational changes that have occurred. This is being completed by the Records Management team and reported to the Chief Nurse and Executive Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000 \ Better View... of mind & body Director for Operations Po This process will audit policy compliance over paper and electronic records and following the review, recommendations for change are to be considered in the amended final policy. v. Review of the provision of physiotherapy and Occupational Therapy. The Trust has carried out a review to identify need in this area and to identify the clinical pathway and demand. Discussions at a senior level are taking place between 5 Boroughs Partnership NHS Foundation Trust and Bridgewater NHS Foundation Trust to clarify arrangements for the provision of physiotherapy and occupational therapy. For the interim period, requests for physiotherapy and occupational therapy from the in-patient wards at Leigh Infirmary are being flagged urgently to our Professional Lead for Allied Health Professionals who will source the appropriate professional from our wider Trust resource. She will also complete the required specification for submission to Wigan Clinical Commissioning Group to maintain the service either from Bridgewater NHS Foundation Trust or the Trust will identify an alternative supplier. Yours sincerely Simon Barber Chief Executive Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House. Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000 \ Better View... of mind & body
| a&CEIvED 03 NOV 2015 ae Departme of Health POCS 960976 Mr A. Walsh Area Coroner Bolton Coroner’s Office Paderborn House Howell Croft North Bolton BLI1 1JW Thank you for your letter of 28" September 2015, following the inquest into the death of Harry Pryal. I was sorry to hear of Mr Pryal’s death and wish to extend my condolences to his family. 30 OCT 2015 There appear to be two main issues of concern that you raise in this case. One is that X-ray information was not available in a timely manner to all of the professionals caring for Mr Pryal. You outline the circumstances which led to this situation and direct several concerns to the 5 Boroughs Partnership NHS Foundation Trust (SBP) and Wrightington Wigan and Leigh NHS Foundation Trust (WWL) which relate to their joint Service Agreement, the reporting times for X-rays, the electronic systems available to support web viewing of X-rays and the recording of appropriate patient notes. These concerns are about the local systems that are in place and rightly addressed to the local providers, who I am confident will consider and review. The other main issue you raise is about the lack of recording of information in the patient’s notes, by medical professionals, that would have ensured a consistency of care for the patient. Not only was this an issue in this case but evidence suggested that the lack of recording of appropriate notes in hospital patient records is a problem on a nationwide scale. Whilst the actual recording of patient notes is something that is agreed and implemented at local level, the general move away from paper to integrated digital care records should improve the comprehensiveness of information held, including essential diagnostic tests and it’s availability to all professionals engaged in the care of individual patients. A further advantage of digital systems is that they can be programmed to alert all professionals involved in the organisation and delivery of care about any outstanding test results. Currently, the Health and Social Care Information Centre (HSCIC) is developing the Transfer of Care Initiative. Further information about the Initiative can be found on the HSCIC website. This Initiative recognises that, in order to support the delivery of high quality care, there is an increasing need to share information in a more efficient and consistent way across health and social care. This is especially important in care settings that cross organisational boundaries. The Initiative aims to enable consistent electronic exchange of information between different care professionals and organisations. This will be achieved by driving the establishment and uptake of consistent professional and technical Transfer of Care data standards across the health and care sector, in direct support of the National Information Board (NIB) objectives, to “help clinicians ensure that patients are safely transferred between episodes of care". In terms of how information is captured and recorded in a consistent manner in clinical systems, the Academy of Medical Royal Colleges (AoMRC) has produced “Standards for the clinical structure and content of patient records” (2013). These Standards can be found on the Royal College of Physicians website. This work is important in standardising approaches for clinicians and healthcare professionals regardless of the care setting and is equally relevant for those who develop and implement electronic or paper care records. The AoMRC standards document states: ‘To record clinical information in a way that can be shared and re-used safely in an electronic environment, the structure must be standardised. For this to be realistically achievable, the standards for structure must reflect the way that patients and clinicians work together to the common goal of best practice and high quality care. This necessity has been recognised by the establishment of an independent Professional Record Standards Body to oversee rigorous development and maintenance of health and social care records...’ The scope of the AoMRC standards includes the structure and content of patient records, covering hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters. The adoption of these standards was proposed by the National Information Board in their published framework for action, (November 2014) which states: "We propose the adoption of the Academy of Royal Medical Colleges’ publication Standards for the clinical structure and content of patient records, with a requirement that all organisations and clinical systems should implement the standards, following consultation and completion of an impact assessment." In addition, the HSCIC strategy 2015-20, Information and technology for better care, drew particular attention to the AoMRC standards: “We will lead the work to deliver one of the key commitments in the National Information Board Framework - for all health and care organisations to adopt the Academy of Royal Medical Colleges’ publication Standards for the Clinical Structure and Content of Patient Records. This will improve the timely integration of information across care settings.” The AoMRC standards are being further developed and implemented as part of the Transfer of Care Initiative. The Initiative has already published specifications using AoMRC standards for the electronic transmission of discharge summaries between acute and mental health providers and GPs. | I am grateful to yop for bringing the circumstances of Mr Pryal’s death to my attention and hope that you find this reply helpful. | +f \ va) | BEN GUMMER
Wigan Borough Clinical Commissioning Group Wigan Life Centre R ECE IVED College Avenue 28 NV a RES 22nd October 2015 Alan Peter Walsh Coroner H M Coroner's Office Paderborn House Civic Centre Bolton BL1 1QY Dear Mr Walsh Regulation 28 Report Many thanks for the Regulation 28 Report dated 28" September 2015. This letter is to provide you with assurance that actions are being taken by the CCG in response to the report and the actions that you have recommended to prevent future deaths. Action VI was “A review of the provision of physiotherapy and occupational therapy to deal with the physical health needs of patients at the Lakeside Unit, to ensure that appropriate treatment is available to those patients’. In response to the above recommended action, the CCG has formally written to 5BP on 43" October 2015, stating that the CCG believes that 5BP should have a service agreement in place with a suitable provider for the provision of physiotherapy and occupational therapy. Please see letter attached (Appendix A). 5BP has since confirmed via e-mail dated 28" October that assurance that all requests for physiotherapy or occupational therapy will be flagged to SBP Clinical Director who will ensure that this need is met. Please see e-mail attached (Appendix B). The CCG does not envisage this to be an issue going forward, however, if there are, then it will be dealt with at the Contract Monitoring Group Meetings with SBP. Wigan Life Centre * College Avenue * Wigan WN1 1NJ * www.wiganboroughccg.nhs.uk Chairman: Dr Tim Dalton « Chief Officer: Trish Anderson & fi Healthy People, Healthy Place. Wigan Borough Clinical Commissioning Group Yours sincerely rat Chief Officer NHS Wigan Borough Clinical Commissioning Group Wigan Life Centre * College Avenue * Wigan WN1 1NJ * www.wiganboroughccg.nhs.uk Chairman: Dr Tim Dalton « Chief Officer: Trish Anderson @ & Healthy People, Healthy Place.
Wrightington, Wigan and Leigh INHS| NHS Foundation Trust Mr Andrew Foster Chief Executive Wrightington Wigan & Leigh NHS Foundation Trust Trust Headquarters / The Elms Wigan WN1 2NN Tel: 01942 82 2194 Fax: 01942 82 2158 Web: www.wwil.nhs.uk Mr Walsh Area Coroner HM Coroner’s Office Paderborn House Civic Centre Bolton BL1 1QY 23 November 2015 Dear Mr Walsh Regulation 28 Response: Harry Pryal (Deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 28 September 2015. Within that Report a number of concerns were highlighted to Wrightington, Wigan and Leigh NHS Foundation Trust (“the Trust”) following the evidence heard at the inquest of Mr Harry Pryal held on 3 and 4 September 2015. | have been fully advised of the circumstances relating to Mr Pryal’s death, and having read your Report, |am grateful to you for bringing these concerns to my attention. Since the conclusion of the inquest the Trust has undertaken a great deal of work to address these areas of concern, and have been working alongside the 5 Boroughs Partnership NHS Foundation Trust (“SBP”), to ensure lessons have been learnt from the events surrounding Mr Pryal’s death. | would like to take this opportunity to advise you of the actions already taken by the Trust to address the concerns outlined on pages 7 and 8 of your Report, and any proposed action to be taken in the future. 1. The provision of notes within hospital records in relation to any telephone referrals or other referrals from health professionals for advice in relation to the treatment and care of a patient. The review wat Adoy, “ Chairman: Robert Armstrong Chief Executive: Andrew Foster CBE 1057, e >> say should include the retention of such notes for observation by other clinicians who may become involved subsequently to ensure continuity of advice in relation to treatment and care. | understand the above was also raised with SBP, as well as the Secretary of State for Health, as it was acknowledged that this was a nationwide concern. It has been shared with the Trust’s Clinical Directors for Medicine, Scheduled and Unscheduled Care, to enquire into what processes could be put in place within the organisation. | am advised that the Trust’s Medical Registrar on-call receives approximately 60 to 70 bleeps a day during his 42 hour shift. The majority of those relate to internal queries; however around 5-10% are telephone referrals from external providers, (such as 5BP, GPs, and other NHS hospitals). Often these calls are taken whilst the health professional is on a ward undertaking clinical duties, therefore making it difficult for a note to be made of that discussion, especially as these calls do not relate to patients currently being treated within the Trust. The majority of these external referrals also relate to patients who do not have medical records, either because they have never attended the Trust before, or the medical records are held offsite in storage (making them inaccessible at the time of the discussion). This makes it very difficult for the health professional to document a contemporaneous record of the referral. According to the General Medical Council, and Royal College guidance, there is a duty on the health professional seeking the advice to ensure a full and accurate record is kept. | note a directive has been given to clinicians within 5BP to ensure all clinical advice received is fully recorded, and for the documentation to include the health professional’s name, grade and contact details. In addition, the Trust has been working with 5BP to create a standardised proforma for use on transfers between the two organisations (please see Appendix 1). The proforma, setting out the patient's medical background, reason for referral, and any prior discussions, would be sent upon transfer and kept within the medical records. Both Trusts are looking to pilot these proformas following approval from the respective clinical committees. As stated above, | note this matter has been raised with the Secretary of State for Health. | would be grateful if you could share his response to this concern so that we may seek to take further action, in addition to that outlined above, 2. Areview of the liaison, understanding and interpretation of the provisions of the Service Agreement in relation to Radiology for the period from the 1 April 2015 to 31 March 2016 and any subsequent years, taking account of the evidence heard at the inquest. The review should include the operation and performance of the terms of the Agreement, and should extend to the involvement of the two Trusts, particularly on the same site at Leigh Infirmary. The review should also take account of any other Service Agreements in existence and entered into by both Trusts either collectively or individually. Shortly following the conclusion of Mr Pryal’s inquest, discussions were held regarding the interpretation of the Service Agreement for Radiology between the two organisations. Leading on these discussions for the Trust has been (NNN (Associate Director of Finance) and Andrew Beatty (Radiology Directorate Manager), with BE contract Manager for 5BP). A further meeting was held on 18 November 2015 where a joint review was undertaken of the Service Agreement for Radiology to ensure patient safety is now at the heart of the specification. Wigan Andrew have also presented to the Trust’s Quality and Safety Committee on what lessons have been learnt following Mr Pryal’s death. lt is acknowledged that there are a number of other Service Agreements the Trust has in place with 5BP, which relate to pharmacy, anaesthetics, domestics, psychology, counter fraud and estates. These Agreements have also been discussed and work is being undertaken to review the terms to ensure a consistent approach by both organisations. In addition to the above, the Trust’s Standing Financial Instructions (SFI’s) have also been updated in respect of the process for sign off for Service Agreements (please see Appendix 2). The attached document will be used as asign off sheet, and is now required for every new Service Agreement the Trust enters into. The revised SFls have been approved at Trust Board level. The Service Agreement will be owned by the operational manager (“Responsible Officer”) within the department which it relates to. It will be their responsibility to send out the sign off sheet to all those named seeking approval, and thereafter to cascade it down to those who provide the service (i.e. the health professionals) to ensure it is complied with. The Divisional Accountant will remain responsible for the financial aspects of the Service Agreement, and the document itself will sit with the Trust Board Secretary. 3. Areview of the electronic systems, which allow access by 5BP to network connections in relation to WWL systems, particularly to allow web viewing of x-ray examinations in accordance with the Service Agreement. Following discussions with 5BP, it was agreed that the Trust would grant secure web based viewing for all diagnostic reports via a secure system which can be accessed by an agreed username and password. It will be decided by 5BP which of their health professionals has access to this system. This is an interim measure until further developments can be made via the Trust’s HIS system which is due to be implemented next year. The Trust is aware that not all health professionals at 5BP have the expertise to identify and interpret diagnostic reports. Therefore in addition to the above, the Trust has a 24/7 “on call” Radiologist who is able to assist in interpreting x-rays, scans etc, if the health professionals are unable to do so. This has been communicated to 5BP who in turn will share this information with their staff. 4. Areview of the reporting times for x-ray examinations with particular reference to triage to identify any urgent or unexpected significant clinical findings, which will need to be communicated to the referring clinicians at the earliest time. In the case of Mr Pryal, the x-rays undertaken by 5BP at Leigh Infirmary were treated the same as if he were based at an out-patient facility. It is acknowledged that there was a lack of understanding by health professionals at the Trust that Lakeside Unit is an inpatient facility. Mr Pryal’s x-rays should have been reviewed as if he was an inpatient, and then they would have been reported sooner. Discusstons have been held at the Radiology Governance Meeting on 22 September and 15 October 2015 reminding all health professionals that patients at Lakeside Unit are to be treated as in-patients. The Radiology Information System (CRIS) has also been updated to reflect this, to prevent a similar delay occurring. Within the Emergency floor at the Trust there is a “red dot” system in place so that if Radiographers have any concerns, an * is put on the CRIS system to alert the referring clinician that they may be an untoward finding. This is something that is currently being considered to be used throughout the organisation, and ongoing discussions at being held within the Governance meetings. “Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another. Due to Mr Pryal’s x-ray request including a chest x-ray it meant, at the time, that it had to be reported bya radiologist. Due to New Year and bank holidays, there was no radiologist available to report plain films, which led to the delay. The risk of this delay happening again has been reduced by the introduction of Specialist Radiographer chest x-ray reporting. Finally consideration is also being given to creating a Policy or Standard Operating Procedure around radiographers identifying unsuspected clinica! findings, and bringing urgent x-rays to radiologist’s attention. This is also being discussed at the Governance meeting within the Radiology department. | hope the above response is testament to how serious the Trust has dealt with the events surrounding Mr Pryal’s death. If you have any comments or suggestions in relation to the proposed actions above, | would be only too pleased to hear from you. Yours sincerely Ape Andrew Foster Chief Executive
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