Terence Hawkins

LIME TREE SURGERY
: 321 High Road
Leytonstone
London
E11 4JT

Tel: 020 8519 9914 | s—“(tisCsz
10-03-2017

Ms Nadia Persaud

Senior Coroner

Coroner area of East London
Walthamstow Coroners Court
Queens Road

Walthamstow

London

£17 8QP

Dear Ms Persaud,

Thank you for your letter dated 23.2.2017 in response to my reply to the regulation 28 report you
sent me dated 19.12.2016. Thank you also for sending me the CD recording of the inquest to clarify
some of evidence presented before you, as | was not present for most of the inquest.

Having listened to the inquest recording | remain concerned about the content of your report dated
19.12.2016. ,

You have mentioned in your letter to me that ‘there was concern in this case in relation to a lack of
medical review. | have therfore oresared a renort under regulation 28 of ihe c

ers (investigation)
reguiations 2013’. The impiication is that there is systernatic lack of medical review due to lack of GP
visits which needs rectifying to prevent future deaths. Your assumption is that the only way to rectify
this is to arrange regular GP visits. | have a serious objection to such conclusion. The evidence
presented to you does not support this view.

Having listened to the evidence there appears to be a total breakdown of communication between
the home and the GP surgery following the new manager taking over, shortly before Mr Hawkins
passed away.

The manager states that it can take 2hrs to get through on the phone on a Monday to request a visit.
Even if this was the case we have a dedicated safe haven fax machine to receive requests for visits as
well as alternative contact numbers. At no point, has she stated that the GP refuses to visit when
asked and clinically indicated. | think the faiiure clearly lies in the management systems in place at
the home.

i will take this evidence as feedback from the home of their experience of visit requests. | will
therefore conduct a survey of visit requests by the home and seek feedback on how to improve
this experience. | will follow this up with designing a new pathway for requesting home visits
incorporating and responding to this feedback. | will also monitor home visit requests for a period
of time.

You state at 5.1: ‘There was no system in place for the regular medical monitoring of residents with
the Care Home’

Your question was: ‘what systems do you have in place for the medical monitoring of residents?’ |
replied ‘the carers request a visit as and when there are concerns regarding any of the patients. This
is the normal majority practice throughout UK General Practice. You also asked if regular visits would
be beneficial for patients and | replied yes. | was not asked whether regular visits could have
prevented this death or any future deaths.

A visit was requested on 11.3.2016 and the patient died two months later on 12.5.2016 from 1a:
congestive heart failure, 1b : Ischaemic Heart Disease and 2: Alzheimer’s disease. The reason for the
home visit request on 11.3.2016 was due to ‘weight loss and medico-legal reasons’. After listening to
the evidence it is clear there was no history of symptoms or care records being recorded in his
nursing records.

It is well documented in the deceased’s GP medical records that he had advanced dementia with
incomprehensible and sparse speech (see memory clinic letter dated 6.11.2015). The deceased also
had a history of difficulty swallowing caused by the dementia (see Speech and Language Therapy
Report dated 15.7.2015). The doctor in question discussed the reason for the visit request on
11.3.2016 with a senior colleague and concluded that the reason for the weight loss is due to
advanced dementia and not due to an acute or other chronic illness.

Carers and relatives are always told as a rule and safety measure that if the health of the patient
changes or deteriorates to call back and request a visit. Why was there no request for a visit
between 11.3.2016 and 11.5.2016 if the deceased was indeed unwell or deteriorating?

The member of staff that the duty doctor spoke to on 11.3.2016 was Lavinia (Carer and Manager at
the time). She knew the deceased very well. Why was she not called as a witness? | understand
there have been considerable difficulties at the home around this time but these difficulties were
not explored?

The level of medical care is only as good as the level of care and knowledge of the patient by the
carers. Good GP care cannot be solely in the gift of the GP. The quality of care a GP can administer is
highly dependent upon the quality of staff in the care home itself (Gladman, 2010 p.20)."

Heart failure is a difficult diagnosis to make clinically in an elderly person”? who is able to give a good
history let alone in a patient who lacks communication. There are two possible scenarios to consider
in the case of the deceased.

1. The deceased has pre-existing heart failure due to heart disease that was not picked up by
the doctors through lack of medical care, examination or home visits.

2. The deceased suffered an acute cardiac event after 11.3.2016 or before 11.5.2016 with
sudden deterioration and died.

In scenario 1 the deceased had been visited regularly since his residency at the home in 2010. He has
had multiple medical assessments which in hindsight suggests that he could possibly have been
suffering from heart failure but not clinically picked up. | was only made aware of the cause of death
at the inquest and not had the liberty of reviewing his medical records with that cause of death in
mind.

He was visited on 5.6.2015 complaining of a chesty cough. No change in breathing. No respiratory
distress. HR 76. Few bibasal crackles. Bilateral oedema. ?pneumonitis. clinically well. Treated with
antibiotics. This presentation would be in keeping with heart failure.

Similarly a GP visit on 7.6.2013 when staff were complaining of ‘unsteadiness and liable to fall. Not
sleeping much and moving around’. On examination he had a normal BP (124/80) with few bibasal
crepitations in his chest. Again the chest signs and difficulties sleeping would be compatible with
heart failure.

In scenario 2 you could argue that the deceased had no clear evidence of heart disease prior to
11.3.2016 and some evidence to suggest he did not have heart disease.

The deceased had his BP taken 5 times during his stay at the home.

Date BP Heart rate/Saturation
11.10.2010 136/69 |

25.10.2011 118/68

10.2.2012 116/66

7.6.2013 124/80

9.12.2013 134/63

5.6.2015 HR 76, O2 Sat: 96%

The above findings indicate that he had a very healthy cardiovascular system. He did however have a
chronically low Hb. Last reading 9.9 g/dl on 8.10.2015. Could the anaemia have triggered an acute
cardiac event resulting in heart failure prior to his death? On the evening of 11.5.2016 the Home
staff did seek advice for penile swelling. Could this have been gross pitting oedema extending to the
genitals and sacral oedema as part of congestive heart failure. This finding would have been
established at post mortem. So should the carers not have noted that the deceased legs have
become more swollen and that he is also having difficulties with his breathing?

In 5.1 you have stated that ‘The Care Home Manager confirmed that it could be difficult for medical

assessments to be arranged for residents within the home who are unable to attend the surgery’. |
have been a GP at Lime Tree Surgery since 1998 and have been looking after the residents of Home
since then. | do not recall a single verbal or written comment regarding a GP not visiting a patient at
the home. The surgery has had an exceptionally good relationship with the previous manager
(Lavinia) who had been at the Home since 1998. Whenever she had any concern about a patient and
both the carer and doctor felt that it would be in the best interest of the patient for the doctor to
visit then the doctor would always visit. Our relationship was such that she could ask for advice any
time or fora visit if there had been any change in the condition of the patient. | understand there
have been some changes at the Home recently but there have been no changes in our approach or
in the way we respond to visits. Even in the case of the visit request on 11.3.2016, if a visit was
medically required it would have taken place. Also, the carers should have subsequently expressed
any further concerns that they had regarding the deceased’s health if there had been any material
changes. It is possible that due to internal issues at the Home, there may have been a breakdown of
the normal procedures for documenting and communicating concerns to the doctor regarding a
patient’s health.

In view of the comments made by the manager | will be responding to these concerns as mentioned
earlier.

In 5.2 you have stated that ‘Both the GP and Care Home Manager indicated that regular GP reviews
(perhaps monthly) within the home, by the GP practice would improve the care provided to
residents.’

There is little to no medical evidence to support this view. The literature describes practice models
such as extended service schemes, preferred practice arrangements, multidisciplinary healthcare
teams of care homes and regular GP ‘surgeries’ in care homes. A literature review by Social Care

Institute for Excellence found little robust UK evidence on outcomes from studies comparing these
models to usual GP care (SCIE 2013 p3).’

The level of care provided to Care Home residents is directly proportional to the level of
communication and working relationship between the GP practice and the Care Home.

Positive, close working relationships between care homes and GPs are reported by care home staff,
GPs and relatives to be associated with positive outcomes (SCIE 2013, p45).* These positive
outcomes include higher quality and effectiveness of GP care and also increased confidence in care
home staff making better judgements when referring residents to the GP."

Several authors have discussed the importance of managers and staff decisions about residents
because “they are with them all the time” (SCIE 2013 p69). One author reports that healthcare for
residents will be poor if care home management is poor.’ In discussing poorly managed homes with
not so well trained staff relatives have reported that they, rather than the care staff often notice a
change or deterioration in the resident’s condition and ask for a GP to be called out (SCIE 2013 p71).4
Several studies have highlighted the poor quality of medical care for residents to be directly affected
by poor judgements, skills, low qualifications, high turnover or staff shortages of care home staff
(SCIE 2013 p72)."

| believe the deceased’s case is a very complex one and your conclusions do not reflect what
happened in reality. | also feel your recommendation for regular GP visits although desirable is not
based on any sound evidence.

Following the deceased’s death, the CCG highlighted to us their concerns about the Home as well as
concerns expressed by CQC. They asked the GP to conduct a review of all the residents. Following
these concerns several visits have been conducted by me to review all the residents medical care.
The first medical review was carried out within 72hrs of Mr Hawkins death end the latest one in
November 2016. There were no significant findings or new medical diagnoses following these visits.
Significant procedural shortcomings and lack of care records were noted. Some of these related to
hospital follow-ups, outstanding bloods results and lack of nursing record keeping. These visits were
not directly related to the deceased’s death but as a precaution given the concerns expressed by
other bodies. | did not mention these visits in the inquest as they were not directly relevant to the
death. However, in hindsight given your recommendation perhaps | should have, as no extra clinical
benefit was gained by conducting these.

| therefore believe that your recommendation in paragraph 6 is not appropriate.

In paragraph 4 you have stated that a GP visit should have taken place but did not. During the
inquest | do not recall you saying that the GP should have visited. In hindsight given that the
deceased died of undiagnosed IHD and CCF two months later | agree perhaps the diagnosis may
have been picked up if the GP visited. However, given the reason for the home visit request (weight
loss in a patient with advanced dementia) | do not feel a home visit was warranted on those grounds
and at that time. | agree subsequently there should have been further communication between the
home and the surgery regarding the deceased wellbeing. There was none. This aspect needed
further scrutiny.

In response to paragraph 7, | cannot see any justifiable action other than to strengthen the lines of
communication between the care home staff and the surgery given that you have reported from the
new manager difficulties in obtaining GP visits. The GP is the person who is delivering bits of service
and the care home manager is the facilitator to ensure the client wets what they he Bove identified a they
need (SCIE survey, 2013 p12). | can assure you that there \ . | Dita

~ visits. An in-house Significant Event nt Analysis was conducted on 18.5.2016 following the information

around the deceased’s death. This resulted in an even lower threshold for home visit requests from
this Home given that the information given on the telephone by carers may not reflect the true
health needs of residents.

| do not believe the action you propose is likely to prevent future deaths of this kind. There are other
factors at play here. There may be other measures that can be more effective and | believe the
safeguarding review team have addressed some of those measures. | however, do not have the
power over those measures.

Lime Tree Surgery has a very good reputation for providing high quality medical care for all its
patients including those residing in care homes despite workload pressures. The actions we have
already undertaken confirm and support this. We will continue to consider and implement any new
proposed feasible actions if they can be shown to and are likely to improve patient care.

Please do not hesitate to get in touch shouid you need any further clarification or information.

Yours sincerely,