Derrick Brocklehurst

229 | 2014

NHS

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Tameside General Hospital
Fountain Street
Ashton-Under-Lyne

Ms Alison Mutch
HM Senior Coroner for Manchester South
The Coroner's Court

Tameside
1 Mount Tabor OL6 SRW
Stockport
SK1 3AG Telephone: 0161 331 6000
18 July 2017

Dear Ms Mutch

Regulation 28: Report to Prevent Future Deaths following the inquest touching upon the death
of Derrick Lawrence BROCKLEHURST

| write further to your letter dated 5 June 2017 enclosing a Regulation 28 Report issued at the
conclusion of the inquest touching upon the death of Derrick Lawrence BROCKLEHURST, which took
place on 17 May 2017.

| hope to be able to address your concerns, as set out in Section 5 of the Regulation 28 Report, and
adopt the same numbering for ease of reference.

2. No discharge summary was provided by Tameside General Hospital to the GP after the deceased
was seen in A and E.

The Trust is aware of a historic issue with regard to the timely completion of discharge summaries in
2016 and | wish to assure you that action has already been taken, and progress made, in order to
improve the situation in relation to both the Emergency Department and the in-patient wards, and
bring the expected completion rates and timescales within those dictated by Trust policy. | am sorry if
the action which the Trust has taken to date was not clearly available to you during the course of the
inquest and you could not be reassured that the Trust had fully identified the issues and put a robust
plan in place to improve the situation.

In order to bring the position back to a baseline from which the Trust could confidently move forwards
with new processes, extra resource was brought in to clear a backlog that had developed with
discharge summaries. | wish to assure you that the Trust fully recognises the importance of discharge
summaries as a handover of care between different organisations and services involved in the care of
a patient. | was disappointed to learn that a backlog had developed due to other organizational
pressures and asked my executive team to take immediate steps to identify the source of the problem
and remedy it as swiftly as possible.

MEE Divisional Director of Operations for Adult Medicine has been tasked with leading on
this issue, with support from a Medical Director. The responsibility to ensure that every
patient has a discharge summary rests with the consultant responsible for that episode of care and
this has been reiterated to alt consultants. Compliance is being monitored by the Trust's Service
Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate
Managers are providing leadership on this issue to ensure that improvements are made.

| am advised that a new process is to be put in place for the discharge of patients from the
Emergency Department. The Trust is planning to introduce new bespoke software to enable the
production of an electronic casualty card, to replace the current handwritten casualty cards produced
by the doctors and nurses in the Emergency Department. The key data from the electronic casualty
card will be used to create a discharge summary which will be electronically sent
to the patient's GP practice. It is anticipated that this will ensure that a discharge
summary is completed for every patient seen within the Emergency Department

E323 disability without unduly increasing the burden on the doctors,
(az ee Chief Executive ~ karen Jamas @
EMPLOYER a Aer ain Ww in| (3)

Everyone
Matters ff rd

Tameside and Glossop

Integrated Care
NHS Foundation Trust

As you will no doubt appreciate, this is a significant piece of work which will revolutionise the way in
which the Emergency Department operates. The bespoke software is currently being written and the
Trust plans to begin the roll out of the new electronic casualty card from October 2017.

The new electronic casualty card system will include a dashboard clearly identifying each and every
patient that has been discharged from the Emergency Department but has not yet had a discharge
summary completed, allowing the management team to effectively scrutinise compliance. The new
process will also allow the Trust to monitor the arrangement of follow up investigations commissioned
at the point of discharge from the Emergency Department which will further improve patient safety.

Although not directly relevant in the context of this Regulation 28 Report, | would like to advise you
that the Trust has also introduced measures to improve the situation in terms of discharge summaries
from in-patient wards. As mentioned above, additional resource was brought in to bring the position
back to an acceptable baseline. The Trust has also introduced increased managerial focus and
monitoring of discharge summaries, with a ‘safety net' email sent out to each ward identifying the
number of discharge summaries outstanding for more than 48 hours, which is the timescale required
by the Trust's Admission and Discharge Policy. The performance of each ward is monitored by the
consultants responsible for the ward, the Clinical Directors and the Directorate Managers to ensure
that the right level of resource is available to prevent a backlog before it occurs.

| am advised that all completed discharge summaries originating from both the Emergency
Department and the in-patient wards are sent to the patient's GP practice electronically using the Hub
System and Synertec. The current process is that a discharge summary is created in the Trust's
Electronic Patient Record (Lorenzo), this is completed by the doctor and finalised by the ward clerk
before being sent electronically to the relevant GP practice overnight who are required to
acknowledge and receive the discharge summary. A paper copy of the discharge summary will also
be provided to the patient in certain circumstances, for example if the patient is being transferred to
another Trust, the Stamford Unit (a discharge to assess unit based on the grounds of Tameside
General Hospital), a nursing, care or residential home facility, or if requested by the patient.

In addition to the completion of discharge summaries, the Trust also monitors the quality of discharge
summaries. Regular audits of approximately 40 discharge summaries per month are carried out by
the Trust's Chief Clinical Information Officer. The quality of the discharge summary is graded as
excellent, good, poor or very poor, with 93% per month deemed as excellent or good between
January and June 2017 inclusive. The Trust has received 9 incidents related to discharge summary
quality from approximately 37,000 discharge summaries; an incidence rate of less than 0.03%.

Whilst | understand that the following area of concern was directed at Tameside Metropolitan Borough
Council, this issue is relevant to the Trust as a provider of community services and | wanted to take
the opportunity to address you on the Trust's work in this area.

1. There was no documentation available of the carer visits. The care provided and any issues with
the provision of care could not be established. They were not recovered by Social Services when
care stopped. There was no system for recovery of care notes when care ceased.

In addition, the Trust is aware that you have previously issued a Regulation 28 Report to Stockport
NHS Foundation Trust in relation to the retention of a central contemporaneous set of notes by the
District Nursing Service and retrieval of those notes following the death of a patient. The Trust is very
keen to adopt a proactive approach and demonstrate leaming from issues which

arise not only in relation to the care of its patients, but also learning from the & \
wider health economy, and other organisations. &/

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Gi confident Chief Executive - Karen James Ei Ww in| (0) aners
EMPLOYER Chalrman = Paul Connellan

Tameside and Glossop

Integrated Care
NHS Foundation Trust

The Trust's District Nursing Service, which covers the Tameside and Glossop locality, has recently
amended the process in relation to note keeping and strengthened the process for retrieval of notes.

| am advised that the old process was very similar to that adopted by Stockport NHS Foundation Trust
in that carbonated evaluation sheets were used to record findings during a home visit.

However, the Trust identified that this represented a concern in that the central set of notes may not
be fully up to date and important information about a previous visit may not be available to the district
nurses at base. It was considered essential to have a central contemporaneous set of notes,
particularly for complex cases where a patient's care needs may be constantly evolving, in view of the
fact that the district nurses work as a team and are not allocated specific patients due to shift patterns
and fluctuating visit requirements. A comprehensive handover of care between staff is imperative to
ensure a consistent and holistic approach to the care of each individual patient in this setting.

The new process requires a separate carbonated evaluation sheet to be completed for each and
every visit (excluding those for routine insulin or low molecular weight injections) and brought back to
base immediately thereafter so that it can be filed in the central notes. A standard operating
Procedure has been produced and disseminated to all staff within the District Nursing Service setting
out the new process and compliance will be monitored by the Team Leaders.

| am advised that the District Nursing Service also use "Team Time” for the handover of important
information between staff. Team Time takes place each day and is used as a mechanism for staff to
highlight any problems or issues that they encountered during the morning. It is also an opportunity
for the Team Leader, who is responsible for leading Team Time, to understand the workload of the
team and to reorganise the workload if necessary

A record of the handover provided during “Team Time" is documented, signed by the Team Leader
and retained centrally at base but not placed in an individual patient's notes as this could contain
confidential information in relation to another patient. If follow-up tasks are allocated during Team
Time, such as increasing the frequency of visits or making a referral to another service, these remain
the responsibility of the district nurse that attended on the patient on the last occasion, unless
specifically re-allocated to another member of staff.

| am very sorry that you had cause to issue this Regulation 28 Report 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 in relation to discharge arrangements. | understand that a meeting has been
arranged for 30 August 2017 with the Trust's Medical Director, — and Director of Quality
& Governance, John Fletcher at which these issues can be further discussed, if required.

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

Yours sincerely

Kafen James
Chief Executive

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Ba confident Chief Executive = Karen James Ei wW Hin Gh}
EMPLOYER Chairman = Paul Connellan

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Deceased: Derrick Lawrence BROCKLEHURST

Date of death: 2 December 2016

Your ref: 5967/HC

BACKGROUND

1. On 6 June 2017, the Chief Executive of Tameside Metropolitan Borough Council received a

report from Alison Mutch, OBE, Senior Coroner for the coroner area of South Manchester.
The report was made under paragraph 7, Schedule 5 of Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

The report was made following the conclusion on 17 May 2017 of an investigation and
inquest into the death of Derrick Brocklehurst (dob 23/07/1930, dod 02/12/2016).

A matter of concern identified by the Coroner and directed to the Chief Executive of
Tameside Metropolitan Borough Council was as follows;

There was no documentation available of the carer visits. The care
provided and any issues with the provision of care could not be established.
They were not recovered by Social Services when care stopped. There was
no system for recovery of care notes when care ceased.

RESPONSE OF TAMESIDE METROPOLITAN BOROUGH COUNCIL

Care Record Book

In circumstances where Tameside MBC (‘the Council’) is required to meet the needs for
care and support of an adult in its area, one of the ways it can do so is by providing
domiciliary care at the home of the adult or “service user’. To do this the Council contracts
with independent providers who are registered with and regulated by the Care Quality
Commission as a ‘homecare agency’.

The service user's care needs are assessed by a social worker or an assessor and this
assessment is recorded on the Council's electronic care management system, IAS.

The social worker or assessor, following consultation with the service user, any family
members or carers for the service user and any other relevant persons such as Moving and
Handling Officers would then prepare a support plan detailing the type and nature of the
care to be provided.

Once this support plan is authorised it, together with any other relevant information, is sent
to an independent care provider commissioned by the Council to provide the care to the
service user. Having regard to this information the provider carries out and records
assessments of the service user's mobility, risk of falls, nutrition, skin integrity,
environmental risks and other such matters. This information enables the provider to
formulate the actual care to be provided to the service user in their home.

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014 requires the provider to

maintain securely an accurate, complete and contemporaneous record in
respect of each service user, including a record of the care and treatment
provided to the service user and of decisions taken in relation to the care
and treatment provided

11.

12.

13.

14.

15.

The “Helping People To Live At Home Service And Extra Care Support Service” contract
between the Council and each care provider states at part 7.2.12

“The Provider will ensure a care record book is introduced within the
individual Service Users’ homes. The Provider will be responsible for
ensuring the information within the care record book (including information
provided by the Commissioner and/or CCG in relation to Complex Care) is
kept safe, is up to date and appropriate records are maintained by its staff’

A provider does this by completing the ‘care record book’ which includes relevant
documentation such as the care plan, the above mentioned assessments with reviews and
updates, Medication Administration Records (MAR), weekly meals records, food and fluid
charts, weight charts, and any other relevant information. Daily ‘running sheets’ would
record the day to day visits of carers, the tasks completed and any issues such as a refusal
of the service user to take medication. The care record book will contain sufficient
information to allow a carer to visit the service user and provide the necessary support that
the service user has been assessed for. Records are required to be thorough and
document any concerns or safeguarding issues that the carer may have. The care agency
is required to notify the Council of any such concerns or issues.

Monitoring by the Council of the Care Provided to Service Users

The Council has a contractual right to request sight of all information within the care record
book. Part 11.5.3 of the Helping People To Live At Home Service And Extra Care Support
Service” contract states a provider must

“comply with all reasonable requests relating to the performance of any
aspect of the Services, including those areas that demonstrate the
Provider's ability to ensure this Agreement is complied with, such
information to be returned to the Commissioner (or the CCG in relation to
Complex Care) within 14 calendar days of the request”

The social worker for the service user completes a reassessment of the need of the
service user six weeks after the commencement date of care being provided. This is to
ensure that the care and support is appropriate and meeting the assessed needs.
Subsequent reassessments are carried out depending on the complexity of the case. An
annual review is also undertaken by the social worker. In carrying out any reassessments
or reviews the social worker will consider the care record book to establish that the required
care is being provided and to identify whether there are any issues with this care.

In addition to this monitoring of the individual service user, the Commissioning Team
undertakes monitoring of the provider by way of a minimum of two validation visits every
year and two contract performance visits per year. The validation visits focus on the
provider's recruitment and selection policies and procedures, and the training of
employees. In addition a number of service user files are randomly sampled to ensure they
have the appropriate information contained within.

The contract performance visits look at any issues raised from the validation visits, as well
as focussing on other issues such as complaints, matters raised by the provider or social
workers, safeguarding investigation outcomes and the steps that have been recommended
following a safeguarding investigation. Additional unannounced visits can also be
implemented should it be deemed necessary following a complaints or concern.

If the Council had concerns that records were not being completed or that a support plan
was not being followed the Council's Adult Services would in the first instance investigate
following which the care agency would be advised of the steps required and the time for
compliance. A recommendation may also be made that care agency staff be provided

16.

17.

18.

19.

20.

21.

training. Adult Services would work closely with the Commissioning Team and
performance would be closely monitored.

The purpose of monitoring following concerns regarding record keeping would be to
encourage providers to improve performance to an acceptable level. The Council will
support providers to do this. Should the Council continue to have concerns with a
provider's ability to maintain accurate records it can take further action such as issuing a
contract default notice and, ultimately, terminating the contract. A default notices could be
issued in circumstances where there has been persistent breaches or for a more serious
breach (normally identified via safeguarding) that has put a service user at serious risk.

System for Recovery of Care Records

When the care provided to a service user is to be stopped the Council will notify the
provider of this. The reason for ceasing care and support are varied but typically would be
because the service user has died, moved to residential or nursing care or been in hospital
for a period of time exceeding 3 weeks. Users and their families can also decide to stop
receiving care and make other arrangements themselves. Once the care is stopped the
provider is notified by the Council's Home Care Commissioning Team and the provider is
then required to recover and archive the care records that have been maintained in the
user’s home. The Care Quality Commission requires a provider to store this information for
7 years from the last date of entry on the records. Each provider has its own procedures
for recovery and retention of records. In preparing this report inquiries were made of the
provider which last provided care to Mr Derrick Brocklehurst. That provider advised that its
procedure is for the last care worker to visit the service user to recover the care book and
other records. These records will then be returned to the provider and placed in a
numbered box which is then sent to a central archive depot. The local office of the provider
maintains a register of archived boxes so that records can be retrieved if necessary.

There will be circumstances where the Council and the provider receive no prior notification
of care ending (such as when a service user is admitted without notice to hospital and
subsequently dies). In such circumstances the provider will be notified by the Home Care
Commissioning Team that care has ended. The provider must take steps to try and
recover the care record book. The provider will rely on the cooperation of whoever may still
be residing at the service user's home, such as family members and others, to recover the
care records. However if cooperation is not forthcoming the provider cannot enter the
property to recover the records knowing that the service user isn’t present and that the
contract to provide care has ended.

In these situations the provider may not be able to recover the care record book. This will
not mean that the provider has no records whatsoever. The provider is required to keep
copies of the care plans and assessments which were carried out. In addition the provider
is required at regular intervals to obtain copies of other documents such as the MAR,
weekly meal records, daily running sheets and all other documents which are updated by
carers on their visits to the service user. However it will mean that on occasions the
provider will not be able to recover these updated records for the period from when copies
were last taken to the period when care ended without prior notification.

Records relating to Derrick Brocklehurst

The Council accepts that the records detailing the care provided to Mr Brocklehurst for the
period 31 October 2016 to 17 November 2016 when care ended had not been recovered by
the provider and were unavailable for the Coroner conducting the inquest.

From 31 October 2016 the provider of care to Mr Brocklehurst had changed following the
Council terminating its contract with the previous provider. The provider had not in that

22.

23.

24.

25.

relatively short time made copies of the documents recording the daily care given in that
period.

On 10 November 2016 the new provider contacted the Council with concerns that Mr
Brocklehurst wanted to terminate his care. A Council Officer together with a manager
employed by the provider visited Mr Brocklehurst on 16 November 2016 when he and his
wife indicated that they wished for care to end. It is clear from the Council's own
reassessment document, updated by the Council Officer on 17 November 2016, the care
record book was being updated. She records that she “looked at the care record book and
minimal tasks are being provided. Derrick does not like the carers supporting with his
personal care and prefers his wife to undertake this”

The provider last visited Mr Brocklehurst on 21 November 2016 following which his care
was ended in accordance with his wishes. The provider was formally notified of this on the
22 November 2017.

It is accepted at this point the provider should have made arrangements to recover the care
record book. This was not done. On 28 November Mr Brocklehurst was admitted to
hospital where he remained until his death on 2" December. Again it is accepted that the
provider did not make any arrangements following Mr Brocklehurst's death to recover and
consequently had no record of the care it had provided since taking over the contract on 31
October 2016.

Efforts were made by the Council in advance of the Inquest to recover the Care Book from
However it appeared that the care book had been discarded by
in February 2017 during a ‘de-cluttering’ of the property she had shared with
her husband.

CONCLUSION

26.

27.

The Council regrets that no documents relating to the care visits were available to the
Coroner. However the Council believes that this was an isolated incident rather than an
example of a systemic failing and it is only very rarely that a care provider is unable to
provide to the Council when requested the actual care record book from a service user's
property.

Care Providers are under both a regulatory and contractual obligation to maintain accurate
and up to date records of the care provided to a service user. Enquiries with the provider
responsible for Mr Brocklehurst’s care have established that the provider was aware of
these responsibilities and also had a procedure for the recovery and archiving of care
record books following the termination of care. However to minimise the risk of a provider
failing to recover a care book following the termination of care the Council has taken or
proposes to take the following steps:

a. The agenda for a Provider Forum, due to take place on 25 July 2017, included an
item relating to Care Record Books. Unfortunately this forum was postponed. The
item will be included on the agenda for the next Provider Forum at which providers
will be reminded of their obligations and in particular the obligation to;

i. maintain accurate records;

ii. regularly obtain copies of documentation contained in the Care Record
Books which is updated on a daily/weekly basis such as, but not limited to,
daily running sheets, MAR, weekly meals records, food and fluid charts,
weight charts, and any other relevant information;

iii. make adequate arrangements to recover Care Record Books when notified
that care is to be or has been ended;

iv. record the reason for failing to recover a Care Record Book;

v. archive the Care Record Book and any other records for a period of 7 years
from the last date care was provided.

b. Following the Provider Forum the above points will be confirmed in writing to all

c.

providers;

With immediate effect on a weekly basis the Homecare Commissioning Team will
run a report detailing which service users have ceased to receive care. The
relevant provider will be sent a copy of this report with a request for confirmation
that the care record book has been recovered from the service user. Where the
provider states records cannot be recovered the provider must notify the Council,
detail the attempts that have been made to recover the records and give reasons for
not being able to do so;

Where a provider has been unable to recover a care record book the matter will be
raised and discussed with the provider at a contracts performance meeting. If
necessary and appropriate to do so the Council will require the provider to take
steps and measures to address the failure to recover record book.

28. The Council trusts that these actions and proposals are sufficient to satisfy that Coroner
that the Council does take this issue seriously, that there is a system in place for the
recovery of care record books and that care providers will be advised of their record
keeping obligations. This in turn will minimise the risk of care record books not being
available at future Investigations and Inquests.

Yours sincerely,

Steven Pleasant MBE
Chief Executive of Tameside Metropolitan Borough Council &
Accountable Offcer for the Tameside & Glossop CCG

Dated 27 July 2017