Olive Daynes

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CARING YOU

Office of the Medical Director

Dr Neill Hepbum, Interim Medical Director (GMC No 2855408)

Email: neil. hepbum@ulh.nhs.uk Tel: 01522 573850

Dr Richard Andrews, Associate Medical Director (GMC No 3172313)

Emall: richard.andrews@ulh.nhs.uk Tel; 01522 573179

Dr Gurdip Samra, Associate Medical Director (GMC No 3180655)

Emall: gurdip.samra@uih.nhs.uk Tel: 01205 445338
Dr Matthew Dolling, Director of Medical Education & Training

SOON -29\0\ 22 MAY 2017
United Lincolnshire Hospitals INHS|

NHS Trust

Trust Headquarters
Lincoln County Hospital
Greetwell Road

Lincoln

LN2 5QY

Tel: 01522 573850
Fax: 01522 573991

Email: Director.Edu N&Train I Tel: 01522573846 PA to Medi :
Email:

12" May 2017

Mr Paul S. Cooper
Acting Senior Coroner for South Lincolnshire

Via email: lincscoroner@lincolnshire.gov.uk

Dear Mr Cooper

| refer to the Regulation 28 Report issue by yourself following the inquest into the death of
Mrs Olive Daynes.

The matter of concern you have raised relate to:

1. Her attendance at the Accident & Emergency Department at Pilgrim Hospital with leg ulcers
resulting in a change to her medication and referral back to her general practitioner.

2. She was seen by a doctor at her GP surgery the following day who was unaware of the
advice provided by the hospital regarding her change in medication and the increased INR
levels (relating to her anticoagulation with Warfarin). 4

3. The hospital did write to the surgery but this letter arrived 5 weeks after she was first seen in
the Accident & Emergency Department.

4. In the intervening period her anticoagulation deteriorated resulting in an INR in excess.of 9
and her passing away on 05/01/2016.

5. In order to prevent similar deaths in the future, the discharge letter is sent by electronic
means to the appropriate GP email address of the appropriate GP surgery.

6. Electronic communication to GPs following the discharge of inpatients is already place and
has been so for some time. The expectation is that electronic discharge letters are sent to the
patients GP within 24 hours of discharge on 95% of occasions. Our compliance with this has
improved from 74% (April 2016) to 83% (March 2017). This is under constant review bya

Task and Finish Group which i te-for ——__—

the electronic communication of deaths in hospital. The aim of this is in order to facilitate time
and communication for the benefit of the relatives, carers and GPs. | anticipate this to be up
and running in the next 6 months.

. at Abo,
Chairman: Dean Fathers ¥y¥e MINDFUL
Chief Executive: Jan Sobieraj (Mr) DAA EMPLOYER

sy oe

7. In 2016 the Trust and the Lincolnshire Local Medical Committee issued a document setting
the standards and principles by which test results should be communicated by secondary
and primary care. | enclose a copy of this document which was sent to all clinicians within
ULHT. This has been circulated again to remind colleagues of their responsibilities.

8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for
Mrs Daynes a Patient Safety Bulletin highlighting this interaction and the need for effective
and timely communication has been circulated across the organization. | attach a copy of
this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments
highlighting the concerns you have raised as well as the need to ensure appropriate and
timely communication.

9. At present electronic communication between the A & E Department and Primary Care is not
available to the Trust. However, we are aware of an impending requirement to move to this.
We are therefore in the process of developing electronic documentation in the A &E
Department which will also enable direct electronic communication of clinical information to
the patients GP. Our ability to progress this is influenced by a range of other actions currently

being rolled out including:

40. Electronic Observation and Charting Trust Wide (approx. 60 Wards), anew electronic
maternity system as well as upgrading our IT software. We are also aiming to introduce
electronic patient records as well as an electronic prescribing; both of which will improve
patient safety. For the immediate future we will remain restricted to conventional

correspondence.

41. Amore detailed root cause analysis of the events surrounding Mrs Daynes is being
undertaken and | would be pleased to share this with you as soon as it is available.

I hope the above provides you with the reassurance you are seeking following the issue of a
Regulation 28 report into the death of Mrs Daynes.

With best wishes

Yours sincerely -

2

Dr Neill Hepburn MBA MD FRCP
Interim Medical Director (GMC 2255408)

Enes

cc: Jan Sobieraj— Chief Executive
Michelle Rhodes — Director of Nursing
Dr Koshy Jacob — Clinical Director, Integrated Medicine (Pilgrim)
Dr Ravindranath Sant — Consultant in A&E (Pilgrim)
Dr Megan Kelly — Consultant in A&E (Lincoln)
Dr Furat Murrani— Consultant in A&E (Grantham)

Rs Noy,
9 /s MINDFUL
© EMPLOYER

POS,

Chairman: Dean Fathers
Chief Executive: Jan Sobieraj (Mr) DAS

Lincolnshire United Lincolnshire Hospitals [\77Ey

NHS Trust

ical Committee Ltd

Regresesioz

Dear Colleague,

In March 2016 NHS England, the Academy of Royal Colleges, and the BMA produced “Standards for
the communication of patient diagnostic test results on discharge from hospital"'2**, This document
sets out the standards and principles by which test results should be communicated between
secondary and primary care. This document, and previous discussions between GPs and hospital
clinicians, has prompted United Lincolnshire Hospitals Trust (ULHT) and the Lincolnshire Local
Medical Committee (LMC) to develop local policies and principles for the delegation of workload from
secondary to primary care.

ULHT and the LMC have agreed-

1)

2)

3)

4)

5)

The underlying principle for this policy is that either the clinician requesting an investigation or
the consultant whose care the patient is under, should be responsible ultimately for ensuring
that the test is acted upon when needed. It is not the role or responsibility of primary care
practitioners to follow up the results of outstanding investigations. As a corollary it would be
equally inappropriate to expect hospital clinicians to review test results requested by GPs.

Every test result received by a Clinician for a patient should be reviewed and where
necessary acted on by a responsible clinician even if this clinician did not order the test. As to
not do so could lead to patient harm.

Primary care teams should have a system to ensure that any discharge information they
receive is seen and acted on in a timely manner by a Clinician able to understand the
importance of the information and able to take responsibility for taking appropriate action.

If a patient needs on-going investigation(s), and will remain under follow up by a hospital
clinician:

a. The hospital clinician should arrange for the appropriate investigation(s) and follow up
the results and the patient should be informed that this is the case.

b. Ifa blood test is required, phlebotomy may be performed at the general practice, and
the request form should be generated by the hospital clinician.

c. If other investigations are required such as radiology, ECG, echocardiogram etc, the
request should be made and sent by the hospital clinician.

If it is felt further investigation(s) are warranted but the patient will not remain under follow up
by the hospital clinician:

a. _ the hospital clinician should depending on the clinical condition:

i. request that the general practice reviews the patient to identify what further
action is required or

ii, make a suggestion to primary care as to the course of action the hospital
clinicians feels is appropriate. In this circumstance the hospital clinician
should explain in writing their rationale for this.

b. Ultimately, it is the responsibility of the general practice clinician to decide with the
patient what further tests are required, to arrange these, and to follow up the results.

6) When a patient has a serious condition which requires urgent referral for investigations,
treatment and management, a consultant to consultant referral should be made without delay.

7) When a patient has a condition which the specialist is not qualified to treat within their own
specialty, for instance, an orthopaedic specialist does not perform shoulder surgery which the
patient requires, a consultant to consultant referral should be made directly.

8) When a secondary care clinician sees a patient who has a non-urgent condition, which is
beyond the expertise of their own specialty and requires further assessment, the hospital
clinician should refer the patient back to the patient's own general practitioner for review. For
instance, an orthopaedic consultant, seeing a patient with psoriasis, may suggest that the GP
refer the patient to a dermatologist. However, the general practitioner is able to treat
psoriasis without the need for a dermatology review. Thus, it would be appropriate for the
consultant to ask the general practitioner to discuss the problem with the patient, so that the
appropriate treatment or referral can be made.

We hope the above will provide some clarity over responsibilities by primary and secondary care
clinicians for the safe transfer of information about diagnostic results and tests. The above agreed
between by ULHT and the LMC should be adopted by primary and secondary care clinicians of all
grades. We envisage continual whole-system learning and improvement and welcome constructive
suggestions to this effect, to improve safer patient care

We thank you for your co-operation

Yours sincerely

SEG 2.

~~

Dr S Kapadia Dr K Sharrock
Medical Director ULHT Medical Director Lincolnshire LMC

NHS England Patient Safety Domain, 10 March 2016: Standards for the communication of patient
diagnostic test results on discharge from hospital :

& https://www.england.nhs.uk/patientsafetyhwp-content/uploads/sites/32/2016/03/discharge-standards-

march-16.pdf

. htto://www.bma.org.uk/support-at-work/gp-practices/service-provision/duty-of-care-to-patients-
regarding-test-results