Prevention of Future Deaths reports · 2015

Harry Pryal

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 report28 Sep 2015
Reference2015-0391
DeceasedHarry Pryal
CoronerAlan Walsh
Coroner areaManchester (West)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedWrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust · Boroughs Partnership NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published4

The report

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

——|

Responses

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.

Response from 5 Borough Partnership NHS Trust (PDF)
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
Response from Department of Health (PDF)
| 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
Response from Wigan Borough CCG (PDF)
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.
Response from Wrightington Wigan and Leigh NHS Trust (PDF)
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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