Rachal Murphy

Grosvenor Medical Centre
62 Grosvenor Street

Stalybridge

Cheshire

SK15 1RZ

Tel 0161 303 4313
Fax 0161 303 8377

09-Jan-2017

Joanne Kearsley
Acting Senior Coroner
Coroner's Court

1 Mount Tabor Street
Stockport

SK1 3AG

Dear Miss Kearsley,

Re: Miss Rachal Marie Murphy

In response to the death of the above young lady and an internal review of her case, the
Practice has put into place measures to avoid the issues noted about the failure to check
her liver function blood tests (LFTs) and how CAF documentation is handled.

1. The British National Formulary issue 72 advises that LFTs “should be checked
before sodium valproate therapy is commenced and during the first 6 months of
treatment, especially in patients most at risk”. Although the BNF does not advise
checking LFTs annually for patients on sodium valproate, we all accept this would
be good practice in view of the risk of hepatic dysfunction and have agreed to
adopt this policy within the Practice.

| have done a search of the Practice list for all patients currently prescribed sodium
valproate and noted when their last LFTs were checked. If this has not been within
the last year, they have been sent a letter inviting them in for a blood test.

An alert has also been added to each set of notes detailing when their annual LFT
is due and all administrative staff who issue prescriptions have been made aware

to check the blood test is up to date before issuing a prescription. Should patients
decline to have a blood test or not respond to the invitation, this will then be
escalated by the member of administrative staff to the patient's usual GP to contact
the patient and determine further action as appropriate.

In the case of children under 18 years of age, all contact would be sent to the
parent/guardian. Failure to respond to monitoring invitations would be escalated to
the lead safeguarding GP to assess and consider whether the child is at risk and
determine whether a referral to safeguarding is indicated.

2. Since the CAF document from 2014 was received and scanned into Rachal’s
notes as file-only, a new member of staff has been employed by the Practice and
trained to scan all paperwork received. She also attends annual training days on
Docman, the software used to scan surgery letters.

CAF documents received through the post will now be given to the duty doctor on
the day they arrive, to determine whether any action is required that day, such as
responding to CAF meeting invitations, liaising with any other colleagues involved
in the patient’s care or arranging any follow up required at the Practice. Should no
same-day response be needed, the document is then scanned and sent to all
regular GP’s at the practice to read, in order that they are all made aware of the
information contained.

We trust that these new procedures will help avoid a repeat of the circumstances involved
in this tragic case.

Yours sincerely,
Nowe

Salaried GP
Grosvenor Medical Centre

y Metropolitan Borough
® Metropolitan Boroug Chief Executive

HYDE

ASHTON-UNDER-LYNE AUDENSHAW OROYLSDEN DUKINFIELD MOSSLEY

Steven Pleasant MBE
Chief Executive

DENTON LONGDENDALE STALYBRIDGE

By email:
Miss Joanne Kearsley Dukinfield Town Hall, King Street,
Acting Senior Coroner Oukinfield, SK16 4LA
Manchester South Coroners
Coroner’s Court www.tameside.gov.uk |
4 Mount Tabor Street Cutie
STOCKPORT
SK1 3AG Call Centre Fe
Your Ref
Doc Ref
Ask for
Direct Line
Date 31 January 2017

Dear Miss Kearsley
Rachal Marie Murphy

| am writing in response to the Regulation 28 Report dated 8 December 2016 and in particular to
the concerns raised regarding the delay in the allocation of cases within Tameside Early Help
Services.

A thorough review has been undertaken of caseloads and allocation of work within the Early Help
Service in part due to learning from cases such as this one and more recently our latest Ofsted
inspection of children’s services. As a result, measures have been put in place which have led to a
significant reduction of delay in the allocation of cases.

The table below provides quarterly data in relation to the number of families who have been
entered onto a waiting list, having been identified as requiring a service from Early Help. The data
gives a snapshot of the total number of families who were on the waiting list at the end of each
quarter and gives clear evidence of the efforts that have been made to eradicate the use of a
waiting list. The three cases that were on the waiting list at the end of the most recent quarter
were allocated as soon as the holiday period came to an end and normal staffing levels were in

place.

July — Sept 2015
Oct — Dec 2015 44

| Oct=Dec2016 |

Assurances can be given that in the past six months, any family entered onto a waiting list was
allocated a worker within a one month time frame and a manager from the Early Help Service kept
in contact with the family during that period to monitor the situation.

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Managers within the Early Help Service continue to monitor this and are now vigilant in ensuring
that the use of waiting lists is not common practice and that families receive a service at the point
that need is identified.

The future monitoring of this performance will be undertaken at a weekly Family Support Panel
which will manage all allocations to Early Help and other services in order to maximise the timely
response to children’s needs. In addition, a report will be submitted to the Tameside Safeguarding
Children Board on a six monthly basis to keep the Board updated on the progress of the Early Help
Services to ensure a strong multi agency ownership.

Itrust that the measures that have been put into place will address the concerns raised within the
Inquest in respect of the Early Help Service.

Ps sincerely,

= i> =
Steven Pleasant MBE
Chief Executive

S SoD PE POE ER, Wek E ee Lg’

NHS Foundation Trust

1* February 2017 Corporate Governance
Trust Headquarters

225 Old Street

Ashton-under-Lyne

Lancashire

RECEIVED
n2 FEB 2016

FRIVATE & CONFIDENTIAL
Ms J Kearsley

Acting Senior Coroner
Coroner's Court

OL6 7SR

Telephone: 0161 716 3000

Our Ref: ||

4 Mount TaborStreet § | Laeesnsescoossccc Department: Trust Headquarters

Stockpo
SK1 3A

Dear Ms Kearsley,
Re: Rachel Murphy (Deceased)

Thank you for your Regulation 28 report dated the 13" December 2016, and for
bringing to my attention the concerns you had after hearing all the evidence. Your
concems relevant to Pennine Care have been reviewed, and the Trust's response is
outlined below.

Concerns:

® There was a lack of understanding between medical professionals as to the
means a referral could be made to Psychological services and to whether there
was an unclear message from Psychological services if they were accepting
referrals.

»  A_Lack of understanding amongst medical professionals as to which cases may
or may not be appropriate for referral to CAMHS services.

Response:

As part of the Trust's quality improvement work during early 2016 the Trust
implemented a new referral process for all aspects of Tameside and Glossop
Healthy Young Minds Services (formally CAMHS). All referrals are now managed via
one single point of entry and then allocated to a range of possible professionals
dependant on the child/young person's needs e.g. Psychologists, Nurse, Psychiatrist
or 3 sector services. This allows for greater clarity and understanding of where to
direct requests for help to for all professionals.

The Trust have also produced a service offer document which details, how to make a
referral, how to contact the service for advice and importantly the document contains
information of the types of problems that are appropriate to refer to Tameside and

at May,
Salas >

Glossop Healthy Young Minds. This service offer document has been circulated
widely to all partners and is also held on our website for easy access.

The document has just recently been reviewed and will be expanded to provide a
named contact for colleagues in the Paediatric medical services to contact for advice
and consultation. The Trust believes that this addresses the confusion and lack of
understanding that you have identified in relation to Rachel's care and treatment.

| hope this response assures you that the Trust takes seriously any concerns that
you raised.

For and on behalf of
Michael McCourt
Chief Executive

ge May,
RAYA

NHS

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Ms Joanne Kearsley Tpmesice oe ae, ete
Acting Senior Coroner for Manchester South Ashbelitigntens
The Coroner's Court ~ Tameside
4 Mount Tabor RECEIVER OL6 SRW
Stockport

SKi 3AG | 2 FEB zug Tdlephone: 0161 331 6000
27 January 201700 ——S™s ee eee Lk

Dear Ms Kearsley

Regulation 28: Report to Prevent Future Deaths following Inquest into the death of
Rachal Murphy

| write further to your letter dated 8 December 2016 enclosing a Regulation 28 Report issued at
the conclusion of the inquest touching upon the death of Rachal Murphy, which took place on
17 to 19 August 2016. We acknowledge that the Report has been issued to us some three
months after the inquest was heard, but are, of course, very sorry that you had cause to issue
this.

Further to a letter received by you from the Trust solicitors dated 30 August 2016, | hope to be
able to further address your concerns, as set out in section 5 of your Report, to your
satisfaction, in this letter. | have addressed the areas of concern, adopting the same numbering
in section 5 of your Report as follows:

You stated:

1. There was a lack of understanding between medical professionals as to the mears by
which someone could be referred to Psychological Services and whether there was an
unclear message from Psychological Services as to whether they were accepting referrals.

As per the letter from our solicitors dated 30 August 2016, Paediatric Psychology Services
within the Trust were at this time provided solely by Pennine Care NHS Foundation Trust. The
Trust were therefore very limited by the services/policies and practices adopted by Pennine
Care. | understand that it was heard in evidence that the clinical psychology services offered at
the Trust through Pennine Care were undergoing a reconfiguration during 2015 and therefore
the paediatric team were informed that referrals to the Paediatric Psychologist could not take
place. ! am advised that this was confirmed by the Trust’s Consultant Paediatrician in evidence,
who stated that to the best of his knowledge the Paediatric Psychologist had been
decommissioned and he therefore understood that referrals could not be made. | understand
that this contention was supported directly by the statement obtained from the Paediatric
Psychologist who stated that ‘ had told all paediatricians that | could not take on any more
referrals as the referral process was changing’.

Similarly when approached by the Trust's Specialist Epilepsy Nurse at the request of CAMHS, |
am advised that the evidence heard at the inquest supports the contention that a referral could
not have been accepted and all referrals were to be sent back to CAMHS. | understand that it
was clear from the evidence of the Trust's Specialist Epilepsy Nurse that she felt that there was
nothing further she could do as she was ultimately limited by the services provided by both
CAMHS (who rejected the referral) and Pennine Care, who were not accepting referrals at that
time.

WHS It SEEMS arguabie trom the evidence summansed above that there was a lack of
understanding about Paediatric Psychology Services at this time, the system within the Trust
has now changed. Please see the further explanation provided at point 2 below.

2. Lack of understanding amongst medical professionals as to cases which may or may not be
suitable for referral to CAMHS.

As indicated to you in a letter from our solicitors dated 30 August, it was the Trust's contention
that during the course of the inquest there was in fact no evidence to suggest a lack of
understanding in relation to CAMHS referrals and where evidence perhaps suggested that
knowledge was limited, the Trust demonstrated that practices have now changed. | understand
that the Trust's Consultant Paediatrician gave clear evidence that a CAMHS referral was not
made by him in March 2015, not because he was unsure of the process, but because he knew
how the process works and understood that without evidence of a more acute mental health
problem, the referral would bé refused (which it ultimately was) and it was therefore important
to look at other avenues of how to manage Rachal’s behaviour.

| am advised that the Trust's Specialist Epilepsy Nurse spoke frankly about her understanding
of CAMHS at this time but provided reassurance in evidence that her knowledge of the service
and the way in which she interacts with CAMHS has now changed, resulting in her undertaking
a much more active role in terms of liaison with CAMHS, even in cases where a referral would
likely not be accepted, and she confirmed in evidence that she will speak with CAMHS
regardless of whether an official referral is in place.

The Trust have in response to this case, made changes to their practices to ensure that
referrals to CAMHS are made in writing in any case where the Consultant Paediatrician has
reasonable cause for concern in respect of a child's psychological wellbeing. The Consultants
no longer filter referrals through Pennine Care staff nor do they consider the likely acceptance
of referrals before making them. The referral is made and it is for CAMHS to determine how to
proceed. | am informed that this change in approach has been successful to date with CAMHS
appearing to be accepting more referrals in response.

The Trust now have in place a number of safeguards to ensure that where a child being treated
for epilepsy exhibits signs that may be consistent with mental health issues, that they are
managed and referred to the appropriate organisation.

Consultant Paediatricians dealing with epilepsy patients develop a plan of care that is
specifically tailored to each child and their family’s needs. If a referral to CAMHS is required, no
matter how small the concern, it is made. If a child exhibits signs that are consistent with them
being high risk of self-harm/suicide, they will be admitted to hospital immediately for further
assessment.

All children treated for epilepsy are reviewed by the Trust's Specialist Epilepsy Nurse. The
Specialist Epilepsy Nurse reviews their progress, liaises with their family and school and if any
concerns regarding mental health are identified, these are discussed with the Consultant
Paediatrician and a referral to CAMHS is made. The Specialist Epilepsy Nurse also liaises
more informally with CAMHS by way of telephone advice, if a concern is identified.

All children treated for epilepsy are given information regarding The Hope Group, a family
support group for families with children suffering from epilepsy. The group is run independently
from the Trust but the Trust’s Specialist Epilepsy Nurse is involved and often encourages
families to attend weekly meetings as a further support network for patients and families who
may be facing difficulties. The group provides a useful framework of support for children (and
their families) to discuss and voice their concerns and worries outside of the hospital
environment. The group is successfully attended and is assisting many families who find
themselves in similar situations to Rachal and her family.

Since this incident, the Trust have employed a Children and Young People’s Mental Health
Development Nurse who works closely with the Paediatric Team offering support and training to

develop mental health knowledge and skills to support safe, high quality and evidence based
care for vulnerable children and young people.

A business case is currently being developed by the Trust to request funding for the
introduction of a Psychologist for Paediatric Epilepsy patients. The introduction of such a role
would provide another level of support to the team in dealing with patients who may be
suffering with mental health issues. The appointment will be subject to the availability of NHS
funding.

3. There was a significant delay in reporting Rachal's EEG and the Court heard that this
remained the case in respect of reporting of EEG’s at the time of the inquest.

24 hour, and in this case, 72 hour EEG’s are very specialist tests that require specialist input
and reporting. In order to interpret the outcome of these tests, analysis of an expanse of data
collected over a 72 hour period has to be performed, the results of which may materially affect
a patient's diagnosis.

As indicated to you, in a letter from our solicitors dated 30 August 2016, 24 and 72 hour EEGs
are performed and reported exclusively by Manchester Children’s Hospital (operated by Central
Manchester University Hospitals NHS Trust). Whilst the Trust can chase up the results, they
are not in control of the timeframes for reporting and delivery of EEG results, although given
their specialist nature a period of analysis is expected. A patient's care is also not affected
whilst awaiting the EEG result.

The Trust therefore reiterate in line with para 7(1)(c), Schedule 5 of the CJA 2009, and also the
Chief Coroner's Guidance No.5 on Regulation 28 Reports, that the Regulation 28 Report must
be sent to “an organisation who the Coroner believes has the power to take such action”. For
the reasons stated above, the Trust respectfully submit that they have no “power to take such
action” and therefore should you still have concerns in this respect, the Regulation 28 Report
should be directed to the requisite organisation.

| am very sorry that you had cause to issue this Regulation 28 and | would like to take this
opportunity to emphasise that | do take your concerns very seriously, | hope that | have
responded to your concerns and reassured you of all the work that the Trust has already
undertaken and is currently undertaking to reinforce the messages conveyed to you at the
inquest regarding Paediatric Psychology Services.

Should you have any further questions arising from the contents of this letter, please do not
hesitate to contact me.

Yours sincerely

cn) -

Katen James
Chief Executive