Percy Jacks

CareQuality . _
Commission cues Commission

Gallowgate
Newcastle upon Tyne
NE1 4PA

Telephone: 03000 616161
Mr A R Barkley Fax: 03000 616171

HM Senior Coroner for South Wales Central Area
Rock Grounds

First Floor

Aberdare

CF44 7AE

4 October 2017

Your Ref: ARB/SLR/997 1
Dear Mr Barkley,
Re: Touching upon the death of the late Percy JACKS

| am writing to inform you of the actions we have taken to date in relation to the
sad death of Mr Jacks and the subsequent steps we are proposing.

Prior to your Regulation 28 Report dated 27 July 2017, we had no knowledge of
Mr Jacks’ death. As the regulator for health and social care in England we would
expect services registered with CQC to notify us of a death happening during the
course or as a result of care and treatment activities coring within the scope of
our regulations being carried out. However, as Mr Jacks was resident in a care
home in Wales at the time of his death, any notification of death would be
required to go to CSSIW as the regulator for care homes in Wales.

On receiving your Regulation 28 report we contacted the two providers involved
in the delivery of Mr Jacks’ care in treatment which are registered with the Care
Quality Commission, namely Pencombe Hall care home and Cantilupe Surgery in
Herefordshire.

Pencombe Hall is a residential care home in Herefordshire, registered to provide
accommodation for persons who require nursing or personal care for up to 32
people. There are conditions placed on the provider's registration with CQC that
the home must have a registered manager and must not provide nursing care.
The home is compliant with these conditions. The last comprehensive inspection
was completed on 23 May 2016 at which time the home was fully compliant and
rated as ‘Good’ in all the key questions we inspected against. We do not have

any current concerns about the quality or safety of care at this location. The next
scheduled inspection for this service is June 2018.

Cantilupe Surgery in Herefordshire is a GP partnership providing primary medical
services to approximately 11,100 patients in an area to the east of the city of
Hereford. There is a condition placed on the provider's registration with CQC that
the practice must have a registered manager. The practice is compliant with this
condition. The last comprehensive inspection was completed on 15 October 2014
at which time the practice was fully compliant and rated as ‘Good’ in all the key
questions we inspected against. We do not have any current concerns about the
quality or safety of care and treatment at this location. The next scheduled
inspection for this service is February 2018.

We have investigated the actions taken by both services whilst they were
responsible for providing care to Mr Jacks. The information provided to us by
both the care home and the GP practice has assured us that they acted
appropriately and in accordance with current regulations and national guidance in
providing care and treatment for Mr Jacks. Accordingly we do not consider that
persons using either of these services regulated by CQC are at current risk.

HM Senior Coroner's Concerns

We note the specific concerns held by HM Senior Coroner arising from the
inquest touching on the sad death of Mr Jacks and raised in the Regulation 28
report. We propose to respond to each of them in turn for ease of reference.

1. The investigation revealed that the system for the Bronglais Hospital
contacting the GP was poor. The result of the DVT scan which took place
on 06 February was sent to the incorrect GP surgery and despite an
investigation as to why that happened no satisfactory explanation could be
found.

Mr Jacks lived at Pencombe Hall from 18 January 2017 to 2 February 2017,
where he was receiving respite care. He was seen at Cantilupe Surgery on 1
February 2017 and was due to move to a care home in Wales the following day.
As a result of this GP consultation, Mr Jacks was diagnosed with suspected deep
vein thrombosis, prescribed a course of rivaroxaban, and given a letter to pass
on to his next GP outlining the diagnosis and prescription and requesting that the
next GP arrange an ultrasound scan locally. We view this as an appropriate
course of action by the practice in the circumstances, as it did not know which
GP practice Mr Jacks was going to register with next.

Mr Jacks’ family gave the rivaroxaban tablets to Pencombe Hall, and signed
Medication Administration records confirm that he took the tablets for the evening
dose on 1 February 2017 and the morning dose of 2 February 2017, prior to him
moving out of the home. The records confirm that he was discharged with all his
medicines.

A scan of the discharge summary submitted to us by Cantilupe Surgery
demonstrates that an ultrasound scan took place on 6 February 2017 at
Bronglais General Hospital in Aberystwyth. This hospital is not regulated by
CQC. This discharge summary, which shows a positive identification of DVT in
Mr Jacks’ left leg was sent in error to Cantilupe Surgery and should have instead
been sent to the GP practice in Wales that arranged for the scan to take place.

When patients move between GP practices in England, practices are able to
forward their notes electronically, provided they have signed up to this service.
When the new practice is not signed up to this system, as in the case when
patients move from England to Wales, this facility is not available and in such
cases the only remaining option is to send hard copies of patients’ notes via a
secure courier system. In England, this role has been contracted out to the
company Capita, who will collect the patient's notes from the outgoing practice
and, once the incoming practice has been identified, will deliver the notes to their
correct destination. This is dependent on the patient registering with a new
practice, at which point the new practice will apply to Capita to have the patients’
notes delivered.

Cantilupe Surgery has informed CQC that hard copies of Mr Jacks’ notes, along
with the scan results which were sent in error to the surgery by Bronglais General
Hospital were collected by Capita on 10 February 2017. While Cantilupe Surgery
did not contact the Bronglais Hospital to inform them of the error, they considered
that the action of including the scan results along with Mr Jacks’ patient records
were sufficient to ensure the information would reach the new practice promptly.
The practice have informed us that in the event of a repetition of this kind of error
they would inform the hospital in the light of Mr Jacks’ case. We do not consider
that there is cause for additional input from CQC here.

Through this process of transferring hard copies of patients’ notes, the outgoing
GP does not know who the incoming GP is unless the new GP practice contacts
the previous practice directly. Although there is no regulatory requirement for
practices to do this, we would consider this to be good practice. Cantilupe
Surgery has informed us that it was not contacted by Mr Jacks’ new practice at
any time.

Information provided by HM Senior Coroner's office indicates that Mr Jacks was
registered with two further GP practices following his departure from Cantilupe
Surgery, namely Rhayader Group Practice and Arwystli Medical Practice. Neither
of these practices is regulated by CQC.

CQC does not provide specific guidance in relation to the passing of information
between hospitals, GP practices and care homes, although in order to comply
with the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014, service providers registered with CQC must ensure that the medicines that
are necessary to meet peopile’s needs are available when they are transferred
between services.

We consider that Cantilupe Surgery took appropriate action to ensure that Mr
Jacks continued to receive safe and effective care and treatment once he left the
practice's patient register.

During CQC inspections of GP practices, where we consider the effectiveness of
the provider, we do examine how information is shared when patients move
between services, One of our Key Lines of Enquiry which we follow during
inspections is ‘ Do staff have all the information they need to deliver effective
care and treatment to people who use services?’ This question is supported by a
specific prompt for inspectors: ‘When people move between teams and services,
including at referral and transition, is all the information needed for their ongoing
care shared appropriately, in a timely way and in line with relevant protocols?
How well do the systems that manage information about people who use
services support staff to deliver effective care and treatment? (This includes
coordination between different electronic and paper-based systems and
appropriate access for staff to records.)' This area was covered through our key
Lines of Enquiry when we inspected Cantilupe Surgery in 2014 and we found that
the practice had systems in place to provide staff with the information they
needed.

We have revised and improved the wording of our Key Lines of Enquiry and from
November 2017 inspectors will be considering the following two specific
questions when they are reviewing the safety of a practice, instead of one being
a prompt supporting the other: ‘When people move between teams, services and
organisations (which may include at referral, discharge, transfer and transition), is
all the information needed for their ongoing care shared appropriately, in a timely
way and in line with relevant protocols?’ and ‘How weil do the systems that
manage information about people who use services support staff, carers and
partner agencies to deliver safe care and treatment? (This includes coordination
between different electronic and paper-based systems and appropriate access
for staff to records.)‘

This will make it clearer for providers how they can meet this Line of Enquiry and
will also allow CQC to monitor more effectively the systems that providers are
using to transfer information.

2. The system within the GP surgery for prescribing rivaroxaban was poor
and relied solely on receiving the notification of the results of the scan
from the hospital. There was no facility to review the medication to ensure
that the correct dosage for the correct period of time continued to be
prescribed.

We expect GP practices registered with CQC to have arrangements in place to
keep patients on high risk medicines under review to ensure they continue to
receive the correct amount of medicine for the correct time period.

Following our review of the information made available to us by Pencombe Hall
and Cantilupe Surgery, we are satisfied that any failure to prescribe a continuing
supply of rivaroxaban for Mr Jacks did not occur at either of these two services.
At the point of leaving Cantilupe surgery, Mr Jacks had been prescribed a
sufficient amount of this medicine to last for 28 days, and so we conclude that the
breakdown in the prescribing system occurred within the GP practices and care
homes that Mr Jacks went to after he had been seen at Cantilupe and had left
Pencombe Hall. As outlined in the Regulation 28 Report, Mr Jacks’ last recorded
dose of rivaroxaban took place on 12 March. This is some 12 days after his initial
prescription from Cantilupe would have run out had it been administered
consistently, and 38 days after he had left Pencombe Hall.

3. The evidence revealed a view from one of the hospital doctors to the
effect that DVT management should be undertaken within the hospital
setting rather than by the GPs to ensure that a comprehensive and failsafe
system operated rather than the somewhat haphazard one revealed by the
evidence.

The management of DVT within a primary care setting is accepted practice. For
this to take place safely we would expect to see a D-Dimer blood test carried out,
followed by an ultrasound scan. Once DVT has been confirmed we would expect
the practice to liaise with the local secondary care provider to agree that ongoing
management within a primary care setting would be appropriate.

We are satisfied that the part played by Cantilupe Surgery in carrying out a
consultation, arranging a D-Dimer test, prescribing rivaroxaban, providing
information for the next GP practice and requesting an ultrasound scan be
carried out by the successor GP was appropriate.

4. The evidence further revealed a practice of sending details of the
medication and clinical plan back with the driver of the patient who had
taken the patient back from hospital to the care home.

In cases of a patient travelling from a care home to a hospital and back we would
usually expect to see a member of staff with knowledge of the patient
accompanying them, or possibly a family member, along with an information
sheet detailing the medicines that the patient was taking at the time and any
other relevant information for the hospital staff. We would also take into account
the mental capacity of the patient and the particular wishes of that person to be
accompanied or otherwise. In the event of a member of staff or family member
not being available to accompany the patient, we would expect to see that this

risk had been assessed and mitigated. We would also expect to see an audit trail
of communication between the hospital and care home.

5. Overall the evidence revealed a very fragile system of communication
between GP hospital and care home in circumstances in which the
deceased had moved between three care homes in a short period of time.

As a result of the concerns being brought to our attention we have taken the
opportunity to review how CQC checks that information about patients being
transferred between services happens in a timely manner and whether there is
any more we as a regulator can do to prevent an incident such as this from
happening in future.

This has involved input from our Head of Primary Care and Community Services
Policy, from our Medicines Optimisation team as well as specialised clinical input
from our senior national GP advisor. We consider that our current inspection
methodology covers the elements of care relevant to Mr Jacks’ case. We feel that
this is a very sad but also highly unusual event, but as a result of our analysis we
are satisfied that no additional policy change from CQC is required at this point.

Yours sincerely,

Head of inspection-GP
Care Quality Commission
Citygate

Gallowgate

Newcastle Upon Tyne
NE1 4PA

RHAYADER GROUP PRACTIC

THE SURGERY
CAEHERBERT LANE
RHAYADER
POWYS, LD6 SED
TEL: 01597 810231
Fax 01597 811080

16 September 2017

Mr Andrew Barkley
HM Senior Coroner
Rock Grounds

First Floor
Aberdare

CF44 7AE

Dear Mr Barkley
Thank you for the Regulation 28 Report relating to the death of Mr Percy Jacks.
We have discussed this in our practice meeting and have made the following changes.

e Allreferrals for suspected DVT are recorded by the Administrative Team at the
practice and followed up 48 hours later to ensure the results have been received

e Patients are referred to Hereford Hospital or Bronglais Hospital, Aberystwyth,
pathways attached.

e Patients with a positive DVT are informed they have been prescribed a 3 month
course of Rivaroxiban by the administrative team at the practice. (Patients
attending Bronglais are dealt with in the A&E department)

e New patients registering at Nursing/Care Homes their medical records are fast
tracked by the Secretary to the practice to ensure the Dr has all past medical
history as soon as possible.

The practice will audit the above process in 6 months time.

Y inceyely

RECEIVEL
19 SEP Zui/

d ) C cet gat | Gwirio bod pobl yng Nghymru
Cymru | yn derbyn gofal da
°
teal Checking people in Wales are
Wales receiving good care

Mr Andrew Barkley Direct Line:
Senior Coroner for South Wales Central Area Bor :
Rock Grounds mul

First Floor
Aberdare
CF44 7AE

Eich cyf / Your ref
Ein cyf / Our ref

3rd August 2017

Dear Mr Barkley
RE: Touching upon the death of the late Percy Jacks

Healthcare Inspectorate Wales (HIV) has received a copy the Regulation 28 Report dated
27 July 2017 further to the Inquest touching upon the death of the late Percy Jacks. The
report was shared with HIW by the Care and Social Services Inspectorate Wales (CSSIW)
as the matters raised by the report relate to concerns about both health and social care.

HIW has noted the findings of the inquest and assure you that this information will be used
to inform our work. HIW is currently undertaking a review of discharge arrangements
focusing on communication and the quality of documentation used to support patient
discharge from secondary to primary healthcare. | can confirm that this report has been
shared with the review lead to consider.

As you may be aware, HiW has an annual programme of inspections of GP practices, and
as such it would be heipful if you are able to share details about the GP surgery in
question so that this report can inform our planning process.

| note the concerns raised by the report regarding fragile communication between health
services and the care home and will discuss further with CSSIW how we may seek to
collaborate and address this issue jointly through our work.

Yours sincerely

VQ?

DR KATE CHAMBERLAIN
Chief Executive

~7 AUG Zul7 |

Arolygiaeth Gofal lechyd Cymru j Healthcare Inspectorate Wales
Liywodraeth Cymer | Welsh Government
Parc Busnes Rhydycar | Rhydycar Business Park Merthyr Tudful | Merthyr Tydfil
Cc 1UZ
Tel: Ffan 0300 062 8163
Fax: Ffacs 0300 062 8387
www, hiw.org.uk,

N HS University Health Board

. G IG Bwrdd lechyd Prifysgol
& Hywel Dda
CE

Ein cyf/Our ref O Swyddfeydd Cortforaethol, Adellad Ystwyth
. Hafan Derwen, Parc Dewi Sant, Heol Ffynnan Job

Gofynnwch am/Please ask for PA to Chief Executive Caerfyrddin, Sir Gaerfyrddin, SA31 3BB
Rhif Ffén ‘Telephone 01267 239581
Ffacs/Facsimile: 01267 239579 Corporate Offices, Ystwyth Building

z email Hafan Derwen, St Davids Park, Job's Well Road,
E-hosvE-mail Carmarthen, Carmarthenshire, SA31 3BB
Dyddiad/Date. 20 October 2017

Mr Andrew R Barkley

HM Senior Coroner

South Wales Central Area
Rock Grounds

First Floor

ABERDARE

CF44 7AE

Dear Mr Barkley
Touching upon the death of the late Percy JACKS - Your Ref: ARB/SLR/9971

Further to the Regulation 28 Report to prevent future deaths issued following the Inquest
into the death of Mr Jacks held on 7! July 2017, the Health Board has now had an
opportunity to investigate the matters of concern that you have raised and would respond
as follows:

The process of managing potential DVT patients has been streamlined and a definite
pathway introduced. All GP referrals which suspected DVTs are referred direct to the
Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs
to commence therapy prior to an ultrasound scan being undertaken. Following their scan,
if the result is positive, the patient is referred back to the A&E Department where they are
reviewed by the on-call Physicians. There is a pre-printed letter that is completed by the
on-call physicians to the GP with recommendations and this is also copied to the
Anticoagulation Clinic. If the result of the scan is negative, the patient is referred back to
their GP for further evaluation.

The Assistant Director for Informatics for the Health Board has undertaken a thorough
investigation into the discharge summary for the deceased being incorrectly addressed
following his attendance at the A & E Department at Bronglais General Hospital on 6"
February 2017. Mr Jacks had been referred by his GP in Rhayader (newly registered from
Hereford). His casualty card via Myrddin shows the GP to be in Rhayader but the
discharge summary apparently defaulted to his Hereford GP so his treating GP in
Rhayader did not receive a copy.

Cadeirydd / Chair

Swyddfeydd Corfforaethol Adeilad Ystwyth, Corporate Offices, Ystwyth Building
Hafan Derwen, Parc Dewi Sant, Heol Ffynnon Job, Hafan Derwen, St Davids Park, Job’s Well Road, ‘Mrs Bemardine Rees OBE
Caerfyrddin, Sir Gaerfyrddin, SA31 3BB Carmarthen, Carmarthenshire, SA31 38B Prif WeithredwriChief Executive

Mr Steve Moore

Bwidd lechyd Prifysgol Hywel Dda yw enw gwelthredol Bwrdd lechyd Lleol Prifysgot Hywel Dda
Hywel Dda University Health Board is the Operational name of Hywel Oda University Local Health Board

Mae Bwrdd lechyd Prifysgo! Hywel Dda yn amgylchedd di-fiwg Hywel Dda University Health Board operates a smoke free environment

The feedback from the information available to the Informatics team via Myrddin and
various national systems is as follows.

it has not been possible to confirm who this patient's registered GP on Myrddin was at the
time of the A&E attendance. However, it has been confirmed that later that day the record
looks as if it has been validated and the GP record amended to show the Hereford GP as
per Welsh Demographic Service (the validation is normally undertaken when the record is
shown as having an Unknown GP assigned — but the comment regarding the casualty
card having the Rhayader GP is then contradictory).

The Welsh Demographic Service shows that the patient was not registered with the
Rhayader GP until 8" February 2017 (2 days after the attendance in A & E).

In summary it seems that the patient's GP at time of entry to A & E was not valid. Mr
Jack's former GP had ieft the practice but the actual Practice was open. This is what has
triggered the validation. Therefore A & E staff should have updated these details to
ensure the information was accurate with the record.

All Primary and Secondary Care Doctors have access to the Welsh Clinical Portal. This
allows them to access test, radiology and documentation for a patient wherever the patient
receives cares in Wales, regardless of geographical or organisational boundaries. See
attached printout from the NHS Wales Informatics Service website which provides further
information. Mr Jacks' GP would have had access to this and would have been able to
review the outcome of his attendance at the A & E Department at Bronglais General
Hospital on 6 February 2017.

if a patient attends Accident and Emergency who is a resident in a care home, there is a
specific proforma which is completed on discharge. A copy of the completed proforma is
given to the patient/carers to provide a summary of the care/treatment/medication received
to allow any treating health professional to have access to an immediate history as
required.

if you require any further information, please do not hesitate to contact me

Yours sincerely

See Wace

Steve Moore
Chief Executive