Francis Lea

Nursing &Quality Directorate 

From the office of: 
Tele  hone. 
Email address: 
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East Leicestershire and Rutland
Clinical Commissioning Group

GCG Headquarters
Leicestershire County Council
Room X30, Pen Lloyd Building
County Hall, Glenfield
Leicester LE3 8TB

Web: www.eastleicestershireandrutlandccg.nhs.uk

Stn February 2017

PRIVATE AND CONFIDENTIAL
H.M. Coroner
The Town Hall
Town Hall Square
Leicester
LE1 9BG

Dear Mrs Brown

Re: Francis James LEA

Thank you for sending us a copy of your report and recommendations following the inquest
into the death of Mr Francis James Lea which took place in December 2016. I thank you for
bringing these to my attention, this type of learning is very important to East Leicestershire
Rutland Clinical Commissioning Group (ELR CCG), helping us to make important
improvements to the way in which services and care is provided for people living in our area.

As part of our investigation into the matters raised in your recommendations, the ELR CCG
Head of Nursing and Head'of Patient Safety were asked to look into your concerns and
provide a response. This has then been reviewed by the Chief Nurse and Quality Officer at
ELR CCG to ensure that all of your concerns have been answered and adequate action has
been taken as a result.

The investigation team have carried out a thorough investigation in order to respond to each
of your concerns below. For ease of reference; we have included your original request in
italics.

For a patient in a care situation, with declining cognitive function (as set out in his home care
plan) it would seem appropriate to consider involving the next of kin in any significant decision
such as a change of GP. This would have enabled the family (who always ensured they
accompanied Mr Lea for any medical care) to pass on the updated information and this
outcome would have been avoided.

Managing Director: Mrs Karen English 

Chair: Dr Richard Palin

 
 
 During the course of our. investigation, we have been informed by the care home manager
that Mr Lea did have the capacity to make the decision to change GP practice. If a person has
capacity, there is  no requirement to inform the next of kin. However, we recognise that
engaging with residents and their families is best practice when making changes such as this.
Therefore there are a number of actions that will be put in place to ensure families are aware
of future changes with which the CCG is involved:

- When making changes, there  must be a robust project  plan, including  plans for

communicating and engaging with all stakeholders.

- Ensure communication and engagement plans include engagement with the family and
next of kin. So that whether residents have capacity to make decisions or not, their
families will be aware of potential changes.

- Project  plans  will  clearly  identify  the  responsibilities  of  all  parties  for  sharing

information.

- All communications regarding planned changes will be shared with all members of staff

at care homes and GP practices.

There appeared to be no notes on the patienf's medical record regarding the rationale for this
change, or any consent from the patient that he was in agreement that it should take place.
There was also no record of whether any consideration of his capacity has been undertaken,
and if so what the outcome of that decision was.

Residents/patients are assumed to have capacity unless proved otherwise. As part of this
project residents were given the choice as to whether to move practice. In future projects of
this type, ELR CCG makes the following recommendations:

- Any proposed  changes are  discussed  with  the  patient  and  documented  by the

organisation instigating the change.

- In future projects, ELR CCG will  require providers to kEep a record of information
received and discussed with residents. There will also be a requirement to include
potential changes in care plans, and on the relevant clinical systems.

- Project plans will include communications to care homes reminding them to update

patient records in a timely manner.

During the course of the investigation it  was established that the care home manager had
signed the form on behalf of Mr Lea although this was not made clear to the Practice.
Therefore we will be contacting all care homes to recommend:

- Policies and processes are put in  place when staff are required to sign on behalf of
residents who have capacity who are physically unable to sign a document (including
documentation standards i.e. designation, black ink, print, two to sign and date).

Since the time of this incident, we have issued standard practice application forms to all of our
membership practices. This includes a section for signing on behalf of somebody else.

 Given this was a joint decision between the GP surgeries and the care home, it would seem
that each surgery should share responsibility for a safe and effective transfer of care and
therefore this report is being sent to each surgery for further consideration and the CCG.

It is clear that there could have been better communication between the different parties
involved in the project. In future we will recommend that:

All  project plans must clearly outline roles and responsibilities for each of the parties
involved

- All  communications involved  in  a project  must be clearly  dated  and documented

(including templates for letters etc.)

- When making changes to practice lists, not initiated  by the patient, there must be a
system for forwarding  on communications regarding these patients for an agreed
timescale (i.e. minimum six weeks).

- Carehomes should have systems for tracking information shared with GP practices;
information should be documented in care plans and signature sheets may be required
to track information depending on the circumstances.

- In future projects, ELR CCG will  require providers to keep a record of information
received and discussed with  residents. There will  also be a requirement to include
potential changes in care plans, and on the relevant clinical systems.

In addition to the actions already identified, a serious incident investigation has been opened
into this case to ensure the widest possible learning. This is amulti-agency investigation,
including the two GP practices, the care home, University Hospitals Leicester NHS Trust
(UHL) and ELR CCG.
We also intend to share the issues raised in your letter with our contracts teams who monitor
the CCG's contracts with care homes and GP practices. This enables our contracting team to
seek assurance from provider organisations, in respect of how they implement lessons learnt
from an incident with an aim to improving patient care.

hope the enclosed response provides assurance about the actions taken following your
recommendations.

Yours sincerely

Managing Director

HAZELMERE MEDICAL CENTRE

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58 Lutterworth Road, Blaby, Leicester LE8 4DN
Telephone: 0116 2771666, Fax: 0116 2772416
Website: http:www.hazelmeremc.co.uk

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2na February 2017

H.M. Coroner
The Town Hall
Town Hall Square
Leicester
LE1 9BG

Dear H.M. Coroner

Re: Francis James Lea (Your ref: CEM/GA/02131-2016)

am writing to you on behalf of Hazelmere Medical Centre I am sorry to hear about the
events surrounding the care of Francis James Lea.

The matters of concern raised in your report have been discussed in a meeting between
Hazelmere Medical Centre, Northfield Medical Centre and The Clinical Commissioning
Group (CCG).

The medical records of the patient do not reflect any evidence of declining cognitive
function requiring the need for a formal capacity assessment. The communication with the
care homes in this project of swapping care home patients between practices was explicit in
stating that the change of registered GP was an active informed decision to be
communicated to the patient, or if the care home felt there was a lack of capacity for this to
be discussed with next of kin. As part of this project letters were written to the care home
patients which was sent to Mr Lea as well detailing the above. Hence it was assumed that
M r Lea had capacity to engage in this process.

As part of the learning point from our joint discussions it has been proposed in the future to
avoid any similar incidents there is need for better advertisement of any such wide changes,
in the form of posters. A,specific recommendation is the need for written signed
documentation of the conversation with the patient or next of kin as appropriate.

There is usually no need for documenting on patients medical records regarding rationale
for change of GP.

As highlighted the care home was facilitating change of GP and patients were offered the
choice of declining to change their registered GP. As mentioned earlier it is not common
practice to hold capacity assessment unless there is a medical need.

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HAZELMERE MEDICAL CENTRE

58 Lutterworth Road, Blaby, Leicester LE8 4DN
Tele  hone: 0116 2771666, Fax: 0116 2772416
Website: http:www.hazelmeremc.co.uk

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As a result of the meeting between the practices and the CCG it has been agreed that to
avoid any future similar incidents any communication received by the donor practice, in
addition to the usual practice of the communication being sent back to the sender; will in
addition be forwarded to the receiving practice for up to a period of six weeks from the
change of registered GP.

Yours faithfully

8, Feb.  2017 13.28

No, 3583  P.  2

NQR7HF1El.l] MEdICAL CENTRE

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Northfield Medical Centre
Viilers Court
Blaby
Leicestershire
LE8 4NS

H.M.Coraner
The Town Hall
Town Hall Square
LeicesteC
LE19BG

Dear H.M. Coroner

Telephone;

Re: Francis James Lea (Your ref: CEM/CAA/OZ131-2016)

I am writing to you on behalf of Northfield Medical Centre.

The matters of concern raised In your report dated 15th December 2016 have been
discussed  in  a meeting between  Hazelmere Medical Centre (HMC), Northfield
Medical  Centre  (NMC) and  The  East  Leicestershire  end  Rutland  Clinical
GommiS.sioning Group (GGG).

NMC response tv coroner's report:

Mr Lea was resident in a care home at a time when a decision had been taken locally
to rationalise the GP provision to care homes, as far as possible, to Improve the care
~[ven to patients. The relevant GP practices wrote to the patients, via the care
homes, explaining the change and giving patients the option to move GP practices or
to remain with their existing practice. A copy of such a let#er $ent by Nor~hfleld
Medical Centre to its care home pati~.nts is attached.

' Mr Lea was initially ~ p~tier~t dC Nazelmere Medical Centre but the GP practise
allocated to his care home was Northfield  Medical Centre. Where patients were
happy to move GP practice, this was facilitated by the care home, as was the case for
Mr Lea.
Mr Lea agreed to change GP practice and there was no suggestion that he did not
have the capacity to make the dEcisibn to change GP. In such circumstances, the GP
practice  Is  not in  a position  to inform tEte  next of kin  due to the  duty of
confideneiaifty~ owed to the patient and practical difficulties of identifying relevant
members of the fami{y or next of kin.

 8, Feb.  2017 13.28

No. 3583  P.  3

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As a Consequence, is appears that although the care home and Mr Lea were aware
that Mr Lea had changed GP practice, Mr Lea's family were not.
In order to avoid such a situation arising again, we will as a practice be liaising with
the care homes to request that:

• Where a patiQnt, with capacity, who is resident in a care hgme, changes GP 
. practice and this chan~e,is facilitated by the care home, arrangements are
put in  place for the care home to provide written confirmation that the
patient is aware of the change, the patient gives consent to the change ar~d
tha# where appropriate the patient's next of kin have been informed.
• Where a patient lacks capacity, the care home should  provide written
con~rrmation that the patient's next of kin has been properly informed and
consents to tf~e change of GP practice. Ifi  there are any concerns about
capacity it would be expected that the care home would raise #here.

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• Wherever a Registration Form i~ signed an a patient's behalf, the person
signing the form on the patient's behalf will be required to print their name
and their relationship to the patient.

In addition it has been agreed that any future projects such as that undertaken to 
rationalise GP provision to care homes, as referred to above, should include better
advertisement, including in the farm of posters, so that families, next of kin and staff
ace fully curare of proposed changes. 
For an existing IoCal agreement above changing patient care from one Ioca( practice
to another when a patient resides in a tare home, any communication arriving at the
old practice in the 6 week period between deduction from the old practice and 
registration at the new practice wil! be forwarded onto the new practice, in addition
tv a copy being returned to the sender. 
With regard to a safe end effectEve transfer of care, it has been agreed that to avoid
any similar accidents, for any future ~ocaliiy projects there will be a written policy 
which needs to have been signed off by all  parties as do the clear process of
facilitating any change of GP regi~tratiQn and who will be informing the next of kin
where appropriate.

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Ithfull

4n behalf of the Northfield Medical Centre