Matthew Edwards

INHS:

Tameside and Glossop

Integrated Care
NHS Foundation Trust

Ms Alison Mutch 0.B.E.,

HM Senior Coroner for Manchester South,
The Coroner's Court,

Mount Tabor Street,

Stockport SK1 3AG

Dear Ms Mutch,

Regulation 28: Report to Prevent Future Deaths, following the inquest touching upon the death
of Matthew Robert Edwards

The purpose in writing is in respect of your letter, dated 17 July 2017, and enclosure in the form of the
Regulation 28 Report, issued following the conclusion of the inquest touching upon the death of
Matthew Roberts Edwards, which concluded on 7 June 2017.

| hope to be able to address the concerns raised in Section 5 of your report, and set oul below my
response, adopting the same numbering for ease of reference.

1. Delay in completion of the discharge summary following Mr. Edwards' discharge from
Tameside General Hospital in February 2016

You will be aware of the Trust having previously responded to a Regulation 28 Report earlier this
year, which was provided to you on 18 July 2017 following the inquest touching the death of Derrick
Lawrence Brocklehurst. | have set out below for ease of reference my response to your concerns in
this respect and which I hope is of assistance.

The Trust is aware of a historic issue with regard to the timely completion of discharge summaries in
2016, and | wish to reassure 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.

in order to bring the position back to a baseline from which the Trust could confidently move forwards
with new processes, extra resources were brought in to clear a backlog that had regrettably
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

Everyone
Matted

| ae giscbhity |
confident Chief Executive - Karen James
EmpLovER. Chairman = Paul Connellan Ei vy ‘in!

INHS:

Tameside and Glossop

Integrated Care
NHS Foundation Trust

The Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue,
with support from Brendan Ryan, 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 all 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 and maintained.

| am advised that a new process is to be put in place for the discharge of patients from the
Emergency Department. The Trust is implementing its plan to introduce new bespoke software to
enable the production of an electronic casualty card, to replace the current handwritten casualty cards
produced by the team in the Emergency Department. This will mean that 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 in near real time. It is anticipated that this will ensure that a discharge
summary is completed for every patient seen within the Emergency Department without increasing
the burden on the clinical teams.

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 finalised 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 discharged from the Emergency Department who has not yet had a discharge summary
completed, allowing the management team to monitor and take action to ensure 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.

The Trust has also introduced measures to improve the process of discharge summaries from in-
patient wards. As mentioned above, additional resource was brought in to restore the position to an
acceptable baseline. The Trust has also introduced increased managerial focus and monitoring of
discharge summaries, with a routine ‘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 under
the Trust's Admission and Discharge Policy. The performance of each Ward is monitored by the
Consultants responsible for the Ward, the Clinical Director 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), which is completed by the doctor and finalised by the ward clerk
before being sent electronically to the relevant GP practice overnight, and who in turn are required to
acknowledge receipt of 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
February and August 2017 inclusive.

(9&2 disability
@Biconfident Chief Executive ~ Kacen lames y in| @
EMPLOYER Chairman - Paul Connellan

INHS|

Tameside and Glossop

Integrated Care
NHS Foundation Trust

2. That a follow up appointment was not made at the point of the discharge being completed.

This issue arose in the context of a particular and historical set of circumstances, in which a discharge
summary was not completed for some five months following discharge. The junior member of medical
staff completing the discharge summary made an assumption that the follow up actions would have
taken place some months previously, and which has since been acknowledged as an incorrect
assumption. This was an individual human error, which has been the subject of reflection and
development on the part of the junior member of medical staff concerned.

As a consequence of the substantial improvements including the robust safety mechanisms
incorporated into the discharge summary procedures as described in detail above, | am satisfied and
can reassure that the particular scenario that allowed this individual human error to be made, should
not reoccur.

3. The delay of at least one week before a CT angiogram could be performed due to a shortage
of available appointments.

It would appear that this issue may have arisen in part out of misunderstanding and which | hope |
can clarify, and having confirmed the position with the Ambulatory Care and Radiology Teams.

On 21 September 2016 Mr. Edwards’ presentation and the results of investigations were suggestive
of either chest infection or pulmonary embolism, and appropriate prophylactic treatment was
commenced at this point. On return to the Ambulatory Care Clinic on 22 September 2016, a CT
angiogram was booked for the following week. It is important to emphasise that Mr. Edwards was not
considered acutely unwell at this point in time and was on appropriate prophylactic treatment until
such point as the CT angiogram confirmed or excluded either chest infection or pulmonary embolism.
The CT angiogram commissioned was for purely diagnostic purposes with appropriate treatment in
place as at 22 September. The Ambulatory Care Clinic has two CT angiogram slots assigned per day.
Patients such as Mr. Edwards who require a CT angiogram are assigned to the next available
Ambulatory Care Clinic appointment and the CT angiogram performed during that appointment. |
have included the current pathway in place for reference. The view taken by the clinicians at the time
was that review and admission for a CT angiogram the following week was appropriate. The
Ambulatory Care Clinic and Radiology Manager have confirmed that had Mr. Edwards been acutely
unwell on 22 September the CT angiogram could have been expedited by a Consultant to Consultant
discussion and no issue would have arisen with regard to availability of appointments. | hope this
clarifies the position and is of reassurance with regard to the availability of and access to this
important diagnostic resource.

lam very sorry that you had cause to issue this Regulation 28 Report and would {ike to take this
opportunity to emphasise that | do take your concerns most 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, particularly in relation to discharge arrangements and procedures.

Should you have any queries arising from the contents of this letter or require any further information
or clarification, then please do not hesitate to contact me at any stage.

Yours Sincerely

antl)

Karen James
Chief Executive

[ae disobilty |
confident Chief Executive — Karen lames
EMPLOYER: Chairman ~ Paul Connelfan  £| WZ in!

Everyone
Mattos