Margaret Dempsie

Leices~e~ ~'~~,~
C"~inical Commissioning Group

~ .

.' J

St Jahn's House
30 East Street
Le(cester
LE1 6NB

Tel: b116 295 0750
www.leicestercityacg.nhs.uk

From the office of:
Telephone:
Email address:

Mrs D Hocking
H.M. Coroner
The Town Hall
Town Ha11 Square
Leicester
LE1 9BG

22"d of November 2016

RE: Regulation 28 Report — IUEargret Mary Oempsie

Dear Mrs Hocking,

am writing in response to your letter of the 1s1 of November 2016 regarding the Regulation 28
Report issued on the 24t" of October 2016 regarding the deafh of Mrs Dempsie.

This CCG and our two commissioning partners in Leicestershire and Rutland recognise that the
provision of accurate and timely discharge information is a pre requisite for safe and high quality
patient care. We have been working together with University Hospitals of Leicester (UHL) to
address this and have taken a number of concrete actions:-

A group of clinicians and managers within UHL considered and reviewed the systems
and processes underpinning the production of discharge letters. This group identified that
there are a number of different IT systems within the trust that prevent the production of a
standardised discharge letter format. An LLR wide discharge group is now looking at
these IT issues, primarily focusing on the process for the electronic transfer of discharge
letters to Primary care. Overview of this work is via the LLR informs#inn strategy group
and will be via the. UHL Contract tEam next year.

• UHL undertakes an audit of a sample of discharge letters on a monthly basis, assessing
their content and timeliness, with feedback directly to the clinician concerned. The trust
reports that they have seen an improvement in bath the quality and the accuracy of
letters since this started. This monthly audit will continue, and the results will now be
reported into the CCGs Contract team for formal overview.

• To ensure that learning from this case is disseminated across the trust, the Regulation 28
Report was included as an agenda' item at the November Clinical Quality Review group
to enable further joint discussion between the mast and the CCG and to consider any

l._- J '

~' 

 
 
 other actions that are being planned within the trust r~Iating fa the {ssue of Discharge
letter accuracy.

Getting accurate feedback from GPs whanever there is a problem with Discharge letters
is a key part of improving performance. We are currently in discussion with UHL and our
GP Calieagues about how this can best be done, probably through a dedicated email
contact point. The intention is #a get feedback wi#hin 24 to 36 hours of receipt of the
letter, with rapid contact wifh the reievant junior doctor both to increase their learning but
also to ensure the provision of a corrected an accurate discharge letter where necessary.
We are exploring the feasibility of this over the coming weeks.

• To ensure there is an ongoing focus an the quality of Discharge lettErs, the 2017 i 2018
contract with UHL will include a quality indicator within the contract which will be formally
monitored and reported to the contract team. This wlkl include discussions around
corrective action should the necessary improvements not be sustained, The contracts
are due to be agreed by the 23~d of December 2016.

o The CCGs are currently in discussion with UhIL about the content of their junior doctors
Induction programme. We will ensure that an item is included within this programme
which highlights the importance of getting accurate information out to primary care
colleagues as soon as possible to ensure the appropriate delivery of care to patients.

and the Governing body have citEd an the issues related to the discharge process and we are
satisfied that we are working with the trust and our partners to seek ways to continualiy improve
the quality and timeliness of Discharge tett~rs.

Yours sincerely,

Managing Director LCGCG

~~~'

• ~

Professor Sir Bruce Keogh
National Medical DErec#ar
Skipton House
80 ~.andon Road
SE1 6LH

It~y~ December X016

Mrs Dianne Hocking
M.M. Coronar
The Town Hall
Town Hali Square
Leicester
LE1 9BG

Dear Mrs Hocking,

RE: Margaret Mary DEMPSIE

Thank you far your letter and report dated 24 October 2016, recEived by my
office on 27 October 2016. I  was vory sorry to read of the circumstances around
Margaret's  death, and wouid  like  to  express  my deep condolences to the
D~mpsie family.

have reviewed your report in detail and I  have identified that the Leicester City
Clinical Commissioning Group ("CCG") is responsible for commissioning services
tram the University Masplt~ls of Leicester NM5 Trust.  I  have therefore asked the
CCG to respond and provide assurance regarding actions they have taken in
order to mitigate the risk identified within your report. A copy of their response is
enclosed with this letter.

have reviewed the response from the CCG and am assured that the actions

identified are robust.

hope this is of some assistance to you and will help to prevent future deaths. In
the mean#ime, if you have any further queries please do not hesitate to contact
rne.

Yours sincerely

r '

Professor Sir~ruce Keogh KBD, MD, DSc, FRCS, FRCP
National Medi al Director
NMS England

High quality care far all, now and for future gen~rafions

Ur,iv~rsity Hospitals of ~eicestcr

1

15 December 2016

Mrs C E Mason
HM Coroner
Leicester City and South Leicestershire
Town Hall
Town Hall Square
Leicester LE1 9BG

Dear Mrs Mason

l~eic~~t~r  ~yal tr~firrr~~rY
Chief Executive's Corridor
Level 3, Balmoral Building
Infirmary Square
Leicester
LE1 5WW
Tel: 0116 258 8940

E-mail:

LEICESTER CITY &
`OL'~ ~ H LEICESTERSHIRE
CO20N~RS DISTRICT

Z 1  DEC 2016

Re Margaret Mary Dempsie
write further to the Regulation 28 Report sent by your Assistant Coroner on the 24t"
October 2016.
In that Report concerns were raised about the accuracy of the information sent to
GP's by junior doctors.  Understandably your Assistant Coroner was concerned that
primary carers are reliant upon the information provided to them in discharge letters
and that if that information is incorrect then patients could come to harm.
As a result of this Regulation 28 Report, the medical records of Mrs Dempsie have
, Associate Medical Director &Consultant Physician,
been reviewed by
who has concluded that the discharge letter should not have referred to the patient
as having had bronchopneumonia. However in  this case, whilst the patient was
clearly unwell and required end-of-life care following discharge; no harm befell Mrs
Dempsie as a result of this inaccurate information being provided to her GP.

The process for compiling a discharge letter at the Trust should be a joint enterprise
between the junior doctor and the most senior clinician on the ward at the time that
the discharge letter is signed off. Information contained in the. discharge letter should
reflect that contained in the patieni's ~~nedical records and best practice occurs when
the discharge letter is prepared in real time at the point the decision to discharge the
patient is 'made in order to ensure that senior members of the clinical team involved
in the care of the patient are involved in the process. Consultants ultimately have
responsibility in providing clinical leadership to their junior teams to ensure that this
process is supported. Our Medical Director has noted that the consultant in this case
appears to have raised concerns with your Assistant Coroner that discharge letters
for patients under their care regularly contained inaccuracies and so will be meeting

University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal
Infirmary.
Website: www.leicestershospftals.nhs.uk

  Chief Executive: Mr John Adler

 with the consultant involved to understand what actions they have taken to address
this and as to whether he has raised this as a concern with the Trust.
Whilst we strive to ensure that all discharge letters contain all relevant and accurate
information, we recognise that we do not get this  right on every occasion. To
minimise the risk of inaccurate information being provided to GP's, the Trust has
developed a standardised template for discharge letters which detail the reason for
admission and main diagnosis at discharge. Additionally the Trust provides an e-
learning package for junior doctors to reinforce the importance of providing accurate
information to GP's.
Approximately 500 GP concerns per year come through the Patient Safety team and
these are themed and discussed at the Clinical Quality Review Group. The Senior
Patient Safety Manager and the Head of Services for GPs now meet monthly to
triangulate GP concern themes to monitor these and inform required actions at Trust
wide level.
In addition, the Trust has for some time requested individualised feedback from GP's
regarding any poor or inaccurate information received from the Trust and undertakes
regular audits to pro~~ide assurance on the quality of the information provided in
Discharge  Letters.  These audits  show an  improvement in  the  quality  of the
information that we provide to GP's.
As a result of this case the Trust has taken and will be taking the following actions:-

The frequency of internal audits for discharge letters will  be increased for
each CMG every month with immediate effect and our Head of Outcomes and
Effectiveness will lead on this.

2. Our Chief Medical Information Officer and Head of Services for GP's will
encourage  GP's to  provide  individualised  and  patient  specific  feedback
concerning poor discharge letters throughout December 2016 to assess the
level of inaccuracies and perception of poor Discharge letters.  Our Chief
Medical  Information  Officer  will  then  review  any feedback  and  discuss
necessary actions with the doctors involved and the GP dependent upon the
findings. He will report on this matter to the Executive Quality Board in March
2017. Our Head of Services for  GP's will  promote the opportunities  to
feedback errors on discharge letters  directly to  her in  the December GP
Newsletter.  This extended audit will then be repeated at regular intervals,
depending on the findings.

3.  Our Head of Effectiveness and Outcomes has raised the issue requesting
GPs to provide feedback concerning incorrect discharge letters at the Clinical
Quality  Review Group Meeting on 17 November 2016. This review Group
includes GP leads for the Clinical Commissioning Groups

4.  Our  Medical  Director  will  ensure  that  this  case  is  discussed  with  the
Consultant involved before the end of December 2016 to encourage reflective
 has met with the junior doctor who wrote the discharge
learning.

University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal
Infirmary.
Website: www.leicestershospltals.nhs.uk

  Chief Executive: Mr John Adler

 letter in this matter. She has reflected upon this case and clearly understands
the importance of accurately completing discharge letters in future.

5. Our Head of Outcomes and Effectiveness will strengthen our "Letters Policy"
to ensure that there is clarity concerning the process for discharge letters and
the importance of senior medical oversight. This should go to the Policy and
Guideline Committee Meeting in January 2017.

trust that this response assures you that we are take these matters seriously and if
you wish for any further information please do not hesitate to contact me.

Yours sincerely

John Adler
Chief Executive

University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal
Infirmary.
Website: www.leicestershospitals.nhs.uk

  Chlef Executive: Mr John Adler