Miles Abel

AR From Nicola Blackwood MP

Parliamentary Under Secretary of State for Public Health and Innovation

Department
of Health RECEIVED] 9 ™mueis
Lond
in| SW1A 2NS

ee 020 7210 4850

Mr Ian Singleton

Assistant Coroner for Wiltshire and Swindon

Wiltshire and Swindon Coroner’s Court ~7 OCT 2016

26 Endless Street

Salisbury

Wiltshire

SP1 1DP

1
Thank you for your report of 29 July 2016, following the inquest into the death of

Miles Benedict Abel. I was very sorry to hear of Mr Abel’s death in January 2016
and wish to extend my sincere condolences to his family.

Your concern relates to the process followed at the Endless Street Surgery for
referring patients to the Community Mental Health Team. I am aware that the
Surgery has responded to your concerns, confirming that a strengthened and robust
system for referral of patients to the Community Mental Health Team is now in
place.

Although this is an issue to be addressed locally, the Government is taking
forward the digitisation of the NHS. A plan of work covers a portfolio of 33
programmes to deliver the technology, digital and data enablers needed to
underpin transformation in the health and social care system. The combined
budget for the portfolio is circa £4.2bn. Several programmes will transform how
the NHS operates and make better use of technology - for example:

e Integrated Care - Better inform clinical decision making across all health
and care settings by enabling and enhancing the flow of patient information;

e Paper free at the point of care — Create an NHS “paper free at the point of
care” to enable the NHS workforce to better utilise the benefits of digital
technology; and

e Transforming General Practice - Use technology to free GPs from time-
consuming administrative tasks and provide patients with online services

Iam grateful to you for bringing the circumstances of Mr Abel’s death to my

attention.
Nob wry

nti

NICOLA BLACKWOOD

The Endless Street Doctors’ Surgery

72 Endless Street, Salisbury, SP1 3UH
Tel. 01722 336441 Fax. 01722 410319

www.endlessstreetsurgery.org

lan Singleton

Assistant Coroner for Wiltshire and Swindon
Wiltshire and Swindons Coroners Court

26 Endless Street

Salisbury

Wiltshire

SP1 1DP

RECEIVED

8" September 2016

Dear Sir

Please find below our response to the “Regulation 28 report to prevent future
deaths” dated 29 July and related to the inquest touching upon the death of Miles
Benedict ABEL.

We understand that the concerns related to the process in operation for
management of faxes and in particular faxed referrals. The specific concerns were
that there was no audit trail to show that the fax had been sent, that the practice of
telephoning to confirm receipt of a fax was not always followed, hence if the fax had
not transmitted, the team to which the patient was referred would not know a
referral had been sent.

The historical procedure for dealing with urgent faxes was as follows:

1. Completed referral form which requires faxing is printed off by doctor.

2. Completed referral form handed to receptionist to fax- (number on form)

3. Fax machine can identify when faxes had been sent by checking the
transmission receipt

4. The receptionist would phone to check that fax had been received.

Following the Critical Reporting Incident that followed the recent death of a patient,
we have reviewed the system above and have instituted the new system —
(Standard Operating Procedure - SOP enclosed):

New procedure:

1. Completed referral form which requires faxing is printed off by doctor.

2. Completed referral form handed to medical secretary by referring clinician
who verbally identifies that this is an urgent fax to be sent and that there is
an urgent fax SOP to follow — details are easily found in the shared staff
folder.

3. The sender completes the fax log documentation, (this is a document located
next to the fax machine which keeps an account of what was faxed, by
whom and the time and date).

4. The sender faxes documentation and then adds the ‘faxed dated ‘stamp
before scanning it into the notes.

5. The sender ensures that the fax is received [the fax machine will give an
auditable beep to show it has sent the fax) by calling the recipient and
documenting who they spoke to and the date/time AND send a task to the
requesting Dr to inform them that the fax has been sent — (tasks are
recorded automatically in the patients notes).

Therefore the fax log documentation will record who sent the fax and the date and
time it was sent.

The document scanned in to the records will have details of to whom the
receptionist spoke to confirm receipt of the fax. It will also have the time and date of
this conversation.

There will also be a task on the system to confirm that the referring doctor has been
advised of successful transmission

Please let us know whether you need any further information

Yours sincerely

Co >

Practice Manager

72 Endless Street, Salisbury, SP1 3UH
Tel. 01722 336441 Fax. 01722 410319
www.endlessstreetsurgery.org